Sunday, September 19, 2004

Mucus, autonomic dysreflexia, and vaguely irritated bovines.


I have a cold. Or a sinus infection; I can't tell which. All I know is that life is currently not happening without pseudoephedrine, a drug I normally avoid at all costs. It makes me do what I did this morning; that is, wake up at 2:20 and not be able to get back to sleep until six.

If I could just sleep standing up, that would be much better.

Autonomic Dysreflexia

Here beginneth the first lesson: autonomic dysreflexia is, according to Taber's Cyclopedic Medical Dictionary, a condition commonly seen in persons with an upper spinal cord injury that is caused by massive discharge of sympathetic reflexes from the sympathetic nervous system.

In English, what that means is this: A person with a complete or incomplete injury of the spinal colum somewhere high, usually in the neck, will occasionally have episodes of hugely high blood pressure, tremors, sweats, panic attacks, and other nasties. These are most often brought on by, believe it or not, a full bladder. A fecal impaction takes second place. Other causes might include positioning or bedsores.

I had five patients on Thursday. Four of 'em I cured by noon, which left me to deal with Patient Number Five. He's a high incomplete tetraplegic (quadriplegic) who had a partial transection of his spinal cord at about C6. Feel that bump at the back of your neck, just above your shoulders. His break happened just above that.

He's a nice guy. He's been a quad for about six years and has been married to his equally nice wife for three. (Note to the gaping masses: quadriplegics can and do have perfectly satisfying lives, including sex lives. It depends on the injury, the deficits, and the person.) He came in because he'd started having odd pains in his belly when he laid down in certain positions. His doctor figured it was his implanted muscle-relaxant pump malfunctioning.

(Note to the interested: baclofen pumps can be implanted in the abdomen and programmed to disperse small amounts of baclofen or baclofen in combination with other drugs to the spine, thus reducing muscle spasms and pain.)

At about one o'clock, this poor guy went into an almost-endless cycle of autonomic dysreflexia. His bladder wasn't full, he wasn't impacted, his positioning was fine, he had no bedsores. *Nothing* could explain what was going on...

...until I took a look at his labs with Sparky, his doc. "Sparky," said I, "I know his urinalysis shows colonization, but is it possible that that colonization could've turned into an active infection?" Sparky pondered for a minute, then decided that I might have a point there.

People who've had bladder infections will tell you that even a tablespoon of urine in an irritated bladder can drive you to distraction. I think that was what was happening with this guy, though I never got a definitive answer. The rest of the day I spent giving him huge doses of baclofen and Demerol in an attempt to break the spasms and the blood pressure problems by breaking the pain cycle.

The trouble with a high spine injury is that the body wants to work on a positive-feedback mechanism. Any mechanical engineer will tell you that that will lead to a burnout in machinery. In a human, it leads to blood pressures of 290/155.

It was not a fun afternoon. He stabilized during the night shift, though, and presumably is on his way home now.

And vaguely irritated bovines

Question: what do you call it when a person has a brain biopsy that comes back inconclusive for Creutzfeld-Jakob disease?

There is no answer for that one. If I knew of a good punchline, I'd've used it already.

Yet another patient came in with some indefinable brain problem that causes them to shake, become nonresponsive, and curl up in a ball. The biopsies we did don't show anything definite, so the diagnosis will probably be made on autopsy (as so many of them are with troubles like this).

CJD is different, by the by, from "mad cow".

Mad cow disease, or variant CJD (vCJD) hits early in life, in a person's twenties or thirties. It starts with odd neurological defects that often involve quite a bit of pain and takes several years to kill the victim. It's transmitted by--and pay attention, here--eating the neural tissue of infected animals. Chuck roast is fine, filet mignon is safe. T-bones are a little tricky, and ground beef (especially the mystery-cut ground stuff in the prefab chubs) is most dangerous, as it's extracted by a process that often mixes in bits of spinal tissue by mistake.

Creutzfeld-Jakob disease, on the other hand, is spontaneous. It has no recognized trigger, though genetic mutations might play a role. For some reason we don't understand, tiny proteins in the brain called prions suddenly start flipping over and turning into what's essentially a mirror image of their old selves. They induce other proteins to do the same, and you eventually end up with a brain full of holes like Swiss cheese.

It hits people in their 50's to 70's and takes about six to eight weeks to finish them off. As far as we can tell, it's relatively painless.

(Tangent: People often ask me if I'm worried about getting vCJD from eating beef. My answer is this: I commute 40 miles a day on a hugely busy highway and cross a busy street to get to work; I stand a much higher chance of ending up pasted to the front of a city bus than I do of getting vCJD. Go ahead and eat your steaks, people.)

CJD is quite rare. Only about one person out of a million will get the disease, which means we've got the area's biggest CJD population rotating in and out of our hospital. You know it's bad when all a nurse has to say during report is, "Well, it's typical CJD" and everybody around the table nods in understanding.

And finally, a piece of good news

Georgia of Odious Woman has been kind enough to link this blog from hers. Omigoodness!

I urge you to check out Odious Woman. Georgia is a crack writer and makes even lifting weights and running sound fun.

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