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Vitals & Bits # 16: Gamma-aminobutyric acid (GABA)
By Whitny Doyle, RN [ Fri Sep 10 2010 1:48 PM ]
When my older sister and I were around 1 and 2 years old, my parents snapped a photo of us sleeping next to one another. In the quarter century that has passed since then, the deep symbolism that was accidentally captured in that photo has slowly emerged. The photo is now the stuff of family legend, an important historical document that is used to explain why things are the way they are.
You see, my sister Emily is the tidy, polished, pretty, immaculately dressed and expertly coifed fiancé of a famous opera star. And I … well, I like cats. And books. And books about cats. My hair automatically assumes the shape of the ponytail I wear everyday, and every single article of clothing that crosses my path bears some kind of oil or mustard or ink or baby vomit stain.
The aforementioned photo has become a famous family document because it perfectly captures, in one elegant little 4X6 time capsule, Emily’s and my future personalities. Two-year-old little Emily sleeps prettily on her side in a sweet little white nightgown, her blond hair gracefully and neatly spread around her relaxed, angelic face. And there I am next to her, fitfully sleeping with my mouth open, my hair hopelessly deranged and my body awkwardly tangled in a bizarre mountain of blankets and partially removed pajamas.
From this photo and other various scraps of anecdote, I’ve come to believe that a person’s sleeping habits can tell us a lot about that person’s personality, which itself is influenced by brain chemistry. My own brain has always been a tortured little theater of cognitive dissonance.
As the photo of Emily and me exemplifies, my sleep habits reflect this. In the miraculous event that I actually fall asleep, I toss and turn and toil away at unsolvable homework problems and an endless series of nonsensical tasks in my dreams. I wake up numerous times throughout the night, and by morning I’m usually more exhausted than I was the night before. Emily, on the other hand, presses energetically and cheerfully through her day and falls into bed sleepy, satisfied and generally unburdened by the useless emotional heft of global death and destruction. Twenty-five years after that photo was snapped, she still sleeps like an angel, and I like a Tasmanian devil.
I’ve always just kinda dealt with my insomnia. I’ve never sought therapy or anything like that for it. But a few years back, a rogue Ambien crossed my path and I, chronically tired and sick of not sleeping, decided to try it. Around 10 pm, I made a cup of decaf tea and drew a bath. Before entering the bath, I took about a quarter of the Ambien pill, thinking it would take effect just as I was ready to emerge from the bathtub and hit the hay. I washed the pill down with tea and stepped into the tub, closing my eyes.
I don’t remember anything between when I closed my eyes and when I opened them again, startled and shivering in a tub of cold water. I attempted to crawl out of the bathtub but couldn’t. My body was trying to go back to sleep, and I couldn’t find the strength or mental focus to remove my freezing naked flesh from the cold tub. I splashed my face with water and tried again, this time managing to drag myself out of the bathtub. After stumbling to my bed, I fell onto my mattress without drying off and pulled a blanket over me, falling asleep again almost immediately.
Ambien, which is a trade name for the generic drug zolpidem, works by enhancing the action of a neurotransmitter (or a chemical used to transmit signals from brain cell to brain cell) called gamma-aminobutyric acid (GABA). While most neurotransmitters stimulate brain activity, GABA actually inhibits brain activity. The ability to inhibit neural activity is absolutely crucial for brain function. Without it, each thought or sensation or active neuron would trigger a full-blown seizure. The brain must have some mechanism of terminating nerve impulses so they don’t just keep firing over and over again.
Neurons talk to one another via chemicals. If a neuron’s job is to activate other neurons, it’ll usually send out a neurotransmitter called glutamate. Glutamate is like a party invitation, and other neurons get all excited when they receive their glutamate invitation. However, if a neuron’s job is to shut the party down, it releases GABA. GABA is like a cease-and-desist notice. It’s like the cops knocking on your door at 3 a.m., busting up the party. So glutamate and GABA (along with a host of other neurotransmitters) work together to regulate brain activity. When you take an Ambien, the inhibitory effects of GABA take over, allowing the brain to slow down. This helps you fall asleep.
However, the “sleep” you get on Ambien is not the same as natural sleep. This is because natural sleep is a very active process requiring all sorts of highly organized brain activity. Inhibiting brain activity may allow you to fall asleep, but it can also stunt your brain’s ability to progresses through the normal sleep cycles. So, like any drug, Ambien has a bunch of risks along with the benefits. It works great for short-term use, to help quiet a noisy brain so that sleep is possible. It’s not so great to use every night, or to help someone stay asleep. And, as my bathtub experience demonstrates, it’s mighty powerful. Tinkering with the brain’s excitatory/
So there you have it. GABA. Now you can rest easy.
Vitals & Bits #10: Piloerector Muscles
By Whitny Doyle, RN [ Fri Jul 16 2010 11:47 AM ]
You know that feeling you get on a beautiful Albuquerque summer evening, when dark purple clouds sit heavily on the northern horizon while the setting sun jettisons the vast western sky with its searing pink and orange afterthoughts? Ok, so I’m no lyricist. But you know what I mean. Our anxiety-riddled, consumption-driven, Facebook-centric modern lives are occasionally punctuated by moments so stunning that your hair literally stands on end.
The “hair standing on end” sensation of life’s finest “Aha!” moments is brought to you courtesy of your arrectores pilorum, or the small muscles attached to your hair follicles. When these muscles contract, they tug on your hair follicles, which causes your hair to stand on end.
The arrectores pilorum, or piloerector (pilo meaning “hair” and erector meaning, um, erection) muscles are not under voluntary control. These muscles are micromanaged by your autonomic nervous system, or the branch of your nervous system that does all kinds of cool crazy shit on its own without you thinking about it (like controlling your heart rate or digestive muscles.)
Certain physical sensations, like cold, will stimulate your autonomic nervous system to activate your piloerector muscles. This is because other furry mammals, like cats and dogs, control their body temperature by puffing up when they’re cold. This allows their fur to trap more body heat. Unfortunately (or rather, fortunately), humans don’t have enough hair to make piloerection an effective method of insulation. Because of this, the ability to piloerect is probably vestigial.
Emotionally-based sensations, such as fear, excitement, or awe can also stimulate the autonomic nervous system to activate the piloerector muscles. While we humans experience this “hair standing on end” sensation as a rather cosmic sixth sense, it is probably also a vestigial function of our hair follicles. You’ve probably seen a cat puff up when he’s spooked. Aside from being hilarious, piloerection allows cats to appear bigger and tougher when they encounter potentially harmful entities, like a neighbor’s dog or a rogue Tickle Me Elmo. Again, humans don’t have enough hair to make piloerection a very useful method of intimidation (though I am having fun picturing rival sports teams puffing up their hairdos as a form of pre-game posturing.)
Still, thinking of the itty-bitty, eager little muscles attached to my hair follicles fills me with appreciation for the fascinating minutia of the human body. While piloerection may not serve a definitive purpose in the human body, it at least allows me to feel all goosebumpy and electric when I contemplate the mind-warping mysteries of life.
Vitals & Bits #9: The Nipple
By Whitny Doyle, RN [ Fri Jul 9 2010 9:00 AM ]
As a former maternal-newborn nurse, I’ve witnessed a variety of behaviors from new parents. These behaviors run the gamut from utterly predictable to amusingly zany. Some new moms ask for a beer the minute the baby has exited the birth canal, while others bedazzle their hospital rooms with unlit incense and prayer beads. But “new mom” behavioral quirks pale in comparison to what I’ve seen new fathers do.
While most fathers-to-be offer support, love and respect during the childbirth experience, some men seem to have poorly calibrated barometers for appropriate behavior. These inappropriate behaviors often involve their partner’s breasts or nipples. Why the nipple is so often the target of poor behavioral choices by men is still a mystery to me, but perhaps it has something to do with the fact that in our culture, the female breast is seen more as an iconic sexual object rather than a functional anatomical structure. It might also have to do with general lack of knowledge about how the breasts and nipples work.
For instance, on more than one occasion, I’ve witnessed men try to suck on their wives’ nipples during labor. While it’s true that nipple stimulation can help jumpstart a waning labor, I don’t understand why a man would choose to attempt this maneuver while the baby is halfway out of the birth canal. Nor do I understand why a man, lacking breasts or any medical background of his own, would criticize his girlfriend’s breastfeeding attempts and coach her on doing it “his way.” I’ve also seen men giggle childishly, crack dirty jokes or become visibly angry while their partner attempts to breast feed for the first time.
I was teaching one new mom how to get her baby latched on to her breast with the father reached out and pinched the tip of his wife’s nipple. “Ouch!” she exclaimed.
“Why on Earth did you do that?” I asked the man.
“I wanted to see milk squirt out,” he replied, shrugging.
Like many people, this guy thought that pinching the tip of the nipple would cause milk to squirt out like the stream from a water gun. His behavior betrayed not only a lack of sensitivity to his partner but also a lack of knowledge regarding the anatomy and physiology of the human body. Believing that the tip of the nipple is a singular milk spout is a pretty common misunderstanding, and I have found that lack of “nipple knowledge” occurs frequently among both men and women.
I explained to the man that contrary to popular belief, the female nipple doesn’t contain one hole in the middle. Instead, the whole nipple is studded with pores through which milk exits the breast. These pores are outlets to the lactiferous (milk-producing) ducts within the breast.
A breastfeeding baby doesn’t withdraw milk from the breast by sucking in the way that one sucks through the straw. Rather, suckling is more like a coordinated, rhythmic motion of the mouth, tongue, and jaw designed to compress and “milk” the lactiferous ducts. The baby has to get as much of the areola (or darkly-pigmented skin encircling the nipple) in her mouth as possible in order to compress these ducts and draw the milk out. It’s important that the baby get as much of the areola in her mouth as possible because the pigmentation of the areola roughly delineates where the ducts of the mammary glands are.
A baby who is just hanging on the tip of the nipple won’t have her mouth far back enough to compress the ducts and therefore won’t get any milk, just like squeezing the very tip of a tube of toothpaste won’t get you any toothpaste.
Also contrary to popular belief, breastfeeding isn’t a “natural, instinctual” process for most moms and babies. Breastfeeding is hard! Although I’ve seen a handful of first-time moms successful latch baby on the breast and continue breastfeeding without problems, this seems to be the exception to the rule.
There are a few reasons why breastfeeding is more of a challenge than an instinct. While babies are born with a suck reflex, the coordination of sucking, swallowing and breathing is a learned skill requiring sufficient neurological maturation to achieve. Breastfeeding is also a learned skill for moms, who often face obstacles like anatomical mismatch between the size of baby’s mouth and the size of mom’s nipple. Moms also have to learn how to position baby, latch baby onto the breast and read infant feeding cues (which seem totally inscrutable at first). Anxiety and misinformation don’t help matters.
I’m not trying to compare women to cows here, but we’re all mammals, so anyone who has ever milked a cow will have a good feel for how the lactation process works. Milking a cow doesn’t involve just squeezing the cow’s teat. Instead, your hand gently compresses from top to bottom and then pauses to allow the milk ducts to refill before repeating the motion. Milking a cow isn’t an intuitive, instinctual motion. It’s actually kinda difficult and requires practice before you get the feel for it. Similarly, breastfeeding requires learning and practice. Luckily, most mom and baby dyads, with a little appropriate guidance and patience, will totally rule at breastfeeding after a week or so.
Men who are curious about how lactating breasts work are advised to take a trip the dairy farm. Practicing on a cow is more socially acceptable than trying to suck, pinch or manhandle your partner’s nipples in the labor and delivery room.
Vitals and Bits #8: Bone Marrow
By Whitny Doyle, RN [ Mon Jul 5 2010 4:13 PM ]
J.R. breezed confidently into the exam room, snapping her gum and chatting up a storm about pedicures with the nurse. By all accounts, she looked like your typical high school cheerleader: ponytail, muscular legs and a quick smile.
J.R.’s parents brought her to the doctor’s office because she’d complained of feeling unusually tired during cheer practice over the past couple of weeks. Other than that, she insisted that she felt fine. Her bright demeanor suggested excellent health. The doctor figured that J.R., like many teenaged girls, was probably anemic. She ran a few tests to check for anemia and for a common viral illness called mono.
When J.R.’s blood test results came back, the doctor stared at them for few minutes in disbelief. The nurse walked into the doctor’s office and saw the doctor sitting there motionless at her desk, jaw agape and eyes wide, staring at the computer screen.
“Oh shit,” the nurse exclaimed. “It must be really bad.”
And it was. J.R.’s white blood cell (WBC) count was through the roof. A normal WBC count doesn’t usually exceed 10. An elevated WBC count, such as 25, suggests infection. But a WBC count approaching 100 suggests leukemia, or a relatively rare type of cancer in which white blood cells undergo uncontrolled proliferation. An extremely elevated WBC count like this is a medical emergency, since the increased concentration of white cells in the blood stream can clog up small vessels like those in the kidney and brain.
The doctor called J.R.’s parents. She told them about J.R.’s elevated WBC count, and instructed them to take their daughter to the emergency room immediately. She hung up the phone with a heavy heart and cradled her head in her hands.
After the emergency room, J.R. would be hospitalized. She would undergo chemotherapy and radiation to kill off the cancerous white blood cells. Eventually, she would need a bone marrow transplant to help repopulate her body with healthy blood cells.
Mother Nature, in her infinitely creative wisdom, decided to utilize the snug, protected space inside of our bones as a nursery for newborn blood cells. Blood cell birth occurs in the bone marrow, or the spongy tissue inside our bones.
There are two different types of bone marrow: red and yellow. Red bone marrow produces blood cells, and yellow bone marrow is composed mainly of fat cells. At birth, all bone marrow is red. As we age, some red bone marrow (such as the marrow inside the long bones of our legs) is replaced with yellow marrow. About half of adult marrow is red, typically found in flat bones like those of the hip and shoulder blade.
A bone marrow transplant involves eliminating the recipient’s cancerous blood-forming cells and replacing them with healthy donor cells. The recipient and the donor must have compatible tissue types. Unfortunately, no one in J.R.’s family was found to be a compatible match. J.R. and her family clung to fervent, anxious hope that her doctors would find her a match in the bone marrow donor registry.
After several extremely tense weeks, J.R.’s doctors identified an appropriate donor. Several weeks after that, an extremely ill J.R. received a life-saving gift of healthy marrow cells from a total stranger.
These days, most bone marrow donation procedures are not all that different from a simple blood donation. If you register to donate marrow and are selected as a donor, you’ll be give drugs for a few days that tell your bone marrow to increase its productivity and churn a bunch of health new cells out into your circulatory system. These cells are then collected through a needle that goes into a vessel in your arm.
Some patients, like children or those with certain types of leukemia, fare better with a more traditional bone marrow transplant, in which donor marrow is harvested directly from the hip bone. If you donate this way, you’ll be numbed up before a doctor inserts a special needle into your hipbone to withdraw marrow cells.
Both procedures are minimally invasive with a very low risk of complications.
If you are interested in joining the national marrow donation registry, visit marrow.org for more information. I joined a few days ago, and it was easy breezy. The registry is especially in need of participants who belong to ethnic minority groups, such as Hispanics, Native Americans and African Americans.
Vitals and Bits #7: The Phagocyte
By Whitny Doyle, RN [ Fri Jun 25 2010 1:56 PM ]
One liter of my blood harbors 6 billion:
a. Red blood cells
b. Molecules of alcohol
c. Professional phagocytes
d. Estrogen particles
e. Undocumented workers
If you answered C, you’re correct! Yay! Now collect your prize and keep your trap shut whilst I drop some knowledge on you.
Phagocytes are white blood cells that eat bad things like bacteria or dangerous substances. The ability to engulf harmful invaders means that phagocytes play a crucial role in immunity.
Many cells can perform phagocytosis (or the act of engulfing a foreign substance), but that’s not their primary gig. A professional phagocyte, on the other hand, is much like a competitive eater in that its only job is to ingest nasty stuff.
In the human body, professional phagocytes come in several different flavors. These include the roving monocyte, the voracious macrophage, the badass neutrophil, the flashy dendritic cell and the multitalented mast cell. These cells are able to sniff out the bad guys by sensing the chemical signals of invaders like bacteria. Damaged or dying body tissues also release chemical signals that alert phagocytes to move in and help with the cleanup effort. In this way, phagocytes facilitate healing and repair.
Not all invading organisms are vulnerable to phagocytes. Like Jonah sitting inside the whale’s belly, some bacteria have learned to actually live inside the phagocytes that eat them. Others have learned how to evade or injure phagocytes.
Generally speaking, though, the ability to phagocytose, or eat, is a fundamental prerequisite to life. Cellular ability to phagocytose evolved early on in the tree of life and has been incorporated into nearly every single life form since then.
You’ve probably touched a few million of your own phagocytes if you’ve ever popped a juicy zit. Pimple pus comprises a bunch of neutrophils that have eaten bacteria and then died, along with a bunch of dead macrophages that have eaten the dead neutrophils. Phagocytes eating phagocytes! I love it.
I feel a particular affinity for my phagocytes, given our mutual love of bingeing. I daresay my diet of cupcakes and merlot is a tad more delicious than the professional phagocyte’s diet of bacterial toxins and dead tissue. But to each her own, I suppose. Bon Appetit!
Vitals and Bits #6: The Cervix
By Whitny Doyle, RN [ Wed Jun 16 2010 3:11 PM ]
The cervix, or the lower segment of the uterus, is sort of like a gateway into the uterus. The pear-shaped body of the uterus tapers into the cervix, which protrudes into the upper part of the vagina. During a pelvic exam, health care professionals can use a speculum to open up the vagina and look at the cervix. We swab it and scrape it to test for cancerous cells (a.k.a. a Pap smear) or bugs like Chlamydia.
The cervix has some cool party tricks. Normally the cervical os, which is the opening at the center of the cervix, is closed to prevent infections and other junk from climbing up into the uterus. But the os opens a little to allow menstrual fluid out every month. The cervix also opens in a major way during childbirth, to allow the baby to exit the womb.
The cervix can also produce fluid. During the time of the month when a woman has ovulated and is most fertile, her cervical fluid has a special thin texture that actually helps guide sperm up into the cervix to increase chances of fertilization. But during “infertile” times of the month, such as before ovulation, the cervix produces a thick acidic fluid that can kill off sperm or other potential uterine invaders. The cervix can also change its position and texture to either help or hinder sperm, depending on where a woman is in her menstrual cycle.
Finding a cervix during a pelvic exam can be really tricky. Sometimes you insert the speculum and open it up and the cervix pops into view, perfectly centered. But oftentimes the cervix isn’t so cooperative. Some women have a cervix that points to the ceiling, or toward the floor, or way off to the left or the right. These are all normal positions. If you’ve ever been told you have a tilted uterus or a cervix that’s difficult to find, it doesn’t mean you’re abnormal or less fertile than other women. In the vast majority cases, it’s perfectly normal and healthy to have a wonky womb.
The cervix, for all of its neat features, has some vulnerabilities too. It’s especially prone to infection by sexually transmitted infections. Some of these infections, like gonorrhea, can clear up after a course of antibiotics. Others, like human papillomavirus, like to hang around and cause problems like cervical cancer.
You can keep your little cervix happy and healthy by using condoms during intercourse and receiving your regularly scheduled Pap tests. The new Pap guidelines say you don’t have to have your first Pap test until age 21, and you don’t necessarily need one every year (more like every other year or once every three years, depending on your age group) unless there’s a problem. You can access the American College of Obstetrics and Gynecology’s new Pap guidelines here.
Women between ages 9 and 26 are also candidates for the HPV vaccine. This vaccine prevents women from catching the strains of HPV most likely to cause cancer. There are two vaccines on the market now: Gardasil and Cervarix. I think these vaccines will greatly reduce the financial and emotional burden of abnormal Pap tests and cervical cancer over the next few decades.
Vitals and Bits #5: The Penis
By Whitny Doyle, RN [ Fri Jun 4 2010 1:58 PM ]
I walked into my patient’s room, shaking slightly and perspiring liberally. In one hand I held a urinary catheter. In my other hand, a worn version of the King James Bible.
“Pray with me?” I asked my patient. He looked at me solemnly and nodded. I placed the Bible on the bed between us and reached for his hand. He closed his eyes and gripped my sweaty palm with surprising strength.
“Dear Lord,” I began, “in mere moments, I will be inserting a urinary catheter into this innocent man’s penis. I have never done this before, and I am praying that you will guide my hand with steady resolve. May this humble little catheter find its righteous path into my patient’s bladder, thus relieving him of his persistent and painful urinary retention. Amen.”
“Amen,” my patient echoed.
OK, that didn’t really happen. Here’s the real story: I walked into my patient’s room, shaking slightly and perspiring liberally. In one hand I held a urinary catheter. My other hand was empty.
“Mr. Patient, the doctor wants you to have a urinary catheter placed to help relieve your urinary retention. This will also give us an accurate measurement of your urine output.”
Mr. Patient eyed me suspiciously.
“You’ve done this before, haven’t you?” he asked.
“Oh yes,” I lied through my teeth. “A million times.”
After opening the catheter kit and preparing all the various components, I lifted the man’s gown and located his penis. In case you’re unfamiliar with the term penis, it is used to refer to a semi-mythical organ that has eluded scientists and philosophers for centuries. But I, a brand new nurse only seconds out of nursing school, managed to find it all by myself.
“OK, I’m going to talk you through this,” I said to my patient. “First, you will feel my hand on your penis.”
The man snorted. “My lucky day,” he replied.
“Next,” I continued, pretending that I wasn’t flustered, “you’re going to feel some pressure at the opening of your penis.” It was at this point that I introduced the catheter, which I had coated with copious amounts of medical-grade KY lubricant, into his urethra. My patient winced.
“You’ll feel me advancing the catheter past your prostate,” I said. The man winced again and uttered some creative profanity when the catheter met resistance. The prostate, which nearly wraps around the urethra just below the bladder, can obstruct the urethra if it’s enlarged. Nearly all men have some prostate enlargement as they age.
I pointed my patient’s penis towards the ceiling and slowly lowered it as I tried to advance the catheter further. This maneuver sometimes allows the catheter to slip past. Aha! I was in luck. The catheter began to advance easily again, and soon the bag attached to it began to fill with urine. This is a sign that the catheter is indeed in the bladder, where it should be. Accurate placement of the catheter was confirmed by the man’s face, which filled with relief as the painful distention of his bladder began to ease.
“We got it!” I exclaimed, unable to hide my happiness at successfully inserting my very first urinary catheter into a penis. I secured the catheter in place and turned to the man, beaming.
The man raised his eyebrow.
“Judging by your excitement,” he said, “I’d say that it was better for you than it was for me.”
If you’re a man reading this story, you might have a horrified expression and a protective hand guarding your crotch right about now. Your penis wasn’t meant to be penetrated, right? In fact, quite the opposite. So how could my patient tolerate such a violation of his manhood? And why on earth would I write about it?
We all know that the penis is a timeless icon of human power and virility. A whole culture of male lore surrounds this famous appendage. It is the stuff of poetry, of architecture, of war and civilization, of life and death. The penis, in all of its symbolic might, is a fundamental feature of human existence. This is because of its vital role in sex, which is something I hear people like to do from time to time.
And yet, at the end of the day, when you’re old and fighting the inevitable physical decline of age, you’ll be reminded of that other penile function, the one that doesn’t involve the grit and glory of male sexuality. When you’re standing over the toilet, straining with that characteristic “stop and go” urinary hesitancy that so many men suffer, you’ll develop a greater appreciation for your little guy’s role in urination. You may even wake up one day and find that you’ve become more concerned with passing urine than with sex. And no one would blame you. Because, let’s face it, no man wants to have a trembling young nurse shove a rubber tube up his penis just so he can relieve his bladder.
Vitals and Bits #4: The Xiphoid Process
By Whitny Doyle, RN [ Fri May 28 2010 4:39 PM ]
I’ll be honest with you. I’m totally going to phone it in with this blog entry. You may be asking yourself, why would Miss Diagnosis disappoint her loyal readers with a half-assed blog entry? Well, it’s simple. I’ve been really busy with graduate school, and I’m thoroughly exhausted.
But it’s not as though anyone’s life depends upon my consistent delivery of high-quality blog entries. My lack of effort won’t result in someone’s death.
I’m used to working in a high-stakes environment where even a mild hangover can result in a grievous medication error that lands one of my patients in the ICU. This is probably why blogging is so fun for me. I’m allowed to suck at it every now and again without the fear of seriously harming anyone (other than my future self). So without further ado, allow me to introduce you to a little bit of anatomical real estate known as the xiphoid process.
I chose to write about the xiphoid this week precisely because there’s not much to say. It’s a little piece of cartilage that protrudes from the bottom of your sternum (breastbone). During adulthood, the cartilage is gradually replaced with bone, which is a process called ossification.
So it’s kinda like this bone-esque thingie in your chest that doesn’t do much. Some people have a uniquely shaped xiphoid process, which is a genetic trait. This means it can be used to help identify dead people. Also, it’s best not to press on someone’s xiphoid process if you’re giving them CPR, since it can puncture the diaphragm. And that’s about all she wrote.
The xiphoid process. Now you know.
Vitals and Bits #3: The Appendix
By Whitny Doyle, RN [ Fri May 21 2010 11:48 AM ]
At the beginning of each new shift, certain members of the hospital staff will receive a pair of freshly laundered scrubs to wear while working. If you’re one of the lucky ones, you’ll be handed a pair of ancient scrubs that have been laundered a billion times. Over time, the unforgiving hospital washing machines pulverize the stiff green scrub material to unbelievably soft oblivion. Old scrubs that are nearing retirement are much more comfortable and better fitting than the awkwardly crisp new scrubs. They’re like a treasured, paper-thin vintage tee shirt. Unfortunately, just like a perfect vintage tee, the ideal pair of worn scrubs is a pretty rare find.
One night while I was working night shift in the newborn nursery, I noticed that one of my favorite pediatric residents had managed to get his hands on a pair of the old soft scrubs. The thing about the soft scrubs, though, is the decades of laundering have also shrunk them to about three quarters of their previous size. My resident, who we shall henceforth refer to as Dr. Abs, kept tugging at the hem of his shrunken scrub top, since it was an inch or so too small for him.
Like many residents, Dr. Abs liked to pass the time during a slow night shift by telling dirty jokes with us at the nurses’ station. That night, around 3:30 a.m., Dr. Abs succumbed to a fit of yawning after delivering the punch line to some filthy joke about Tipper Gore. As he yawned, he raised his arms over his head and the hem of his short scrub top untucked itself and traveled northwards. The five nurses hanging around the desk were held spellbound for the few brief seconds that his bare, toned abdomen revealed itself. I couldn’t help but notice a finger-length scar on his lower right abdomen.
“Is that where Tipper Gore bit you?” I asked him, pointing to the scar.
He glanced casually down at the scar.
“Actually, I had to leave my appendix in Thailand a few years ago,” he replied.
The appendix is an enigmatic segment of bowel-like tissue that juts off of the colon, near the place where the small intestine meets the large intestine. The appendix does not perform any digestive function, and so there are a few theories out there as to just why the heck we have an appendix anyway.
The older argument is that the appendix is vestigial, meaning it used to be an organ that served a purpose in our ancient humanoid ancestors but lost its function as modern humans evolved. Newer theories propose that the appendix, which is a rich reservoir of lymph tissue and healthy intestinal flora, plays a role in immunity and digestive health.
Whatever function the appendix may or may not serve, people who have had theirs removed seem to do just fine without it. In fact, the appendix is a relatively high-risk accessory to be sporting on one’s colon. The appendix has a nasty habit of becoming inflamed or infected, which is the case when someone gets appendicitis. Appendicitis is life-threatening, since an inflamed appendix can rupture. A ruptured appendix spills a slew of bacteria into an abdominal cavity that’s supposed to remain sterile. This means people can become septic and die if their appendix decides to go all supernova on them.
As it turns out, my pediatric resident’s appendix had ruptured while he was vacationing in Thailand. Although he was a medical student at the time, he didn’t put two and two together and waited until he was on the brink of death before dragging himself to a medical clinic in the small Thai village where he was staying. The staff at the clinic recognized what was happening right away, despite a pretty significant barrier language. They started antibiotics and transported him to the main hospital for surgery with lightening speed. He was in surgery that same day, and remained in the Thai hospital for almost two weeks while he recovered from his surgery.
After telling us his story, Dr. Abs stood up and stretched one more time.
“These scrubs are so comfortable,” he said mid-yawn. “They feel like pajamas. I’m going to have to take them off if I’m going to be able to stay awake.”
Five grinning nurses nodded in agreement.
Vitals and Bits #2: The Epiglottis
By Whitny Doyle, RN [ Fri May 14 2010 5:12 PM ]
Some body parts, like lungs and the brain, have relatively fancy, white-collar jobs. Other body parts, such as the rectum, take care of the dirty work. Still, other body parts perform their humble trade dutifully without complaint, like a crossing guard who has been ferrying children safely across the street for forty years, rain or shine. The little epiglottis falls squarely into this latter category. And, like so many marvels of nature, it’s easy to take the epiglottis for granted. It just kinda hangs out, doing its thing, and typically its absence is far more noticeable than its presence.
The epiglottis is a flap of cartilage (the type of firm yet flexible connective tissue found in your ear) covered in mucus membrane (or the kind of specialized “wet” skin found in places like the mouth and the vagina.) It is attached to the root of the tongue, way back there inside the throat. The epiglottis is like a lid that sits above the larynx, or voice box. The larynx sits on top of the trachea (aka the windpipe) and is part of the airway. So the epiglottis is essentially a lid perched on top of the airway, but the lid always remains open unless the person is swallowing.
The act of swallowing moves the larynx upwards and causes the epiglottis to fold downwards, so that the epiglottis covers the opening of the larynx. With the airway closed off, food is directed down the esophagus instead, which is the tube that connects the mouth to the stomach. This way, the windpipe remains open during normal business hours so that the person can breath, but is briefly closed off during swallowing to prevent food or fluid from going down the wrong tube and entering the lungs. This is what allows us to eat and drink and make merry without choking to death.
When it’s not called to action during swallowing, the epiglottis also lends a hand to the rest of the body parts in its neighborhood to help out with things like gagging and coughing.
Problems with the epiglottis most frequently arise from dysfunctional swallowing or from infection.
Humans swallow many hundreds of times per day without even thinking about it. But swallowing is actually a pretty high-stakes activity that requires very complex coordination of numerous nerves, muscles, and other bits and pieces. Stroke victims will often lose their ability to swallow properly. When the epiglottis does not completely cover the airway because of faulty swallowing, people end up with food and water and all kinds of nasty stuff in their lungs. Food and junk going down the wrong tube is called aspiration. Significant aspiration will oftentimes lead to pneumonia, so many stroke victims with difficult swallowing will end up with an aspiration pneumonia.
Another problem we see with the epiglottis is infection, which we call epiglottitis. We see this most often in children. Certain bacteria, like Haemophilus influenzae, or Hib, can infect the epiglottis. When this happens, the epiglottis can swell up and occlude the airway. Epiglottitis, which can cause a high fever and a sore throat, is a medical emergency. Difficulty breathing and drooling are red flags for epiglottitis. Fortunately, use of the Hib vaccine in children has reduced the incidence of epiglottitis.
Although the little epiglottis is not the fanciest body part on the block, it makes the two very important acts of breathing and eating possible. And hey, I’m willing to raise my glass and toast anything that lets me enjoy my cupcakes and boxed wine without fear of choking to death.
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