TtINNITUS

Tinnitus

Introduction

Tinnitus is the perception of sound in the absence of external stimuli. The term comes from the Latin term tinnere which means ringing, but is used to describe sounds that are buzzing, roaring, pulsatile, or clicking in nature. The sound may be perceived as either unilateral or bilateral. Tinnitus may be the first or only symptom of a disease process which threatens the patient’s health or well being.
It is estimated that 40 million people in the United States suffer from tinnitus with 10 million of those severely affected. The prevalence is highest in 40-70 year-olds and it is more common in men than in women. Tinnitus can have a great impact on a patient’s quality of life. Ludwig Von Beethoven described his experience with tinnitus in a letter to a friend in 1801, “only my ears whistle and buzz continuously day and night. I can say I am living a wretched life.”
Tinnitus may be classified as either objective tinnitus, which may be heard by an examiner, or subjective tinnitus in which the sound is only perceived by the patient. Subjective tinnitus is much more common than objective tinnitus. Tinnitus may also be classified as pulsatile or nonpulsatile, with pulsatile usually indicating a vascular etiology.

Objective Tinnitus

Objective tinnitus is the patient perceiving sound produced by paraauditory structures which may be heard by an examiner. It may be either pulsatile or nonpulsatile in nature. Take a careful history from the patient including the relationship of the sound to the heartbeat, the quality of the sound, aggravating/relieving factors, associated hearing loss, and whether the sound is unilateral or bilateral. Possible etiologies include vascular abnormalities, Eustachian tube dysfunction, or muscle spasm.

Vascular Abnormalities

Tinnitus which is described by a patient as pulsatile or with a rushing sound may be of vascular origin. The sound is produced by the flow of blood through paraauditory structures. Vascular tinnitus may be either objective or subjective. Possible causes are arteriovenous malformations, vascular tumors, venous hum, atherosclerosis, ectopic carotid artery, persistent stapedial artery, dehiscent jugular bulb, vascular loops, cardiac murmurs, increased cardiac output (pregnancy, anemia, hyperthyroidism), Paget’s disease, and benign intracranial hypertension.
Arteriovenous malformations are congenital lesions. Types include communication of the occipital artery and the transverse sinus, the internal carotid artery and the verterbral arteries, the middle meningeal artery and the greater superficial petrosal artery, and those of the mandible, brain parenchyma, or dura. Pulsatile tinnitus may be the initial symptom, but AVMs can also be associated with headache, papilledema, or discoloration of skin or mucosa.
Vascular tumors which can cause tinnitus include glomus tympanicum and glomus jugulare. These are paragangliomas which arise in the middle ear or jugular bulb respectively. A glomus jugulare may extend up into the middle ear. When the mass involves the middle ear it may be seen as a reddish mass behind the tympanic membrane.
A venous hum may be present from increased or turbulent flow through the venous system. Possible causes include a dehiscent jugular bulb, transverse sinus obstruction, benign intracranial hypertension, or increased cardiac output from pregnancy, anemia, or thyrotoxicosis. A dehiscent jugular bulb may be seen on otomicroscopy as a bluish mass in the middle ear. Patients with benign intracranial hypertension are usually female, overweight and have symptoms of hearing loss, aural fullness, dizziness, headaches, and visual disturbances.

Patulous Eustachian Tube

In patients with Eustachian tube dysfunction in which the tube remains open abnormally, it is called a patulous Eustachian tube. Patients may describe the sound as an ocean roar in the ear which changes with respiration. They may have relief with lying down or putting the head in a dependent position. A tympanogram may show motion of the tympanic membrane with respiration.

Muscle Spasm

Palatal myoclonus is a muscular cause of tinnitus. It is caused by contraction of tensor palatini, levator veli palatini, tensor tympani, salpinopharyngeal, or superior constrictor muscles. It is described as a clicking sound which is rapid (60-200 beats per minute), repetitive, and intermittent. It is associated with multiple sclerosis, small vessel disease, tumor, and degenerative neurological disorders. The muscle spasms may be seen either transorally or transnasally. A plot of compliance as a function of time on tympanometry will show the rhythmic change in compliance of the tympanic membrane corresponding to the muscle contraction.
Idiopathic stapedial muscle spasm induced tinnitus is described as a rough, rumbling, or crackling noise which may be exacerbated by outside sounds. The tinnitus tends to follow a sound stimulus, is brief and intermittent.

Subjective Tinnitus

Subjective tinnitus is not able to be heard by an examiner. It is more common than objective tinnitus and is usually nonpulsatile in nature. Subjective tinnitus is associated with presbycusis, noise exposure, Meniere’s disease, otosclerosis, head trauma, acoustic neuroma, drugs, middle ear effusion, temporomandibular joint problems depression, hyperlipidemia, meningitis, and syphilis.
Conditions which result in a conductive hearing loss, such as middle ear effusion, otosclerosis, or cerumen impaction may decrease the level of external sound to the point where the patient is able to hear normal skull sounds. In these cases, treatment of the cause of the conductive hearing loss may alleviate the tinnitus.
Tinnitus which is sensorineural in origin does not have a clear physiologic explanation. It may be caused by abnormalities of the cochlea, cochlear nerve, ascending auditory pathway, or auditory cortex. Many theories of the origin of tinnitis have been proposed which generally involve hyperactive hair cells or nerve fibers activated by a chemical imbalance across cell membranes or decoupling of stereocilia. A neurophysiologic model of tinnitus has been proposed by Jastreboff. In this theory, tinnitus emerges as the result of interaction of a number of subsystems in the nervous system, with auditory pathways playing a role in the development and appearance of tinnitus as sound perception, with the limbic system responsible for the development of tinnitus annoyance. The perception of tinnitus provides negative reinforcement which enhances the perception of tinnitus and the perception of time the person is aware of its presence. This model has led to the development of tinnitus retraining therapy to habituate the patient to the tinnitus.
Depression has been shown to be more prevalent in patients with chronic tinnitus than in people who do not complain of tinnitus. Folmer et al have reported their finding that patients with depression and tinnitus rated their tinnitus severity higher than patients with tinnitus who did not have depression.

Drugs

Many drugs have been linked to tinnitus. Although almost any medication can be a possible cause of tinnitus the most frequently implicated drugs are the antinflammatories, antibiotics, and antidepressants. Both aspirin and quinine are associated with tinnitus. This tinnitus is high frequency, tonal in nature, and accompanied by a temporary threshold shift. The tinnitus is reversible with cessation of the medication. Aminoglycoside antibiotics are also often implicated as the cause of drug-induced tinnitus. Other medications include loop diuretics and chemotherapeutic agents such as cisplatin and vincristine. Any of the heterocycline antidepressants (i.e. amitriptyline, imipramine) can cause tinnitus. This is interesting because antidepressants have also been investigated for the treatment of tinnitus.

Evaluation

The evaluation of a patient with tinnitus should start with a carefully taken history. The patient’s description of the tinnitus is very important, it can provide key information during the initial evaluation. The quality of the sound, especially whether it is pulsatile or nonpulsatile, the perceived location, the pitch, the loudness, constant or episodic, onset, alleviating/aggravating factors, history of infection or trauma, noise exposure, medication usage, medical history, associated hearing loss/vertigo, family history of hearing loss and associated pain should all be topics of inquiry. Another very important factor is the impact of the tinnitus on the patient. There are several tinnitus-specific self assessment tools available for evaluating the perceived severity of the tinnitus to the patient. The Tinnitus Handicap Inventory is a 25 item survey that provides a total score and three subscale scores for functional, emotional, and catastrophic impact on the patient.
After a thorough history is taken a complete head and neck exam, as well as a general physical exam should be performed. Otomicroscopy should be performed to look for a middle ear mass or motion of the tympanic membrane with respiration. A glomus tympanicum can be seen as a reddish mass in the middle ear or a dehiscent jugular bulb may be seen as a bluish mass. With a history of pulsatile tinnitus, the physician should search for an audible bruit by auscultating the external canal with a Toynbee tube, and over the orbit, mastoid process, skull, and neck using the bell and diaphragm of a stethoscope. The heart should be auscultated for murmurs. The patient should perform light exercise to see if this increases the pulsatile tinnitus. Tinnitus of arterial origin will often worsen with exercise. Venous induced tinnitus may decrease with light pressure on the neck, turning the head, or with the Valsalva maneuver.
All patients may undergo audiometric testing including pure tone audiometry, speech discrimination, tympanometry, and acoustic reflex measurements. The pitch of the tinnitus may be matched by the patient to an administered pure tone. The loudness of the tinnitus may be estimated by having the patient adjust the level of a pure tone to the loudness of their tinnitus. The minimal masking level is the number of decibels required to mask the tinnitus. In the case of vascular or palatomyoclonus induced tinnitus, a graph of tympanic membrane compliance versus time will show changes in compliance which correspond to the pulse or palatal movement respectively. Patulous Eustachian tube induced tinnitus can be diagnosed by a change in the compliance which corresponds to respiration. Unilateral high-frequency sensorineural hearing loss associated with tinnitus and asymmetric speech discrimination scores suggests an acoustic neuroma. Patients with unilateral symptoms may undergo auditory brainstem evoked response testing. These patients should undergo an acoustic protocol MRI to evaluate for acoustic neuroma, which will be further discussed below.
Laboratory studies may be obtained as indicated by the history and physical exam. Possible studies include hematocrit, fluorescent treponemal antibody absorption tests, blood chemistries, thyroid studies, and a lipid battery.
Weissman and Hirsch recently reviewed the imaging of tinnitus. They recommend contrast-enhanced computed tomography of the temporal bones and skull base as the first line
study for evaluating pulsatile tinnitus. The diagnosis of glomus tympanicum tumors is made on the bone algorithm scans which best shows the extent of the mass. It is usually not possible to see enhancement of a small tumor confined to the middle ear on a CT study. Either T1-weighted MRI with gadolinium enhancement or T2 weighted images will show the tumor enhancement. The earliest detectable abnormality on CT of glomus jugulare tumors is erosion of the lateral and anterior walls of the osseous jugular fossa. These tumors enhance significantly with contrast material, it may not be possible to differentiate the internal jugular vein from tumor. As with glomus tympanicum tumors T1-weighted MRI with gadolinium or T2-weighted images will show tumor enhancement. The classical characteristic MRI pattern is a “salt and pepper” appearance. Extracranial arteriovnous malformations as well as brain parenechymal AVMs are usually readily identified on contrast CT and MR studies. A patient with pulsatile tinnitus and a normal otoscopic exam may have a dural AVM or AVF. These lesions are often invisible on CT and MRI. Conventional angiography may be the only study to show the abnormality. Other abnormalities which can be identified on contrast enhanced CT include an aberrant carotid artery, a dehiscent carotid artery, dehiscent jugular bulb, and a persistent stapedial artery. CT findings of a persistent stapedial artery are the appearance of soft tissue on the promontory, enlargement of the facial nerve canal, and absence of the foramen spinosum.
Unilateral tinnitus or asymmetric sensorineural hearing loss is an indication for MRI to evaluate for an acoustic neuroma. A gadolinium enhanced MRI of the cerebellopontine angle is the study of choice to diagnose these lesions.

Treatment

The multiple etiologies and poorly understood mechanisms of tinnitus have led to the attempt at multiple treatment modalities. These include diet modification, medications, habituation, masking, electrical stimulation, acupuncture, hypnosis, and surgery. Some patients need only reassurance that the tinnitus is not a sign of a serious medical disease. Having a physician acknowledge that their symptoms are real and receiving follow up appointments, possibly with repeat audiogram to allay fears of worsening deafness may be of benefit to some patients. Avoidance of stimulants such as coffee, tea, chocolate, cola, and other caffeine containing medications as well as smoking cessation may help some patients. Patients should be instructed to avoid medications, which are known to cause tinnitus such as aspirin and NSAIDs. The use of white noise from a radio or a home masking machine is also helpful in some cases.
Many medications have been researched for the treatment of tinnitus, including lidocaine, tocainide, carbamazepine, benzodiazepines, tricyclic antidepressants, and ginko biloba. Lidocaine administered intravenously has been shown to improve tinnitus but is impractical to use clinically. Tocainide is an oral compound closely related to lidocaine, it has been shown to be ineffective in the treatment of tinnitus. Several randomized-controlled trials have also shown that carbamazepine is ineffective and may cause bone marrow suppression. Johnson et al performed a double-blind, placebo-controlled study of the effectiveness of the benzodiazepine alprazolam and found 76% of patients had improvement in their tinnitus. The risk of dependency to this medication is a significant risk of its use. Interestingly, given that tricyclic antidepressants are implicated as a possible cause of some tinnitus, is that nortriptyline has been
shown to be more effective than placebo. Ginko biloba has also shown some benefit in the reduction of tinnitus in some studies.
Hearing aids, maskers, or combinations of the two may help some patients. If the patient has some hearing loss, amplification of background noise by a hearing aid can decrease tinnitus. A masker produces sound to mask the tinnitus and decrease the annoyance to the patient. There are combination hearing aids/maskers which can be used which are called tinnitus instruments.
Tinnitus retraining therapy is a technique of habituation using a combination of masking with low level broadband noise and counseling to achieve habituation of the reaction to tinnitus and the perception of the tinnitus signal itself. In a study of 32 patients Berry et al found a significant improvement in the Tinnitus Handicap Inventory scores of tinnitus patients following six months of tinnitus retraining therapy.
Electrical stimulation of the cochlea has been studied for the treatment of tinnitus. Transcutaneous, round window, and promontory stimulation of the cochlea have shown some benfit. Direct currents may produce permanent damage and cannot be used clinically. Steenerson and Cronin used transcutaneous stimulation of the auricle and tragus to decrease tinnitus in 53% of 500 patients treated in this manner. Cochlear implants have also shown some promise in the relief of tinnitus. Ito and Sakakihara reported 77% of 26 patients with tinnitus who underwent cochlear implantation had relief of their tinnitus and 8% had aggravation of their tinnitus.
Surgical treatment of tinnitus is used in the treatment of arteriovenous malformations ,vascular tumors, otosclersosis, and acoustic neuroma. Some authors have reported success with cochlear nerve section in patients with intractable tinnitus that is recalcitrant to all other treatment modalities, however this is not advocated by most otologists.
Other treatments that have been studied are biofeedback, hypnosis, magnetic stimulation and acupuncture. Studies of these modalities have shown conflicting results as to their benefit.

Conclusion

Tinnitus is a symptom that can be classified as objective or subjective. The majority of patients have subjective tinnitus associated with presbycusis. The impact of tinnitus on the patient’s well being and quality of life is an important factor in deciding upon treatment. As we are faced with the aging of the population in the United States, tinnitus will surely become even more prevalent. Continued research into the mechanism and treatment of tinnitus is necessary to make progress in relieving the suffering of our patients.
References
1. Hazell, JP, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J. Otolaryngology 1990;19:1-5.
2. Ator GA, Lambert PR. Tinnitus. In: Canalis RF, Lambert PR, eds. The Ear: Comprehensive Otology. Philadelphia, Lippincott Williams & Wilkins, 2000:559-570.
3. Schleuning AJ, Martin WH. Tinnitus : Bailey BJ, ed. Head and Neck Surgery-Otolaryngology, Third Edition. Philadelphia, Lippincott Williams & Wilkins, 2001:1925-1931.
4. Tyler RS, Babin RW. Tinnitus. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery, Second Edition. St. Louis, Mosby-Year Book, 1993:3031-3053.
5. Seidman MD, Jacobson GP. Update on tinnitus. Otolaryngologic Clinics of North America 1996;29(3):455-465.
6. Sismanis A, Smoker W. Pulsatile Tinnitus: Recent advances in diagnosis. Laryngoscope 1994;104:681-688.
7. Lockwood AH et al. Tinnitus. N Eng J Med 2002;347(12):904-910.
8. Folmer RL et al. Tinnitus severity, loudness, and depression. Otolaryngology-Head and Neck Surgery1999;121(1):48-51.
9. Jastreboff PJ et al. Neurophysiological approach to tinnitus patients. The American Journal of Otology 1996;17(2):236-240.
10. Weissman JL, Hirsch BE. Imaging of tinnitus: a review. Radiology 2000;216:342-349.
11. Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109:1202-1211.
12. Pulec JL. Cochlear nerve section for intractable tinnitus. ENT Journal 1995;74(7):468-476.
13. Steenerson RL, Cronin GW. Treatment of tinnitus with electrical stimulation. Otolaryngology-Head and Neck Surgery 1999;121(5):511-513.
14. Ito J, Sakakihara J. Tinnitus suppression by electrical stimulation of the cochlear wall and by cochlear implantation. Laryngoscope 1994;104:752-754.
15. Araujo MF et al. Radilogy quiz case I: persistent stapedial artery. Arch Otolaryngol Head Neck Surg 2002;128:456-458.
16. Berry JA et al. Patient-based outcomes in patients with primary tinnitus undergoing tinnitus retraining therapy. Arch Otolaryngol Head Neck Surg 2002;128:1153-1157.
17. Johnson RM et al. Use of alprazolam for relief of tinnitus. Arch Otolaryngol Head Neck Surg 1993;119:842-845.

Erectile Dysfunction – ed (Impotence)

Kemboi Kibet

Erectile dysfunction is when a man cannot get an erection firm enough for satisfactory sexual intercourse. He may not have an erection at all or may lose erection during intercourse. Inability to get an erection may happen once in a while but if it happens all the time, then it is erectile dysfunction. Erectile dysfunction can occur at any age but it’s more common in men age 45 and above. An erection problem can damage a man’s self-esteem and destroy a relationship.

You should note that male infertility is different from erectile dysfunction. Male infertility is when you are unable to produce sperms that can fertilise an egg. You can however get an erection. People with erectile dysfunction however may be able to produce sperm that can fertilise an egg. Premature ejaculation which is reaching orgasm too quickly is also not the same as impotence.

If impotence is caused by underlying disease such as diabetes, treating the disease may reverse the condition. There are also other treatment methods available if your impotence is not caused by underlying disease.

CAUSES

Sexual arousal in men is a complex situation that involves the brain, nerves, hormones and blood vessels. Anything that interferes with their normal function can lead to erectile problems. Psychological issues like stress and depression can also cause impotence.

Physical Causes of Erection Problems

diseases such as diabetes, heart disease, multiple sclerosis, high blood pressure, thyroid problems, Parkinson’s disease, atherosclerosis etc.
obesity
high cholesterol
alcohol, tobacco or cocaine use
spinal cord injury
low testosterone
treatment for prostate cancer and enlarged prostate
surgery or injury to the pelvic area
medications such as blood pressure medications especially beta blocker, heart medication especially digoxin, antidepressants, sleeping pills etc

Psychological Causes of Erection Problems

anxiety, depression and other mental heath problems
stress
low self-esteem
fear of sexual failure

Physical causes of impotence is more common in older men. Younger men usually experience impotence associated with psychological problems.

SYMPTOMS

Erectile dysfunction may present symptoms like the following :

trouble having an erection

trouble keeping an erection

reduced sexual desire

TEST AND DIAGNOSIS

A physical exam and medical history may be enough to diagnose impotence. However, in some cases where an underlying problem or condition is the cause of the erectile dysfunction, further testing may be needed.

Blood test : Blood sample is sent to the lab to check for diseases like diabetes, cardiovascular problems, low testosterone and so on. It also checks for the levels of various hormones in your body (hormone profiling).

Physical Exam. This is done to check the penis and testicles for any abnormalities. Your nerves for feeling may also be checked.

Urine test : This is done to check for diabetes and other health problems.

Penile ultrasound : It creates a video image that helps your doctor check for blood flow to your penis.

Nocturnal penile tumescence (NPT) : It checks for night-time erection. If it is found out that you do have night-time erection, then your impotence may be psychological and not physical.

Psychological exam : Your doctor will screen you for depression, anxiety and other psychological problems.

TREATMENT

First treatment for erectile dysfunction is to treat the underlying medical condition.

Other treatment options for impotence depends on the severity and type of underlying condition causing the erectile problem. They include the following :

Oral Medications : This includes Sildenafil (Viagra),Tadalafil (Cialis) and Vardenafil (Levitra, Staxyn). They are called phosphodiesterase-5 (PDE5). They increase blood flow to the penis and only work when you are sexually aroused. Do not use these drugs with medications such as nitroglycerin as they can cause a drop in blood pressure. Ask your doctor before using these medications because they can cause problems if you have heart disease, uncontrolled diabetes, very low blood pressure and other health problems.

Testosterone replacement uses skin patches, gel or injections into the muscle . This option is for people with low testesterone levels.

Alprostadil self-injection – Medication is injected into the penis to improve blood flow to the penis. It works better than oral medication. The medication can also be inserted into the urethra, in which case it is called Alprostadil penis suppository.

Penile implants: It involves surgically placing devices into the two sides of the penis. It is usually the last resort if other treatment options do not work.

Penis pumps : A penis pump is placed over your penis. This creates a vacuum that pulls blood into your penis.

Psychotherapy : This is done if stress, anxiety, depression and other psychological issues are the cause of your erectile problems.

NATURAL REMEDIES

Alternative treatment for erectile dysfunction include :

Acupuncture
Korean red ginseng (Panax ginseng) is known to increase energy, stamina, and sexual function.
L-arginine signals smooth muscle surrounding blood vessels to relax and dilate increasing blood flow.
Ginkgo is used especially in people who experience sexual dysfunction as a side effect of antidepressant drugs. It relaxes smooth muscle and enhance blood flow to the penis.

COMPLICATIONS

Erectile dysfunction can lead to :

low self-esteem
marital or relationship problems
poor sex life

PREVENTION

The following steps can help prevent impotence.

Maintain a healthy weight.
Do not smoke, drink alcohol in excess or abuse street drugs.
Manage your health conditions like diabetes, heart diseases and so on.
Exercise regularly
Minimize your stress level and get help for depression and anxiety.

SUDDEN INFANT DEATH SYNDROME (SIDS)

Kemboi Kibet

Sudden infant death syndrome (SIDS) is a sudden unexplained death of infants under one year of age. This usually occurs during sleep and hence the name crib death. The cause of SIDS is unknown although some researchers believe it is due to abnormalities in the portion of the infant’s brain that control breathing and arousal from sleep. All babies (healthy or sick) are at risk and certain sleep environment also increases your infant’s risk. It is important to remove blankets, pillows and toys from the crib to reduce the risk of SIDS. Also placing baby on the back to sleep and using a firm crib mattress may all help to prevent SIDS.
CAUSES
The main cause of SIDS is unknown although doctors believe it may be related to a combination of sleep environmental and physical factors.
Sleep environmental factors – A baby’s sleeping position, crib toys and a lot of physical factors can greatly increase the baby’s risk of SIDS. A baby may have difficulty breathing if place on their stomach or side to sleep than those placed on their back. Blankets, pillows, quilts and crib toys placed in a baby’s crib may cause suffocation if they are not kept away from the baby’s face. Also laying your baby on a soft fluffy surface can block the baby’s airways. The risk of SIDS is reduced in babies who sleep in the same room as their parents however, sleeping on the same bed as their parents is dangeruous because they are more exposed to a tremendous amount of soft surface which will in turn impair their breathing.
Physical factors – These include brain abnormalities, respiratory infections and low birth weight. In some babies the portion of the brain that controls arousal from sleep and breathing does not work properly and this makes them more susceptible to develop SIDS. Respiratory infection like colds may cause SIDS in infants due to difficulty breathing. Babies with low birth weight (eg multiple birth babies) and premature babies generally have brains that are not well developed to control breathing and heart rate and hence more likely to develop SIDS.
RISK FACTORS
Cetain factors increases a baby’s risk of SIDS. SIDS is more likely to occur between ages 2-4 months although it could occur later (up to 1 year old). Boys are at increased risk of SIDS than girls. Other risk factors include:

Baby sleepin on the stomach or side
Baby sleeping on a soft bedding in the crib
Race – Black, american indian or eskimo babys are more likely to develop SIDS
Premature birth
Multiple birth babies (twins and triplets)
Family history of SIDS
Inadequate prenatal care
Alcohol or illegal drug use during pregnancy
Smoking during pregnancy
Short time periods betweeen pregnancies
Babies born to teenage mothers
Poverty

SYMPTOMS
SIDS occur with no signs or symptoms. It happens when your baby is thought to be sleeping.
TEST AND DIAGNOSIS
An autopsy will not confirm the cause of death but may give additive knowledge about SIDS.
PREVENTION
There is no sure way to prevent a baby from developing SIDS but some measures can be taken to reduce a baby’s risk. These include:
Placing baby on the back to sleep instead of on his side or stomach
Placing baby to sleep on a firm sleep surface
Keeping soft objects, toys and loose beddings out of the baby’s sleep area.
Keeping your baby’s room at a tempreture comfortable for adults and dressing them in light sleeping clothes to prevent overheating.
Offering your baby a pacifier at naptime and bedtime may reduce the risk of SIDS.
Avoid co-sleeping with your baby. A baby sleeping on an adult bed may become trapped in headboard slates, sheets and other loose beddings and this will cause suffocation.

COPD – Chronic obstructive pulmonary disease

Kemboi Kibet

COPD comprises a group of lung diseases which includes chronic asthmatic bronchitis and emphysema. Most people with COPD have a combination of both conditions. These conditions make it difficult to breathe by obstructing air flow through the airways and out of the lungs. It eventually interferes with exchange of oxygen and carbon dioxide in the lungs. This condition is permanent and may progress overtime. There may be periods of exacerbations when symptoms get worse and may be life threatening. COPD is the most common lung disease and the leading cause of death worldwide. Damage done to the lungs by the disease cannot be reversed. Treatment is aimed at relieving signs and symptoms.

Chronic Asthmatic Bronchitis : It causes inflammation and narrowing of the airways that leads to narrowing and obstruction of these airways. It may result in long-term cough with mucus and wheezing.

Emphysema : This involves lung destruction over time. Damage occurs in the tiny air sacs in your lungs called the alveoli. Emphysema may gradually destroy the inner walls of the alveoli thereby reducing the surface area available for gas exchange. It may also weaken the alveoli wall, making it less elastic. These walls collapse during exhalation and trap air in the alveoli.

STAGES

STAGE I : Minimal shortness of breath with or without cough and mucus. The disease is considered mild.

STAGE II : At this moderate stage, shortness of breath may be severe with or without cough and mucus. Medical attention is usually sought at this stage.

STAGE III : It is considered severe. It is accompanied by severe shortness of breath with or without cough and sputum, fatigue, reduced exercise capacity and repeated exacerbations .

STAGE IV : At this stage, the disease is very severe, quality of life is affected and exacerbations may be life threatening.

CAUSES

Smoking is the leading cause of COPD. The more a person smokes, the higher his risk of getting this disease. Non smokers may also get this condition and so does long periods of exposure to dust, chemical fumes and air pollutants.

RISK FACTORS

Some factors may put one at high risk of this disease than others. These factors include the following:

Smoking : Long term exposure to tobacco smoke puts you at high risk of getting this disease. Your risk of this disease is increased by the number of years and packs you smoke. Second hand smoking also puts you at risk.

Age : COPD usually occur in people 40 years and older.

Genetics : A rare genetic disorder known as alpha-1-antitrypsin deficiency is the source of some new cases of COPD.

Long-term exposure to chemical fumes, vapors and dusts can also inflame and irritate your lungs. Frequent use of cooking fire without proper ventilation may also be a contributing factor.

SYMPTOMS

Some typical signs and symptoms of COPD include the following:
•shortness of breadth (dyspnea)
•cough with or without mucus
•wheezing
•chest tightness
•fatigue
•respiratory infections
•fever

In severe cases patients may experience headache, weight loss, cyanosis (bluish discoloration of the lips and nail beds) and pulmonary hypertension (elevated pressure in the blood vessels of the lungs ).

TEST AND DIAGNOSIS

Doctors diagnose COPD based on questions about medical history , symptoms and physical examinations. Typical tests to diagnose this disease include :

Imaging Test : Chest x-ray may be done to rule out other lung problems, such as lung cancer or heart failure. The x-ray can also show an enlarged chest cavity and decreased lung markings which may indicate lung tissue destruction. Computerized tomography (CT) accurately shows the abnormal lung tissue and airways in COPD. It gives detailed cross-sectional areas of internal organs.

Arterial blood gas : This blood test measures how well oxygen goes to the blood and carbon dioxide is eliminated from the blood. It also determines the acidity (pH) of your blood.

Sputum examination : Mucus that come up when you cough is taken to the lab to be analysed for bacteria pathogens. This helps rule out other possible causes of your symptoms.

Lung function test : Spirometry is the best lung function test for COPD. Your lung capacity is checked by blowing out as much as possible into a large tube connected to a spirometer. The spirometer measures how much air your lungs can hold and how fast you can blow the air out of your lungs.

TREATMENT

There is no cure for COPD. Treatment is aimed at relieving symptoms and reducing your risk of exacerbations and complications.

Smoking cessation is the most essential step in treating COPD. This may prevent further damage to the lungs and prevent the disease from getting worse.

Medications may also be used to treat COPD and these include the following :

Bronchodilators : They are used to open the airways by relaxing the muscles around them. They usually come in the form of inhalers. Examples include ipratropium (Atrovent), tiotropium (Spiriva), salmeterol (Serevent), formoterol (Foradil), or albuterol. Broncholdialators makes breathing easier.

Inhaled steroids : They make you breath better by reducing inflammation in the lungs. They are usually reserved for people with moderate to severe COPD because of it’s potentially serious side effects.

Antibiotics : They are used when necessary to fight bacterial infection of the upper respiratory tract. These infections such as pneumonia and influenza may aggravate COPD symptoms.

Anti-inflammatory medications such as montelukast (Singulair) and roflimulast may also be used.

Other treatment options for this disease include:

Oxygen therapy : This include using lightweight portable devices to deliver oxygen to the lungs.

Pulmonary rehabilitation program : It teaches you to breathe in a different way so you can stay active. It also includes education, exercise training, nutrition advice and counselling.

In severe cases when medications alone are not enough, surgery may be needed.
•Lung volume reduction surgery creates extra space in your chest cavity so that the remaining lung tissue and the diaphragm work more efficiently .
•Lung transplant can improve your ability to breathe and be active.

Even with treatment, there may be times when symptoms may get worse. This is called acute exacerbation. Seek immediate medical attention when this happens.

COMPLICATIONS

COPD can present these serious complications.
•heart problems such as arrhythmia
•respiratory infections such as pneumonia
•severe weight loss
•osteoporosis
•high blood pressure

PREVENTION

The best way to prevent this disease is to stop smoking. Don’t start smoking if you haven’t already. Don’t sit in a smoking zone when you go out because second hand smoking can be as harmful. It is also important to protects yourself from lung irritant and chemicals at work by wearing mask .

Kaspersky Lab Developing Its Own Operating System? We Confirm the Rumors, and End the Speculation!

Reblogged from Nota Bene:

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Hi all!

Today I’d like to talk about the future. About a not-so-glamorous future of mass cyber-attacks on things like nuclear power stations, energy supply and transportation control facilities, financial and telecommunications systems, and all the other installations deemed “critically important”. Or you could think back to Die Hard 4 - where an attack on infrastructure plunged pretty much the whole country into chaos.

Read more… 1,744 more words

Thyroid Cancer

by Kemboi Kibet

Thyroid cancer is cancer that starts in the thyroid gland. The thyroid gland is located at the base your neck just below the adam’s apple.Thyroid glands produces thyroid hormones which are important in regulation of the metabolism of the body.Thyroid cancer is three times more common in women than men and there are four types namely papillary, follicular, medullary, and anaplastic. Thyroid cancer does not always cause symptoms. The first sign of this type of cancer however is a thyroid nodule.People who have received radiation to the head and neck in their childhood are at high risk for thyroid cancer. Most thyroid can cancers are very curable.

TYPES OF THYROID CANCER

Papillary carcinoma . This is the most common type of thyroid cancer.It begins in the follicular cells and usually grows slowly.It is also the least dangerous type. When caught early, it is very treatable.

Follicular carcinoma is more likely to come back and spread. It is the second most common type and easily treatable when found early. It occurs in slightly older age people and rare in children.

Medullary carcinoma It occurs in non-thyroid cells that are normally present in the thyroid gland.It begins in C cells and can make abnormally high levels of calcitonin. This type runs in families.

Anaplastic carcinoma is the most dangerous type of thyroid cancer and spreads qucikly.Even though it is rare, this type is very hard to control.

CAUSES

The exact cause of thyroid cancer is unknown however it happens when cells of the thyroid gland acquire some mutations. These make the cells proliferate abnormally and forming a mass called a tumor.The abnormal cells can spread throughout the whole body.

RISK FACTORS

Exposure to high levels of radiation to the head or neck during childhood or during a nuclear accident

Personal history of goiter

Having genetic syndromes that increase your risk of thyroid cancer. These include familial medullary thyroid cancer, multiple endocrine neoplasia and familial adenomatous polyposis.

Family history of thyroid cancer

SYMPTOMS

Symptoms vary depending on the type of thyroid cancer and this may include

difficulty swallowing
pain in neck and throat
hoarseness
neck lump
thyroid lump
coughing
swollen lymph nodes in the neck

TEST AND DIAGNOSIS

Physical exam. The doctor may check for swollen lymph glands in the neck and lumps in the thyroid

Blood test. This is to check for the level of thyroid-stimulating hormone (TSH) in your body. Too much or too little means thyroid is not working well. If medullary carcinoma is suspected, your doctor will check for high calcitonin.

Ultrasound of the thyroid gland. This uses sound waves to create a picture of the thyroid and the doctor checks for any tumors and abnormalities.

Thyroid biopsy is done by taking sample tissue from the thyroid and checking in the lab for cancer cells .

TREATMENT

Treatment for thyroid cancer may depend on the type and stage of cancer,the overall health of patient and preference.

Surgery Most people with thyroid cancer may undergo surgery to remove all or part of the thyroid.

Removing all or most of the thyroid (thyroidectomy) It is the most common treatment for thyroid cancer. Surgeon leaves small rims of thyroid tissue around the parathyroid glands to reduce the risk of parathyroid damage.

Removing lymph nodes in the neck and testing them for cancer

Taking radioactive iodine by mouth. This treatment is often used after thyroidectomy to destroy any remaining healthy thyroid tissue, as well as small areas of thyroid cancer that weren’t removed during surgery.

Chemotherapy is a drug treatment that uses chemicals to kill cancer cells.It is given through IV and travels through the blood killing cancer cells.

Radiation therapy uses high-energy beams to kill cancer cells

Thyroid hormone medication levothyroxine (Levothroid, Synthroid, others) are given for life. It supplies the missing hormone your thyroid would normally produce, and it suppresses the production TSH.

COMPLICATIONS

spread of cancer to lungs, bones and other parts of the body
injury to voice box
low levels of calcium due to accidental removal of parathyroid glands during surgery

PREVENTION

There is no sure way to prevent thyroid cancer however knowing about risk can help in early diagnosis. People with family history of thyroid cancer or inherited gene mutation may remove the thyroid gland through surgery to prevent this cancer.

Asthma Awareness

by Kemboi Kibet

Asthma affect the airways of the lungs. Asthma is a disease that makes it difficult for people to breathe. It can be kept under control with treatment but it never goes away. During an asthma attack, the airway becomes narrow or blocked and swells leading to wheezing, shortness of breath, chest tightness and coughing. Asthma had genetic origin and can be passed down from generation to generation It affects people of all ages but usually starts during childhood. Asthma cannot be cured but symptoms can be controlled.

CAUSES

The real cause of asthma is unknown. Asthma attack is however known to be brought on my certain environmental and genetic factors. Certain environmental factors that trigger asthma symptoms include the following

Allergens such as dust, pollen , molds, pet dander can all trigger asthma.

Some foods can also trigger asthma. Foods like peanut,shellfish, cow milk, soy salads.

Air pollutant like smoke.

Stress and strong emotions

cold and other respiratory infections.

physical exercise

cool air

Certain medications such as aspirin and other NSAIDs and beta blockers

STMPTOMS

People with asthma may have varying range of symptoms. Severity of symptoms may differ from person to person. Some people have occasional symptoms flare ups while others may have symptoms all the time.

Wheezing which is a whistling sound heard when exhaling
cough which comes on and off and worsen at nigh
chest tightness and pain
difficulty breathing

Asthma symptoms may get worse and may require emergency care

extreme breathing difficulty
lips and mouth turning blue or purplish
no relief after using a quick-relief inhaler

Who is at risk of getting asthma

Genetics Having a blood relative with asthma

Smoking can also increase your risk of having asthma or having a mother who smoked while pregnant can also increase your risk

Being overweight greatly increase your risk of developing asthma

Asthma is more common in the black race .

Low birth weight can also contribute to one getting asthma

TEST AND DIAGNOSIS

Physical exam Your doctor will listen to your breathing and look out for signs of asthma such as wheezing and coughing. Physical exam is done to rule out diseases like respiratory infections.

Lung function Test These are a group of test done to find out how much air moves in and out when you breathe. These test includes

spirometry which measures air flow. It estimates how narrow your bronchial tubes are by detemining how much air you breathe out after a deep breath. It also checks how fast you can breathe.
Lung volume measurement is done to estimate your lung volume
Peak flow is also done to check how hard you can breathe out. Lower reading may indicate asthma is getting worse

Imaging test A chest x-ray or an EKG (electrocardiogram) of your lungs is done to check for structural abnormalities. It is done to check whether another disease or infection is the cause of your asthma symptoms.

Blood Test is done to check for eosinophils count and IgE .The mucus one discharges during coughing is also checked for eosinophils.
TREATMENT

Asthma can not be cured but living with asthma can be made easy when you know what the symptoms are and how to treat them.Medications are given based on one’s age and symptom, triggers. There are long-term medications that prevent inflammation of the airways and quick relief inhalers like bronchodialators. Patients may also be given allergy medication to prevent the appearance of allergies that trigger the disease. Self care is very important in asthma treatment. This include knowing what your triggers are and taking steps to prevent contact with them or knowing how to treat or ease your symptoms

Long Term Asthma Controlled Medications These medications controls asthma on a day-to-day basis and makes it less likely for an asthma attack to occur.

Leukotriene modifiers relieves asthma symptoms for up to 12 hours. These include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo)
Inhaled corticosteroids prevent symptoms by preventing airway swelling. You may need to take these medications for several days to weeks before you reach your maximum benefit. They work well and almost always the first choice. They include (Flovent Diskus, Flonase), budesonide (Pulmicort, Rhinocort), mometasone (Nasonex, Asmanex Twisthaler.
Long-acting beta-agonist inhalers They are used together with an inhaled corticosteroid drugs and helps prevent asthma symptoms. Examples include fluticasone-salmeterol (Advair Diskus), budesonide-formoterol (Symbicort) and mometasone-formoterol (Dulera)
Theophylline is a bronchodialator. This daily pill opens the muscles around the airways keeping it open.

Quick Relief Rescue works fast to relief asthma symptoms in the short-term. These rescue drugs are taken when you are coughing , wheezing or having an asthma attack. They may also be taken twice a week to control asthma symptoms or taking right before exercising to prevent exercise induced asthma. They include

Short-acting bronchodilators (inhalers) include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA) and pirbuterol (Maxair). They are taken as a portable inhaler or nebulizer.
Oral and intravenous corticosteroids They relieve the airway inflammation caused by severe asthma attack. These medications include prednisone and methylprednisolone

Allergy medications may also be given to relieve allergies. Allergy medications may be given in the form of allergy shots, oral and nasal spray antihistamines and decongestants.

COMPLICATIONS

death
lack of sleep due to interference from asthma symptoms
persistent cough
difficulty breathing due to permanent narrowing of bronchial tubes
decreased ability to exercise
side effects from long-term use of some medications

PREVENTION

Asthma symptoms can be reduced by avoiding asthma triggers such as pollen , mold , dust , polluted air , mites

Be up to date with pneumonia and influenza immunization to prevent them from triggering the disease

Know your asthma symptoms and treat them early to prevent severe attacks.

Take medications as prescribed

Vitamin K- The Clotting Vitamin

By Kemboi Kibet, Eldoret October 5, 2012

FACTS

Vitamin K is a group of fat soluble vitamins made up of vitamin K1 is also known as phylloquinone or phytomenadione (phytonadione) and vitamin K2 which includes menaquinone and menatetrenone. Vitamin K1 is made by plants and that is where we get are dietary vitamin K from and vitamin K2 is made in the large intestine by bacteria.Vitamin K is essential for proper coagulation of blood which is blood clotting. Vitamin K2 deficiency is rare unless there is damage to the large intestine that prevents it from producing this vitamin

FOOD SOURCES

Foods rich in vitamin K include

green leafy vegetables like spinach, turnip greens,
fish, meat ,egg, liver
vegetables such as Brussel sprouts , cauliflower, cabbage
fruits such as grapes, plums, raspberries

HEALTH BENEFITS

Vitamin K is important for blood clotting. Without it blood wont clot

It also helps protect bones from fracture and prevent post menopausal bone loss

Vitamin K protects against liver and prostate cancer

It has anti inflammatory properties that reduces inflammation in the body

Vitamin K is essential for synthesis of sphingolipids and therefore helps in brain and nervous function

Vitamin K2 is known to protect against cardiovascular diseases such as coronary heart disease

SIDE EFFECTS

There are no side effects for high levels of vitamin K

It should however be noted that vitamin K can interfere with blood thinning medication, warfarin and it is important to limit intake of foods that contain vitamin K when on this medication

DEFICIENCIES

Vitamin K deficiencies is extremely rare. It only happens when the body can’t absorb vitamin K from the intestinal tracts. Some of the symptoms of vitamin K deficiency include

bleeding such as nose bleeds and gum bleed
anaemia
heavy menstrual bleeding
osteoporosis and coronary heart disease linked to vitamin K2
easily bruising
prolonged clotting time
hemorrhaging

Pneumonia

By Kemboi Kibet

Pneumonia is an inflammation of one or both lungs caused by infection by microorganism like bacteria, fungi and viruses. It is the sixth leading cause of death in the United States. It can range from mild to fatal or life threatening. Pneumonia infections caused by bacteria or fungi can be treated by antibiotics but not those caused by viruses. Pneumonia can also result from accidental inhalation of a liquid or chemical. It is especially common in children and people 65 years or older.
CAUSES AND RISK FACTORS
Pneumonia is commonly caused by bacteria or virus in the environment. Your body’s immune system’s mechanism usually prevent these microorganisms from invading your lung to cause infection. However sometimes due to weakened immune system (due to a stroke, diabetes, heart disease), pre-existing conditions like cold or flu, age or some other reasons, these organism breech your body’s defense mechanism and invade your lungs. It should be noted that different types of microorganism are responsible for the different types of pneumonia. Also the microorganism that cause this disease in healthy people is different from those that cause it in people with weakened immune system.
TYPES
There are different types of pneumonia. These include;
COMMUNITY – ACQUIRED PNEUMONIA – This is usually caused by microbes we encounter in our everyday life. These are present in the environment that we live in. These cause the mild form of pneumonia which is easily treatable. Example of microorganism that cause community-acquired pneumonia are;
Bacteria like Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae and Klebsiella pneumoniae. The previously health-care-acquired pneumonia bacteria Methicillin-resistant Staphylococcus aureus (MRSA), an antibiotic-resistant bacterium now causes pneumonia and skin infections in community settings.
Bacteria – like organisms like Mycoplasma pneumoniae – causes walking pneumonia. Chlamydia and Legionella pneumoniae are also pneumonia causing organisms that are neither bacteria or viruses.
Viruses can also cause pneumonia although most cases of viral pneumonia are less severe. Viruses that cause colds and flu can also cause pneumonia and particularly pneumonia caused by the influenza virus can be fatal. Note that most viral pneumonia pave way for a secondary infection by a bacteria.
Fungi, parasites and germs that cause tuberculosis may also cause pneumonia although this is less common. This type is more prevalent among people living in developing countries or people who travel to such places.
HEALTH-CARE-AQUIRED PNEUMONIA – Most of the resistant strains of bacteria like Pseudomonas aeruginosa and MRSA are found in the hospitals. These bacteria cause severe and difficult to treat pneumonia because they are resistant to antibiotics. The main concern of health care professional in this type of setting is to identify the strain of bacteria and find a correct antibiotic that can treat it. It is also possible to find community – acquired strains like Streptococcus pneumoniae and Haemophilus influenzae. This type of infection occurs in hospitals, dialysis centers, outpatient infusion centers and nursing homes.
INHALATION OR ASPIRATION PNEUMONIA – This happens when people accidentally breathe foreign material into their lungs due to a medical condition like Parkinson’s or a stroke which makes swallowing difficult or vomiting while unconscious or sleeping.
OPPORTUNISTIC BACTERIA, FUNGAL AND VIRAL PNEUMONIA – People with weaken immune system are especially susceptible to this kind. These include people with AIDS, stroke and diabetes. People who have received an organ transplant and those who have taken medication (chemotherapy and corticosteroids) that suppress the immune system are also very much at risk of this kind of pneumonia
Generally the risk of getting this disease increases with age, with certain medical conditions like COPD and AIDS, smoking and exposure to certain pollutants and chemicals.
SYMPTOMS
Symptoms differ for each individual depending on the type you have, your age and your preexisting medical condition. However, there are some general symptoms which is very characteristic of pneumonia. These include ;

Fever
Shortness of breath
Chills
Coughing
Headache
Muscle ache
Fatigue
Chest pain
sneezing
sore throat

People with bacterial infection most of the time cough and produce a lot of sputum which is usually greenish or tinted with blood. This is the opposite of what happen for non-bacterial infections where individuals cough but produce less sputum.
The elderly and children experience very few symptoms when they get the disease. One sure sign or symptom for elderly pneumonia is confusion or a preexisting lung condition which seems to worsen.
In babies and infants symptoms of pneumonia include poor feeding, being lethargic, looking pale, grunting and fever.
Most children have the same symptoms as healthy adults will experience
TESTS AND DIAGNOSIS
First of all your doctor will ask you questions about your medical history. He will then perform a physical examination on you. He will listen to your lungs with a stethoscope to check for crackling sounds and rumblings which is an indication of the presence of a thick fluid. He will then do a chest X-ray to confirm the diagnosis. Chest X-rays however do not always confirm pneumonia, especially when it is done too early. There are other test available that the doctor can perform to confirm diagnosis. These include ;
Blood tests – This is done to measure your white blood count. This often checks the severity of the pneumonia and also to identify the kind of microbe (bacteria or virus ) causing the pneumonia.
Sputum tests – This will also help to identify the kind of microbe causing the pneumonia by doing a gram stain and sputum culture.
Rapid urine test – This test is also done to identify the kind of microorganism causing the bacteria. It may also be used as a treatment guide
TREATMENT
Treatment of pneumonia depends on age and over all health of patient, type of pneumonia and severity.
Medications needed to treat pneumonia include
Antibiotics It is mostly used to treat bacterial pneumonia. Choosing a particular antibiotic for your pneumonia may involve trial and error in which your doctor may prescribe one antibiotic and change it to another if it doesn’t work. Your doctor will do this until he gets an antibiotics that is suitable to you and treats your bacterial pneumonia. Be sure to take the whole dose of the antibiotics if even you start to feel better.
Antiviral medications are effective against viral pneumonia. Antibiotics don’t work well with viral pneumonia.
Aspirin, ibuprofen, naproxen or acetaminophen are used to reduce fever
Cough medicine to relieve cough symptoms. It is however important to talk to your doctor before taking cough medication.
Hospital admission may be crucial if patient is a child or adult over 60, if patients needs help breathing, if blood pressure drops and patient is confused.
PREVENTION
Vaccination It lowers your risk of getting pneumonia
Seasonal flu shot lowers your risk of getting viral and bacterial pneumonia. This is because influenza can cause both of these types of pneumonia.
Pneumonia vaccine This vaccine is recommended for people at high risk of getting pneumonia. It is also recommended for adults age 65 and older and people of any age who live in nursing home and elderly centers. It is a one time shot against streptococcus pneumoniae bacteria (pneumococcus)
Childhood vaccine. Children should receive their yearly flu vaccine. It is also important for children under age 2 to get the pneumococcal conjugate vaccine especially those at high risk for pneumonia
Hib vaccine Haemophilus influenzae type b (Hib) is a type of bacteria that can cause pneumonia. The vaccine is recommended for all children below age 5 and should be given after 2 months of age. The vaccine helps prevent pneumonia infections.
Other ways to prevent pneumonia include

washing hands frequently with warm water and soup or using alcohol based sanitizer
don’t not smoke
eat healthy foods
get enough rest
engage in exercising to keep strong and healthy

COMPLICATION

Bacteria can enter the blood stream causing septic shock
Pneumonia involving both lungs can cause respiratory distress making breathing difficult
Pneumonia can cause fluid accumulation and infection of the lungs

A story – Sad but True

The day I did surgery dressed like a priest
I remember that fateful Friday as if it was yesterday. I had been on call for two days, and I left the hospital at 7.50 am to dash home to grab a shower before going back to the district hospital where I was working as an intern. No sooner had I gotten home than my phone rang. It was maternity, and anyone who has been there knows how the story goes…. You know, rifaroos and emergencies as the sisters like calling them. I dashed into the bathroom and showered as fast as I could. There was no time to eat breakfast, for the ambulance was waiting outside. I got to the hospital, and there was an emergency for real. She was a primigravida, who had been draining liquor for more than 3 days in a certain dispensary which did not deem it appropriate to refer a patient who was clearly having obstructed labor. Somehow the fetus was still fighting, but the distress was obvious. A foul smell was emanating from the birth canal and the fetal heart rate was misbehaving. For once I heard those acceleration and decelerations that they describe in obstetric books.
I quickly prescribed a caesarian section, and not long afterwards, the patient was wheeled to theatre as evidenced by the meticulous nursing cardex. Nurses love to cover their asses. As the anesthetist was receiving the patient, I scanned through the cardex. It had all the details anyone wishing to crucify you would look for, including the time when the ambulance came for me and when I arrived at the hospital. These things are recorded in real time.
I rushed to the changing room to put on my scrubs in readiness for the operation. My fellow intern, Dr. Doreen, had just arrived. I welcomed her to theatre. The anesthetist was ready and the nurse was busy setting for us. Dr. Doreen and I had scrubbed, and we were waiting for gowns to be placed on the cart. Then something unexpected happened. The nurse announced that there were no gowns. I was furious. It was true that we had done a couple of caesarian sections the previous night, but that was no excuse as to why there were no gowns. The nurse explained that the autoclave machine had broken down in the wee hours of the night, and the maintenance guys could not figure out what was wrong with it. In short, the gowns were stuck in the damn machine.
We stared at each other as we pondered our next move. In our naivety, we thought of referring until one of the nurses suggested that we improvise. Believe it or not, she got two abdominal sheets for us, and we put them on. The sides were clipped with artery forceps. One nurse walked into theatre as we just about to start operating and her words echo in my ears up to date. She joked about it. “Dr. Mburu and Dr. Doreen, have you changed professions? The place of priests is in the altar where they consecrate bread and wine into the body and blood of Jesus Christ, not theatre, where blood is the order of the day.”
As the anesthetist gave us the go ahead to cut through the skin, another nurse joked. “Mass is about to begin! In the name of the Father, Son and the Holy Spirit.” We literally waded through the operation, and our encounters in there are events that made me very sad. As we made a smile incision in the lower uterine segment of the uterus overt chorioamnionitis was staring at us. A foul irritating smell that is similar to that of pungent chlorine hit our nasal cavities, but then we were keener on extracting the fetus. It could not get worse. As I handed over the kid to the receiving nurse, I saw her face drop. I could tell it was a fresh still birth. They tried resuscitating to no avail as I battled with bleeders. Streaks of blood were dripping to the floor as if it was a stream. I tried packing, but the bleeding was still torrential. I requested the anesthetist to pump more oxytocin for the uterus to contract more, but that did not help either. I requested the sister to call the lab to get blood for the dying mother but as it is in our labs, there was no blood. It was only when I clumped the uterine arteries that the bleeding stopped. I asked for plasma expanders, only to be shocked that a whole district hospital did not know what those were. At that moment the MO called the consultant to bail us out. Our woes were far from over. Long before we knew it the anesthetist mumbled something that I did not quite get. I watched as his instincts swung into action. The patient was still lying supine on the table with an open abdomen as the consultant scrubbed when the anesthetist did something unexpected. He reversed the general anesthesia he had administered to the patient. We stared at him in shock. I could not understand why he would do such a thing given that our patient had almost gone into shock. Then he explained. “The cylinder that supplies oxygen is out of gas, and there is no reserve. I had to reverse GA so that she can breathe for herself.”
As I paved way for the consultant to proceed with the operation, I felt a wave of sadness sweep through me. My heart was hollow. I chose to become a doctor so that I can help the suffering, but how do I do that if I do not have equipments and drugs to do achieve my goals? The consultant, just like us, was dressed in an abdominal sheet, which served as a substitute to a gown.
To bring this story to a culmination, I wish to state that the mother eventually left the operating table stable, without a child and without a uterus. Please bear in mind that the child she was carrying was her first, and sadly, her last.