Monday, May 28, 2007

Tombeau de Couperin

You just have to love some people, just because. Just because they have good humor, intelligence, and graciousness. The patient in the last room was such a person and I took an immediate liking to them. Luckily I wasn't having a hair-on-fire screamer of a busy day so I chatted with them a bit on every round I made.

A few years ago they'd had bariatric surgery and they were so successful in losing excess weight that they needed a tummy-tuck to remove some annoyingly large abdominal skin folds. Part of the pre-operative work-up included a routine CAT-scan.

The radiologist called them as soon as they got home from the scan and told them to go to the hospital immediately.

Surprise. The scan revealed a seven-plus-centimeter abdominal aortic aneurysm. Not so bad in and of itself, but it if ever ruptured the patient would very likely die from internal bleeding in a very short time, so surgical repair was required.

"You've got a good vascular surgeon," I had told the patients, "I'd let them work on my kid." True enough. The patient was glad to hear that and said that they were confident that things would go well and they expected to be up and out of the hospital in a couple days. Exactly what I myself expected.

I sent another patient home; an unrepentant drinker and smoker holding off hepatic encephalopathy and its accompanying dementia only by taking loose-stool-inducing lactulose four times every day. They'd felt a little sick and stopped taking the stuff. Their blood levels of ammonia shot up well into three figures. That's bad for the brain. They got confused and were brought in by their spouse.

After a day of resuming the lactulose and some IV fluids they were back to being themselves and their labwork had shown an improving trend. They spent more time outside smoking than they did in their hospital room.

From the National Institute of Alcohol Abuse and Alcoholism:

"Positron emission tomography (PET) analyses of a healthy person and a 47–year–old alcoholic cirrhotic patient with mild hepatic encephalopathy. The blood flow through the brain (i.e., cerebral blood flow [CBF]) differs only minimally between the two subjects. However, the cerebral metabolic rate for ammonia (CMRA) and the permeability–surface area product (PS)—a measure of the extent to which ammonia can pass the blood–brain barrier and enter the brain—are significantly increased in the alcoholic patient, as indicated by the wider distribution and enhanced brightness of the light areas."

The brain can do very little to protect itself; for example, relying on the liver and the diaphanous blood-brain barrier to fend off a host of toxins. As goes the liver so goes the brain.

If that patient keeps his promise to me and resumes his tobacco and alcohol abuse, he will invite early senility or cancer into his life.

As if there isn't already enough senility and cancer in the world.

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