Saturday, February 26, 2011

Atrial Fibrillation, A Rapid Heart Beat

"Don't call for your surgeon, even he says it's late.  It's not your lungs this time but your heart holds your fate."          Manfred Mann

Although it might be somewhat surprising, the single most popular piece I've written here, and mind you this is a triathlon oriented blog, was on pills.  Antihypertensives to be specific; medication for blood pressure control.  So this issue will expand on the 12/10/2010 writing that addressed rapid heart rates in general and review a very commonly seen abnormal rhythm called atrial fibrillation also written AF or Afib.

Usually the heart beat is regular and labeled normal sinus rhythm, NSR.  But in Afib, the ventricles, or major pumping chambers, receive a rapid, erratic signal and pump at a varying irregular rate.  Although some can have AF and be symptom free, others can experience chest pain, dizziness, fainting, or be intolerant to exercise,etc. They can be at a 7-8 times increased risk of suffering a stroke.

The diagnosis is made after obtaining a history, physical exam and EKG.  Occasionally an echo cardiogram or blood work are also indicated.  Then, one would search for the underlying cause to choose treatment options.  Interestingly, a common cause is dehydration.  Also found can be an over active thyroid, hypertension, certain types of lung disease, diabetes, excessive alcohol consumption, etc. although finding no definite cause is quite common.  If the diagnosis is in doubt, the patient can be fit for a monitor which continuously records the EKG for 24 hours or longer. Once this diagnosis is made, the goal of treatment is to restore the heart rate back to a normal level and diminish the risk of stroke.
                                                               Medically, a number of medications are available for stroke prevention including aspirin and warfarin.  When addressing the abnormal rhythm, various meds are available and, when ineffective catheter ablation may be offered.  This is catheterizing the heart and attempting to both locate and destroy the tracks along which the abnormal electric signal travels.  As you might imagine, it's a big deal!  I found an on line ad for the Cleveland Clinic where they advertise having performed more than 1200 ablations for AF last year with success.

I've read various posts over the years on various tri forums, readers echoing the disappointment that their medical issues not only limit their ability to train but race as well.   One athlete with significant AF summed it up this way, "I am not letting it take over my life, but it ****ing sucks that I can no longer participate at the level in endurance sports that I had been able to achieve with 20 years involvement in one sport or another (running, cycling and tris).  I even dropped out of IMLP since I knew I couldn't train for the race in my condition."  (I really feel for this guy and I know you do too.)

So, if you've recently been given the news that you have AFib and it requires treatment, research it out, get as much information as you can, and do what you and your physician think is best for you.


"No One Said It Would Be A Piece Of Cake?"
This hand written note was tied to a sign at about the one mile mark of the bike in Kona in October.  A mile later there was one that read, "Cake?  We have an App for that!"  And a mile get the picture.  Isn't it nice that on days when we occasionally feel isolated and exhausted, that we have friends and family to remind us that they're still there, and they care.  Make sure you thank them every day.                                 

Friday, February 18, 2011

Dog Bites, What To Do First!

Does The Name Pavlov Ring A Bell? 

Some time back, while on a very early morning bike ride with a lawyer friend of mine, far out in the country, a dog shot from behind a house and bit my friend's ankle for no particular reason.

NOW WHAT! We were the only ones moving at that hour, but with the noise the dog made, as we circled back to get it's address, we saw this very sleepy looking woman in the front behind the glass door.  As we got to the house, Mike just leaned on their mailbox without even unclipping, to get out a piece of paper and pen to write down this address. The door slowly opened and the woman looked at him.  He just kept on writing then stared at her saying, "Your dog just bit a LAWYER!" 

Well, we got some attention now!  You betcha.

As we slowly rode away to get to a place where we could tend to the wounds, a tremendously obese man wearing blue jeans and nothing else approached us asking, "You boys alright?"  Long story short, Mike wasn't the dogs first victim and although Mr. Blue Jeans asked for leniency, none was shown. We turned Fido in as soon as we could.

 Now, you try to get as much info about the dog as you can. I saw that the dog had a collar and asked about rabies shots.  I told him I was going to report the incident to animal control, and got his name and address. Key items. (I always have a working pen and paper in my fanny pack and in a situation like this, more than a little stressful, I wrote it down as I was sure not to remember it.)

Then I had to think about this wound. Dogs mouths, like those of the human, are filled with bacteria, really, millions of them, which once the skin has been violated, have a pathway into the rider's blood stream. Bites to the hand or foot can be especially troublesome. Dogs have strong jaws and dull teeth which can crush a good deal of human tissue. And, those athletes with preexisting diabetes, steroid dependency, AIDS or those with circulation problems can be particularly at risk.  We took off  Mike's shoe and sock and thoroughly cleansed the wounds with the contents of our water bottles.  Even if you have an energy drink, the manual act of flushing the wounds immediately is quite helpful.  You can finish it off with a swig of water to remove the energy drink.  I then cleaned off his ankle with alcohol and betadine and put on a couple band-aids ("You have that in your fanny pack?".......  Hey, I'm a surgeon, what do you expect?  I also have Benadryl in case someone has an allergic reaction, Tylenol, Bacitracin, money, a thumb flashlight that fits in my mouth for changing flats in the dark, etc. You?)

Once I had a return of cell service, we called Mike's doctor and then rode to the office for definitive wound care. Some of these bite marks were pretty deep and although you don't generally suture these wounds, if a tendon or other structure is exposed you sometimes have to.  It took 50 minutes to ride there but he was triple washed, given a tetanus shot since his was 8 years old (no swimming for a couple days - these babies give you a right sore shoulder!) and we called animal control.

In that Mike is generally healthy and has not had his spleen removed, no antibiotics were necessary. Things  healed nicely, the dogs rabies shots indeed turned out to be up to date and we're back in training. If you follow these simple measures you will do well too.

I think we'll ride a different route next time!

What would you try to accomplish if you believed it was impossible to fail?

Sunday, February 13, 2011

Quadriceps Tendon Ruptures

"Is it hot in here or is it just me?"

This is Niel Mason, PharmD, head of the Drug Information section of Sentara Hospital in Virginia Beach, Virginia.  He's a great source of information for this blog.  Much of what you've read here needs to be backed up for accuracy and he's always there.  Haven't you found that each of us needs a back up, someone to go to when the triathlon forum doesn't give us the information we need, particularly when it comes to our health?  I certainly have.  Thanks, Niel.
Oh, and he's a triathlete too.

Quadriceps Ruptures

Rick T. is a runner/biker in my practice.  A few years ago, he was down hill running just outside of town when his right knee just gave way causing him to fall.  The leg was acutely weak and for a second he thought, "Am I having a stroke?" Later, evaluation in the Emergency Department revealed a swollen, painful, tender knee and a complete inability to extend the knee against gravity.  But, the nurse could easily straighten it so it wasn't locked.  His x-rays were negative and he had not had a stroke.  He'd ruptured his quadriceps tendon, the big one just above his knee cap. 

Although relatively uncommon, in my type of practice I see these fairly frequently.  Generally the patient is over 40 but in the athletic community those with a previous diagnosis of "jumpers knee," partial ruptures can be seen.  In one recent study the average patient was male and approximately 28 years of age.  In any case, with a rupture of this tendon, the best long term result comes from early diagnosis and repair.  In most cases, whether symptomatic or not, the tendon was abnormal prior to the rupture.  Interestingly, it almost always ruptures in the same place, about 2 cm above the knee cap.  Contributing to failure of this tendon could be being previously diagnosed with gout, steroid abuse, diabetes, rheumatoid arthritis, obesity, lupus, etc.  For those of you who've undergone ACL reconstruction or total knee replacement it can occur, although rarely.  The diagnosis is made on a clinical basis but occasionally an MRI is indicated if searching for a partial tear.

So, if you find yourself in a similar situation, to the Emergency Department you go.

Now, back to Rick.  I fixed his with an uneventful recovery.  Uneventful till about 2 or 3 years later when he called me from Seattle on vacation. "Hey, John, remember that quadriceps tendon you fixed in my knee a while back? Well, guess what I did to the other side?  See you in a couple days!"

As noted, early surgery is the next step for these folks.  It can be done under general or regional (spinal) anesthesia, likely as an out patient, and depending on the solidity of the repair (each of us is different) the limb will be immobilized for a time with the owner on crutches.  If the repair is delayed, the level of surgical difficulty rises and the probability of an excellent result decreases.  Obviously, this could have negative implications in the future.  Partial tears would ordinarily be treated non-operatively.

Don't thank a race volunteer, thank every race volunteer!

It's easy to complain.  In fact, the way some triathletes act, you'd think it was the national pastime.  But, for the most part, volunteers are unpaid helpers who give selflessly of their time to help you!

Like Mike McCurdy (left), a volunteer Transition Director in Kona.  Mike runs the manpower end of the entire transition area on the pier and it's a big job.  He has to make sure there are enough people in the right places at the right time wearing the right clothing who understand not only what they're supposed to do the help the triathletes...but what not to do so no racer is impeded or injured.  And also so nobody steals or messes with your bike or stuff.  Like most, he's not paid, takes a week of vacation from work, pays his own way to Kona, etc. just because he cares about helping others.  Oh yeah, and he's crossed the finish line on Alii Drive and been told, "You're an Ironman!" by Mike Reilly.  He puts a great deal of time and effort into his volunteer job so that it's done correctly and you have a successful race.

There are lots of Mike McCurdys at every race. We should say thank you to each one.

Above knee image: Google images

Thought for the week: If you train hard, you will not only be hard, you will be hard to beat.

Saturday, February 5, 2011

Cortisone Shots: The Good, The Bad and The Ugly

"I need more than just words can say, I need everything this life can give me."  Van Halen

DEAL WITH IT the tattoo reads.  Pretty easy to say when you're 30 years old, in perfect health, after a morning practice swim where everything goes well.  But how about the rest of us?  What about those of us with shoulder bursitis, a touch of arthritis in the knee, plantar faciitis, those of us whose training - and therefore performance - are limited by injury or age?

With age/pain/injury/wear and tear occasionally comes the visit to the doctors office, and when deemed appropriate the physician may recommend a cortisone injection.  Should you find yourself in this situation, this piece may help you work with your medical team to determine if this is the best treatment for you.

So, first, what is cortisone?  It's a corticosteroid, a natural hormone made by the adrenal glands.  OK, so what's an adrenal gland?  Humans have two adrenal glands, or supra-renal glands as they're sometimes called, secondary to their being located on top of the kidneys.  This would be near your 12th rib in your back.  Like the thyroid, pituitary and pancreas, the adrenals are part of the endocrine system.

Credit for initial synthesis of synthetic cortisone goes to an African-American researcher named Percy Julian.  He accomplished this almost 80 years ago.

Cortisone, like aspirin and Advil (ibuprofen), functions as an anti-inflammatory agent.   When these drugs are taken orally, the effect is systemic, seen in the whole body.  Even when injected into a joint cavity there can be a systemic distribution of the substance.  The advantage of injectable cortisone is obvious in that when a particular inflammatory condition is diagnosed, a high concentration of the anti-inflammatory medication can be placed at the identical location.

I'm always asked if these injections hurt.  Well, it is a needle but if your skin is "numbed up" first, you hardly feel it.  I've been told countless times "That wasn't so bad" by folks who were prepared for the worst.  And, the educated triathlete also asks about the potential for side effects and yes there are a few.  Although quite rare, infection following a cortisone shot could be quite serious.  However, your physician will thoroughly cleanse your skin with alcohol and betadine to reduce this possibility.  Folks with an iodine allergy are cleansed differently.  If my office is an example, I'd estimate that I  give almost 2,000 of these injections each year, and have for a number of years, but have never had one get infected. Not only that, I know of none occurring in patients of my peers at our hospital.  Diabetics should be told that they may see a short term rise in their blood glucose and it's been reported that very occasionally patients with darker complexions can see a whitening of the skin at the injection site.

The most common negative would be what's called a cortisone flare, a short term painful reaction which spontaneously resolves in a day or two.

So, who is a candidate for a cortisone shot?  In my practice, the most common indication is arthritis, particularly of the knee (see previous blog), followed by bursitis of the shoulder.  It's also used very commonly in Tennis Elbow (see previous blog), Morton's neuroma of the foot, carpal tunnel and trigger fingers just to name a few.  Also, they can be repeated if required although again the intelligent athlete thinks before acting.  In my office, except for knee joint arthritis in the elderly where the plan includes eventual replacement, the limit is usually three.  More than this and you actually run the risk of doing more harm than good by sometimes weakening the soft tissue of softening the joint lining cartilage.

So, the take away is that cortisone injections are not an instrument of the devil and when used judiciously with the right indications and diagnostic acumen, they can be quite beneficial to the triathlete.

Finally this quote:  You never get tired of winning, thus you should never get tired of what it takes to win.