From our anonymous insider…
“We live every second on the edge between bleeding to death and death by heart attack,” exclaimed the young hematologist attending. She introduced us to the coagulation pathway and the lucrative and life-sustaining hematological drugs. Numerous clotting factors (proteins) are produced in the liver and released into the bloodstream. My favorites were the actions of fibrin and plasmin. Vascular damage initiates a cascade of clotting factors to cleave the precursor fibrinogen into fibrin. Fibrin acts as a sticky filament that forms an intricate spider web, binding platelets together, creating a thrombus (blood clot). This nanoscopic mesh traps everything from red and white blood cells to the numerous clotting factors such as plasmin to plug the vessel breach. Vascular remodeling and wound repair signals activate the entrapped plasmin which degrade the fibrin web through fibrinolysis.
Simply resting one’s arm on a table creates cuts in the microcirculation. Our finely-tuned coagulation system is able to plug these cuts to prevent severe bleeding, while not creating too many blood clots that would obstruct flow to tissues. The hematologist explained that mutations in clotting proteins lead to uncontrolled bleeding disorders such as hemophilia (factor VI, IX or XI) and von Willibrand Disease or uncontrolled thrombosis formation such as in Leiden Factor V. She finished by explaining that vitamin K is essential for the activity of a liver enzyme that is used in the production of several important clotting factors (Factors II, VII, IX, X, numbers that become ingrained into any medical student’s mind for Step I). Drugs such as warfarin target the enzyme that catalyzes the reduction of oxidized vitamin K. Without this reduction process, fewer functioning clotting factors are synthesized. This results in decreased clotting function for a given signal, the costs and benefits of which were presented in this week’s patient case.
“Gerry” is an eighty year old black male who suffers from congestive heart failure after three heart attacks. “I did not treat my body well for many years.” Gerry became an alcoholic in his twenties, and smoked two packs a day from his late teens through his 60s. Vodka was his drink of choice.
Gerry grew up fatherless in a crime-ridden neighborhood. “Ma did her best to raise my two brothers and me. She would whip us if we did anything wrong. She’d grab us by a leg, hold us upside down and smack away. If none of my brothers would turn the culprit in, she would whip us all to ensure the guilty got punished,” Gerry reflected. “Much of my neighborhood’s problem was from the destruction of the family. No one has respect for authority. When I grew up, the cops were the good guys, Ma the bad one. We grew up wanting to be cops.”
Gerry described the low point in his life as returning home to see his wife and children conducting an alcohol search. “They missed the bottle that I hid in the toilet cover.” He claimed that he was able to “drink a bottle of vodka before work and no one would notice.” His wife divorced him after catching him driving drunk with their two girls and then his unmanaged health conditions continued to deteriorate.
Gerry began to have congestive heart failure from combined systemic hypertension (high blood pressure everywhere) and pulmonary hypertension (high blood pressure in the lungs). His second heart attack in his sixties was a wake-up call. “My doctor said, ‘If you do not make drastic changes, I do not expect you will live another year.’ I went completely cold turkey. I moved back home at sixty and quit cigarettes and alcohol.” Gerry now lives in a retirement home. “I was very anxious about death, so much so I would be afraid to sleep in my bed. I would try to stay awake in my recliner. Eventually I realized when I go, going in my sleep is the best way. Now I sleep like an angel.”
Gerry’s cardiologist explained that Gerry owes his life to advances in pacemakers and fibrinolytic pharmaceutical drugs. His weakened heart, after three separate heart attacks, has less contractility. Certain areas of the his heart, such as the atrial appendages and ventricular apexes, do not fully contract. This causes “pooling” of blood or hemostasis. Still blood is more likely to form a thrombus (or blood clot). These clots, unless broken down, can travel and obstruct vessels to vital organs causing a thromboembolism. A thromboembolism lodging in a coronary artery is the most common type of heart attack; a thromboembolism lodging in a vessel supplying the brain is called a stroke. Gerry is also at increased risk of Deep Vein Thrombosis, or DVT, due to sedentary lifestyle in advanced age and poor circulation from decreased cardiac output . If a DVT in a femoral vein gets dislodged it can lead to rapid death from a pulmonary embolism, blocking blood flow to the lungs (the cause of death in at least one of our cadaver).
“Even ten years ago, the general consensus was to avoid excess bleeding,” explained the cardiologist. “This has shifted to prevention of clots. You can recover from excess bleeding by getting a transfusion or IV fluids. You will not recover from brain damage from a stroke, sudden death from a PE or heart damage from a MI.” Gerry and the cardiologist discussed how warfarin and coumadin are difficult to take and to prescribe because their effect varies with vitamin K input. “If my patient eats a lot of spinach one meal, it could throw the whole clotting system out of whack with drastic consequences.” A new age of fibrinolytic drugs are coming that are vitamin K-independent (see eliquis ads on TV). However, this new age would not alleviate a common concern for Gerry and other elderly people: “I sometimes have trouble remembering if I took my medications in the morning if I do not put them in the pillbox. If I took my meds again at night, could this kill me? This is something that gives me so much anxiety.” The cardiologist added that one occasional double dose would not kill him, but emphasized these are powerful drugs.
Jane recounted a “Women in Surgery” interest meeting she attended with other interested female medical students. A young trauma surgeon who has been an attending for three years led the discussion on the life of surgery. “Go into something else if you could be happy there. Surgery is only for people for whom nothing else would satisfy.” Jane recounted the surgeon’s main point: “There is no such thing as work-life balance. Anything not work becomes a distraction against surgery… Getting married, distraction. Having children, distraction. I was in surgery on my son’s birthday. He waited until 10:00 pm to give me a slice of his birthday cake. His birthday was a distraction.” The surgeon recounted a story of informing the parents their 17-year old child is dead. “Women cry a lot more than men. Men are usually silent. I woke up at 3:00 am for weeks thinking about that case, of what I could have done differently. Surgery never leaves you.” The trauma surgeon said to wait for the surgery rotation (third or fourth year) before seeking to go into her specialty: “Most of you will be pulling your hair out on the first 24-hour shift, but a few of you will become captivated. Don’t force it.”
Our medical school requires students to do community service projects in six-person groups. My group chose to work with opioid addicts. The program was started by the local police department to try to fight the rise in opioid overdoses in the area. As long as there is no outstanding warrant, opioid users can bring in drugs and paraphernalia to the local police station, or a recently added clinic, and receive counseling and access to rehab programs. We met with the director, a middle-aged woman whose college son overdosed on heroin laced with fentanyl, and a nurse.
I asked how many addicts would willingly give up their drugs? The answer turned out to be three or four individuals per day. The nurse explained that based on an interview, a “program ambassador” customizes a recovery plan tapping into local, state, and federal programs: “The resources are there, just it is impossible for a non-expert to navigate them. One common complication is addicts having children. They are afraid of losing custody if they ask for help from healthcare professionals.” Our group will able to serve as ambassadors once we complete an 8-hour training program.
Tuition is due this week. I have a Graduate Plus loan at 6.31 percent. There is no federal subsidy for this loan and the interest begins accruing immediately, but payments are deferred until after graduation. If I work in a non-profit health care system, i.e., most American hospitals, monthly payments are capped at a percentage of my salary. After ten years, the principal will be forgiven (paid by taxpayers!) if it hasn’t been paid off. The program was designed for people who joined the Peace Corps, not for radiologists earning $350,000 per year, so there is some talk about the new Congress closing “the Doctor’s Loophole.”.
Statistics for the week… Study: 25 hours. With exams next week, I wish I was at this stage two weeks ago. Sleep: 7 hours/night; Fun: 1 night. Example fun: Evening watching Netflix’s The Crown followed by Sunday brunch.
The Whole Book: http://tinyurl.com/MedicalSchool2020