Saturday, April 23, 2011

Because I know you've been wondering...

Here we are, waiting out our time before Spiff graduates from medical school and we move on to the next stage in our lives. Spiff is completely done with classes, and it's awesome/strange to have him home with us. He's not quite sure what to do with himself, and the rest of us are not quite sure what to do with him. We're trying to be creative about our activities and have a list of things to do before we move, including family outings and yummy places to eat. We tried a burger joint last night and enjoyed our bottomless mugs of house root beer and cream soda (or "juice" to a certain little person who came with us). So, besides the obvious planning for the move, going through and sorting our belongings, and beginning to pack, here's what we've been up to lately.

Spiff recently discovered a new app for his i-pod. It's a Touch Mouse that will control the cursor on the laptop. It's handy for controlling the volume on the computer when we're watching shows on Instant Netflix, thus fixing our lack of remote control problem and making it so that we don't have to walk all the way across the room to manually push "play next episode." It's also a handy little tool for messing with one's spouse as she is trying to write a long-overdue blog post. I have found myself wondering why the cursor isn't where I left it, how I could possibly have typed certain letters that are on the screen, and why the word I just typed isn't there anymore. It's really great entertainment for someone who doesn't need so study all that much at the moment.

We have a rental contract on a house! I scoured rental listings for about a month, stressed about it, dreamed about it and got super frustrated with the whole darn house-hunting thing. Then we happened upon the perfect house for us. Hopefully. We haven't seen it in person (although my sister did), but I'm in love with the pictures. I'm super excited about the finished basement and laundry room, and our very own, brand new (well, 15-years old and used) $100 washer and dryer. I'm just so relieved to have our living situation nailed down for the next year, and not having to worry about house hunting for a whole year. Great. We get to do this again next year. I can't wait.

Hobbes is three months old already. I can't believe it! Gunner's infancy seemed eternal. I swear it took him a year to reach each month milestone, and Hobbes's little life seems to be flying by. He's still a dream baby, and I can't believe how lucky I am to have such a mild-tempered baby who eats and sleeps well. He has started to smile and laugh at us, he's ticklish, he's interested in his new little toys I hung over his bouncer chair, and he can roll over to his side. Big stuff for a little guy! His eyes are still blue, and I'm secretly hoping they stay that way. I check them for signs of Hazelization every day.

Gunner is learning how to behave around his little brother. It has taken all three months for him to figure out how to be soft with the baby, but he is finally figuring it out, with lapses in concentration, of course. Two-and-a-half-year-old Gunner is hard. He's emotional, whiny, needy, and naughty. There have been times in the last couple months that I have wanted to quit and run away. But there have also been a lot of times that I'm totally blown away by all he has learned lately. I love listening to him sing to himself, and I'm always amazed when I hear him singing a song that we didn't teach him. I love nursery at church and his little mommy co-op preschool for that. I loved the other day when I figured out that he was playing a joke on me. His little sense of humor is blossoming. I love how he can't quite figure out how to use prepositions or pronouns. I love how inquisitive he is, even if we have to answer the reflexive question "Why" about a million times each day. He's a pretty neat little kid, even if he does make me want to pull my hair out multiple times a day.

One quick story to illustrate my point: On our drive to the restaurant last night, Spiff and I noticed just how observant Gunner is to noises and sounds around him. We were listening to some John McCutcheon children's song that Spiff grew up with (which are pretty darn good and something I would recommend to anyone with kids). The songs are filled with all different instruments in the accompaniment, and as we drove along, a new song would come up and Gunner would comment. Here was our conversation:

Gunner: "What was that? That larlarlarla (with his tongue)?"

We replied, "Oh, that instrument? That was the hammered dulcimer."

On the next song, G: What was that? The huh huh huh?

Us: That the Tuba

Next song, G: What was that? Bling bling bling?

Us: That was the Banjo

We realized that he is so very observant about everything around us. I can recall countless times when we have been sitting around our living room, and he asks about sounds, always with a "What was that?!" "Oh, Gunner, that was just the neighbors going down the stairs." "Oh, that's a lawnmower going outside." "That a bird singing." Seriously, so very observant.

Except with us. He has an uncanny ability to tune us out. He has gotten to where he hardly listens to a word either me or Spiff says. We know he hears us. He just chooses not to listen.

Like I said, he's so naughty and so awesome at the same time.

Oh, and by the way, Spiff is a genius. He taught Gunner how to take bites of food and wash them down with a drink of milk. It takes some coaxing still, but we have actually had some success getting Gunner to eat his meals (or at least a couple small designated bites). It is glorious! Thank you, Spiff!

That's probably enough rambling for now. We're going to go dye Easter Eggs. Gunner is ready for it, clad in only a diaper. Happy Easter!

Sunday, April 17, 2011

Morgue III

Monday: 3 heroin overdoses. Most interesting tattoo to date: a lion-headed man having 'relations' with a monkey while a nude woman crawled around on all fours beneath them.

Tuesday: no cases. Gave a presentation on non-cardiogenic pulmonary edema in heroin OD.

***Warning: gratuitous physiology lecture ahead ***

Basically about 80-90% of the fatal OD's have this pink frothy fluid fill their lungs, sometimes to the degree that it comes out their nose and mouth. Why? The answer isn't fully known, despite this phenomenon being first described by Sir William Osler in 1880.

From a physiologic standpoint, there are several reasons that fluid can be in the lungs. It can come from 2 possible places, from the lungs themselves or from the outside world. If water is introduced through the airway, as in drowning or near drowning, then obviously the lungs can have fluid in them. Fluid can also come from within the lungs themselves. Blood flows through the lungs from pulmonary arteries, to capillaries, then to pulmonary veins. If the venous drainage is diminished, then the fluid backs up and leaks out of the capillaries because the hydrostatic pressure is increased, thus causing edema. This is analogous to kinking a hose, and water leaking out of the body of the hose. A situation which would cause this is failure of the left side of the heart, which normally receives its blood from the lungs. This would be an example of "cardiogenic" pulmonary edema, because it is caused ultimately by the heart. The inability of the left heart to pump causes fluid to back up and leak.

The foamy pulmonary edema seen in heroin overdose however, is non-cardiogenic i.e. does not originate from intrinsic problem with the heart. There are several schools of thought as to what causes it. First, a word as to non-cardiogenic causes of pulmonary edema. The pulmonary capillaries are where gas exchange takes place, where oxygen enters the blood and carbon dioxide leaves. By necessity, the membranes separating blood from air are thin, so that the gasses can move easily. If these membranes are damaged or rendered more permeable, then contents of blood can leak out. Blood is made up of primarily water, but also has proteins and of course red blood cells. If the holes in the pulmonary capillary membrane are small, then only water and protein leaks out. If the holes are bigger, then red blood cells themselves can leak out, tinging the fluid pink or even red, depending on how much blood extravasates (leaves the circulation).

What causes holes these holes then? Histamine is one postulated player in this little drama. Most people are familiar with the effects of histamine through allergies. With hay fever or seasonal allergies, the eyes and nose have clear discharge, and sneezing is commonly a symptom. The clear runny discharge is caused in part by histamine which makes the blood vessels in the nose dilate, causing congestion. The blood vessels are also rendered more permeable, so they leak fluid, contributing to the runny nose (not the only component of the nasal discharge however). This is why you take anti-histamines like Claritin or Zyrtec to alleviate hay fever symptoms. So, we see that histamine is able to make blood vessels more permeable and leaky. There is lots of histamine present in the lungs, so one thought is that histamine released in the lungs causes the pulmonary capillaries to be more leaky and causes fluid to leak from the blood vessels into the airway.

How does histamine relate to heroin though? Heroin is an opioid, which means that it is a synthetic derivative of morphine, which is the natural derivative of the Papaver Somniferum poppy, the source for opium. Opiates of all kinds can cause release of histamine in varying degrees. Morphine is especially known for this, histamine is responsible for the itchy sensation some people encounter when they receive morphine. Since heroin is diacetyl morphine (morphine with two synthetically added acetyl groups. I won't bore you with more organic chemistry). So, heroin, which is a synthetically modified morphine, can cause histamine release in the lungs, which increases permeability of the blood vessels, causing pulmonary edema.

(For the medical purists, I acknowledge that this is a simplification. The bulk of my readers are lay people married to medical students. For some reason, they are also afraid to post comments when I post.)

*** End of gratuitous physiology lecture ***

Wednesday: Car accident. Luxury sedan v. semi truck.

Thursday: No cases
Friday: Heroin OD, GI bleed secondary to duodenal ulcer, questionable pancreatic/ GI neoplasm.


48 months of studying, lectures, clinical responsibilities has come to an end. I now have 5 weeks before we move, and begin internship in June.

Saturday, April 09, 2011

Funny Conversations

During lunch today I had the following dialogue with my 2 year old son:

G: Wassat daddy?
SS: That's the knife block.
G: Issa knife bock?
SS: yes.
G: Knife a sharp. Djanger. Knife for mommy and daddy, not little boys.
SS: that's right.
G: Djanger, sharp. A cutta me? I get hurt. Maybe die. Then I see Jesus and he hug me. Jesus love a me. I love Jesus.
SS: (unsure which part to respond to), uhh well, maybe. Knives are for mommies and daddies, and yes, Jesus loves you.
G: Give Hobbes a blessing? Give mommy a blessing?
SS: yes, in the past.
G: I love my noodles. More noodles please?

And with that we were off of toddler-level spirituality and back to the mundanities of life.

Friday, April 08, 2011

Morgue II

Monday: Floater. 3+weeks old. The body was green with decomposition, and the smell was unbelievable.
Obese lady OD'ed on Xanax.
GSW to head

Tuesday: Car accident, massive trauma.

Wed: Day in court, no cases.

Thursday: Self inflicted gunshot wound to heart.
Heroin OD

Sudden death secondary to cardiac arrest.

Friday, April 01, 2011

The Morgue

I'm on a forensic pathology elective at the moment which is something I chose to do because I figured I'd never have the chance to do something like this again. Our charming city being what it is, there is never a shortage of cases in the medical examiner's office. This week's collection of cases was as follows:

Monday: Self inflicted gunshot wound to left chest with .40 caliber pistol.

Non-accidental trauma 2 years ago. Just died of complications, so this counts as murder/manslaughter even though the inciting event was 2 years ago.

Tuesday: Heroin overdose. Despite what the word on the street is, packing your friend's crotch with ice will not revive them from a heroin OD. Naloxone might, but ice-crotch will not.

Wednesday: Alprazolam OD (Xanax) in a massively obese patient. People don't wear as much clothing at home as you think they might.

Self inflicted GSW to the head. Split the mandible, maxilla, and exited through the top of the head.

Thursday: Schizophrenic with seizure, unknown cause.

Friday: no cases.

Since it's sunny this weekend, I expect that people will be outside shooting each other again.

It's been an interesting experience, but oh the smell can be so strong.