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.