The San Bernardino Tragedy and Mr. Trump

I certainly deplore Mr. Trump's comments regarding his approach to our Muslim friends, but at least he is emphasizing the potential threat we are facing.  Things are not getting better.  I think Mr. Trump is trying to get our President motivated to do something different than he has been doing the last 7 years.  I have listened to his repeated assurances that he are doing everything possible and that we are going to win this battle, but these terrible attacks are occurring with increasing frequency.  I am no longer reassured.

I think he has only himself to blame.  He took our troops out of Iraq creating a vacuum ripe for the extremists.  He failed to follow through on crossing the line if Assad used chemical weapons.  He is not providing the leadership needed here.  He blames Congress and "rose colored" intelligence, for problems. He needs a new approach.  He reminds me of a doctor who refuses to change or consider an alternative diagnosis even though the patient keeps returning repeatedly with the same or worse symptoms.  There has to be more that can be done here to get these brutal people on the run.

The Obama Approach to ISIS

I listened to President Obama's speech today November 25th on NBC surrounded by the important people in the administration.  I presume these officials were there to give credence to his message.  I am now reading Rebel Yell written by S.C. Gwynne.  It is a book about Stonewall Jackson.  The author goes to great lengths to describe how General McClellan sat on his hands with 150,000 troops near Washington, D.C. for months on end and failed to attack the confederacy even though he outnumbered them 6-1.  He over estimated the number of confederate troops and hesitated to attack fearing another Bull Run.  Finally Lincoln relieved him of his command and Generals willing to fight were appointed.

There are similarities between McClellan and Obama.  We cannot afford to sit on our hands any longer.  We have to take significant action and show we have the will to fight even though there will be casualties and the future is uncertain.  I don't feel any more comfortable after his speech this morning than I did after the Paris attacks.  Lets show them what we are made of.

The Electrical System of the heart

I think it is helpful to compare the human heart with the automobile engine.  To work properly the auto must have 3 components:  An engine to power the car, an electrical system that includes a generator of electrical current and a wiring system to carry the current to every cylinder (spark plug wires), and an energy source, gasoline.   Similarly with the heart, the left ventricle is the engine and it powers the heart and circulates the oxygenated blood, the gasoline or energy source for the body,  The heart also has a generator of electrical current, called a pacemaker,  that generates an electrical impulse.  This electrical current  is distributed to all the heart muscle via a wiring system composed of specialized muscle cells to stimulate a heart contraction.  All 3 components must be working properly to have a smooth running car as well a smooth running heart.  This all happens in a fraction of a second.  If anything goes wrong with any one of these 3 components, symptoms develop.  Without a generator the car will not start nor move even though the engine is in excellent shape and the tank is filled with gas.  The same is true of the heart.  Without a pacemaker we don’t go anywhere, illustrating the importance of a normally functioning pacemaker in preserving and maintaining life.

Pictured here is a cut-away picture of the 4 chambered heart with a schematic diagram of the electrical system.  The generator of the electrical impulse that drives the heart is called the “Sinus Node or SA Node” and it is located in the right upper corner of the right atrium.  The SA node is composed of specialized cells that spontaneously depolarize (ignite) and generate an electrical impulse.  Isn’t that amazing that human cells can generate the electrical impulse all by themselves?  The impulse then spreads through the heart from the SA Node to the lower chambers, stimulating heart muscle to contract as it travels this course.  Think of this:  Our heart will beat in the neighborhood of 100,000 times per day, year in and year out, which means it is an extremely stable and reliable system, functioning normally under all types of human conditions.  The SA node can speed up with exercise and/or slow down depending on body requirements for blood flow, showing the versatility of the system. (to be continued)

THE ELECTROCARDIOGRAM (ECG)

The ECG is used to evaluate the cardiac electrical system.  The ECG is an invaluable tool and provides a wealth of information about the heart and heart function, and it does not require any needles.  Shown here is a short ECG strip that includes 3 heart beats.  Each heart beat is composed of three waves.  The first is a small wave, called the “activation” wave and occurs when the SA node fires.  As the electrical impulse spreads across the atria the atria contracts and sends blood down into the ventricles.  The sharp wave occurs when the ventricles contract, sending blood out into the body.  Third wave is called the “recharge” wave and indicates the heart is ready for the next beat.  I don’t expect anyone to become an ECG reader, but it helps to have a mental picture of an ECG tracing and appreciate how useful it is in the management of the cardiac patient.  Virtually every TV show of the emergency room will include a picture of the monitor showing the ECG.  We like to see a nice regular heart rate on the monitor similar to what is shown here.  A skipping, erratic heart beat may mean the presence of an underlying heart problem requiring further evaluation.

Bradycardia and Tachycardia:  These are two terms that are often confusing.  The normal heart rate is between 60 and 100 beats per minute.  A heart rate below 60 is called Bradycardia (slow heart) and over 100 is called Tachycardia (like Tachyometer).   Bradycardia and tachycardia are technically abnormal, but not necessarily an indication of underlying heart disease.  For example a heart rate of a normal person may drop below 60 during sleep and greater than 100 during exercise, but we consider these to be normal physiologic responses.  However, persistently high or low heart rates should be evaluated by the doctor.

Taking the Pulse:  All of us should know how to find and count our pulse rate or heart rate.   We should also be able to find and take the pulse of another person to determine if the heart is pumping.  When you take a pulse you are feeling the pulsation of an artery (there is no pulse in veins) so you need to know the easiest place to find the pulse.  Large arteries are found on both sides of the neck beside the voice box, and in the groin between the hip joint and the pubic bone.  You should find these arteries on yourself while lying quietly in bed and count your pulse.  Use your watch and count the number of beats in 10 seconds and multiply by 6.  The artery in the wrist is found just above the base of the thumb in a groove next to a tiny bone in the wrist.  Use one or two fingers to feel for the pulse and not your thumb because our thumbs have a pulse of their own.

NATURE'S BYPASSES

WHAT TO EXPECT IN THE EMERGENCY ROOM

The treatment of a heart attack has changed dramatically in the past 20 years.  Heart attack patients are no longer admitted to the hospital to be observed and kept at bedrest for two weeks.  Emergency rooms (ER) are now designed to place heart attack patients on a fast-tract to immediate, interventional, treatment.

A heart attack is caused a thrombotic (a blood clot) obstruction of one of the coronary arteries.  The chest pain associated with this obstruction is due to injury or damage to the heart muscle supplied by that artery.  The heart attack may be large or small, but all heart attacks are serious and are treated similarly.  There are no “mild” heart attacks.  Injured heart muscle can recover, but dead heart muscle cannot.  The aim is to reduce heart muscle damage by restoring blood flow in the affected artery.  Blood flow is restored by opening the artery and getting rid of the blood clot (thrombus) with a tiny balloon catheter in a Catheterization Laboratory (Cath Lab).  The longer the artery is obstructed the greater will be the heart muscle damage so we want to go to the cath lab as quickly as possible.  The aim, in ideal circumstances, is to open the artery within 90 minutes of the onset of the chest pain. 

Once the cardiologist arrives in the ER and the diagnosis is established, the ER becomes a flurry of activity.  Laboratory work, x-rays, ECG, I-V fluids, and oxygen must be obtained and started.  The procedure must be fully explained to the patient and the family to get the necessary permits signed.  This is a difficult time for the patient and family because there is some risk in the cath lab.   There is also risk in not doing anything.  My advice is to sign the permits and get to the cath lab as quickly as possible.  This approach to the heart attack patient has been approved by the hospital and the medical staff and the results are closely monitored.  The goal here is to stop further cardiac muscle injury.  This is modern day cardiology .  See blogs 12 and 13. 

Summary:  If you suspect a heart attack, call 911 and get to the hospital as quickly as possible.  I will devote a later blog to help you recognize the type of chest pain associated with a heart attack to assist you in deciding whether or not to call 911. 

AN APPROACH TO ISIS

We are all watching and worrying about ISIS and further terrorist attacks.  What can the US do in addition to the air strikes without putting a large army on the ground?  I am no military strategist but we all recognize the element of surprise in fighting a war.  One approach would be to develop sophisticated strike teams, similar to the one that took out Bin Laden, that have the ability to strike a quick blow and then get out of the area.  When I say sophisticated I mean new weapons, special helicopters, small tank-like vehicles that could be lowered from a helicopter and then destroyed and left behind.  The number of teams, equipment technology etc would need to be carefully determined.

The one thing we do control is the air space.  The use of multiple strike teams, able to strike anywhere in the region, would serve to keep ISIS on edge not knowing where we would strike next.  It could be an oil refinery, a supply train, a command center etc.  The unpredictability  of a strike team would keep the enemy off balance and spread their troops far and wide.  I would visualize this would be an entirely US effort with the strike teams who knew and trusted each other.  This approach has the potential to be effective and avoid deploying and supplying a large ground force.

I am sure there would be casualties, but this is war and that is why we have an army..  Lets get our best minds, supported by our reluctant president, working on an effective strategy to stop these brutal people.  I don’t see how REAL men can feel good about murdering innocent people and children.  They are appealing to the worst traits in human nature.  How can you attract anyone to your cause if all you do is kill and destroy?  Further, lets don’t give the terrorist anything more than the briefest publicity and continue to broadcast the pictures of carnage and photos of the perpetrators day after day.  This only gives them more widespread publicity and serves to emphasize their cause.

Treatment of Atrial Fibrillation, Part II

Anticoagulant Drugs:  Warfarin has been the standard anticoagulant drug for the past 50 years and is given for a variety of cardiovascular conditions to prevent blood clots, including patients with coronary disease and prosthetic heart valves.  Warfarin is inexpensive.  Regular blood tests (a prothrombin time) are required, usually monthly, to determine the anticoagulant level (INR) is necessary if the patient is taking warfarin.  Recently newer drugs called "thrombin inhibitors" have been introduced that are equal to warfarin in effectiveness and do not require regular blood tests.  These drugs include Pradaxa (Dabigatran), Eliquist (Apixabam) and .  Xarelto (Ruaoxiban) and Savaysa (Endoxibam).  However, the thrombin inhibitors are quite expensive.  The Doctor should discuss the  pros and cons of these anticoagulant medication to use with the.  The one down side to these thrombin inhibitor drugs is that they are not readily reversible should you have a bleeding ulcer, auto accident, some other bleeding episode.  Current research looks very promising that this aspect will soon be solved.

Cardioversion:  Cardioversion (converting the heart back to normal regular rhythum) is accomplished by putting the patient briefly to sleep and applying an electrical charge to the chest using a machine and the paddles that everyone sees regularly on TV.  Cardioversion is ususally successful, but there is a tendency for the A.fib to recur, primarily because cardioversion does not address the root cause of the A.fib in the first place.  Never the less, cardioversion it is worth a try because some patients are able to be converted to normal rhythm and the A.fib never returns.

Medications:  A number of medications have been tried over the years to treat A.fib, but most of them have been abandoned because they tend to aggravate rather than control the A.fib.  The one medicine that has been shown to be effective is called Multac (amiodarone).  The main problem with Multac is a long and serious list of side effects.  The patient will need to be watched very closely for the first several months after starting the drug.

Ablation:  Ablation is a procedure that necessitates a cardiac catheterization and the use of catheters to perform electrical mapping inside the heart.  The aim is to search for a specific electrical focus causing the A.fib.   If such a focus is found then this focus is "ablated" (destroyed) by delivering an electrical charge through the catheter.  There are no incisions.  The results of ablation are encouraging, but it doesn't work in every patient.  In general it is a procedure of last resort when all else has failed.  The doctors that do ablation are called cardiac electrophysiologists.

Pacemakers:  Pacemakers are often inserted in patients with A.fib whose pulse rate has become so slow, about 40, that the patient has difficulty being up and about.  Weakness, dizzyness, fatigue, loss of energy develop primarily because of low cardiac output due to the low heart rate.  Pacemakers are very effective in this situation because they maintain a minimum heart rate of at least 60-70 beats per minute and the patients symptoms are greatly improved.

Summary:  A.fib is a common heart problem in the elderly and is associated with stroke, something we all want to prevent.  It requires close and persistent attention to medical management over long periods of time.  The treatments are variable and differ widely from patient to patient.  Stay in close touch with your doctor to avoid problems and be sure to maintain your anticoagulant level within the prescribed range.

ATRIAL FIBRILLATION

Atria Fibrillation (A. fib) is the most common heart rhythm disturbance in our society.  A.fib increases with age. The cause is not entirely clear, but it probably is related to a number of factors.  A.fib, as the name implies, affects the atria or the upper chambers of the heart.  The job of the atria is to contract and fill the lower chambers, the ventricles, just prior to heart contraction.

A.fib is a condition in which the regular, synchronous contractions of the atria is lost.  The loss of atrial contraction means the ventricles fill with blood by the force of gravity.  If one were able to look at a heart in A. fib you would see the atria  quivering, but not contracting.  The quivering is due to each muscle bundle contracting at its own inherent rate and not in synchrony with its neighbor.  The result is a very erratic, irregular heart beat.  If you put your finger on the pulse of a patient in A. fib you would find it difficult to count the beats because some are very strong beats and others very weak.  This variable pulse is due to inadequate filling of the ventricles between beats.

A.fib is important to recognize because it carries greater risk than most heart arrhythmias.  The diagnosis is made by taking an electrocardiogram (ECG).  If you happen to notice that your heart is skipping it is important to get to the doctor so the correct diagnosis can be made.  The presence of A.fib puts you in a special category of those patients who are at a higher risk of STROKE than those that do not have A.fib.

Gun Control and School Shootings

I want to enter the discussion on guns and mass shootings.   My wife and I, along with another couple,  made a cycling trip to Ireland in 1988.  We spent 10 touring southern Ireland and then rented a car to visit Northern Ireland to visit relatives of the other couple.  Once we crossed the border into Northern Ireland we noticed  every police station was a virtual fortress surrounded by high fences, barb wire and obstruction s to prevent any person or vehicle to enter the area.  The first night in a B&B we heard a loud explosion.  In the morning the sky was filled with helicopters ferrying injured soldiers to a local hospital.  The IRA had bombed a SCHOOL BUS of British soldiers on a road nearby.

We are not far from that reality at the present time with all of our education institutionsvirtually under siege.  We must do everything we can to prevent such events from developingWe must protect our children and provide the needed safety.

   
The Founding Fathers, when writing the second amendment, did not have in mind that the citizens would buy and accumulate military grade weapons.  How encompassing is the second amendment?  There is no mention of specific arms that is approved for the ordinary citizens.  Does the second amendment include machine guns, grenade launchers, bazooka’s and other heavy weapons.  I think not.  What if one our school buses was bombed or riddled with bullets?  The second amendments provisions were written for self defense, not aggressive mass 

killings.  General Grant allowed the confederate soldiers to keep their side arms for self defense.

 
We need to put a stop to this nonsense and start bringing order out of chaos.  There is no need for any citizen to own anything more than a hunting rifle or two and a single handgun.Certainly there is no need for anyone to be able to buy 400 rounds of military grade ammunition without being questioned.   Or accumulate an arsenal of 20 or thirty guns including military grade weapons.  Freedom has limits.

 
Lets put our thinking caps on and solve this issue while preserving the individual right tobear arms and prevent any more mass killings. Please give me your comments.