COMPLICATIONS - ATUL GAWANDE - A SURGEON'S NOTES ON AN IMPERFECT SCIENCE
A SURGEON'S NOTES ON AN IMPERFECT SCIENCE
"The most important talent, may be the talent to practice itself. Top performers dislike practicing just as much as others do. That's why, for example athletes and musicians usually quit their vigorous practicing routine when they retire. But, more than others, they have the will to keep doing it anyway. " - Atul Gawande
- You can use a central line - a way of directly feeding something into the vena cava because the digestive system isn't working, or if medicine is absolutely needed and you can't put it in intravenously (e.g. antibiotics) because for example, the patient may be morbidly obese.
- Hernia: a weakening of the abdominal wall, usually in the groin, that allows the abdominal contents to push through.
- The first thing you do with any trauma patient: make sure the patient can breathe without difficulty.
- When gallstones form in the gallbladder, it is very painful, so the gallbladder is removed. This is done with a laparoscopic cholecystectomy. The main danger is injuring the main bile duct, which is the liver's only conduit for sending bile to the intestine - the bile backs up and ends up destroying the liver. 10%-20% of patients die when this happens.
- Women in a study (5 year self-poisoning admissions Australia) were 25% less likely to overdose around the time of the full moon than a new moon.
- The full moon also brings a drop in suicide rates (in some studies but not others)
- Previous pain theories have considered pain to be like pulling a rope to ring a bell in the brain. Pain-specific nerve fibres get activated by injury and send signals to the brain.
- The Gate-Control Theory of pain states that before pain signals reach the brain they must go through a gating mechanism in the spinal chord.
- Dancers have 3 times higher pain thresholds than non-dancers.
- Placebo injected with a "no pain" reassurance worked much better than no placebo, and even real aesthetic without reassurance.
- Modern Theory of pain: no physical injury is even needed to make the pain system go haywire. The brain can produce the experience of pain without any physical stimuli at all. Pain and other sensations are neuromodules: like a computer program. Feeling pain is your brain running that neuromodule program: pain experience is produced. What will set the program running though?
- It is network, connecting components from every brain region, sensory nerves, memory, mood. If the signals reach a certain threshold, they trigger a neuromodule.
- So if you stub your toe, and the signal passes the physical barrier, the spinal chord gate, it still has to combine with anticipation, memories, mood, distractions and the overall result may or may not activate the pain neuromodule. So it can also be thought that a certain pain neuromodule can become primed as a hair-trigger: and so can be set off by anything: touch, fear, frustration, memory.
- Treatment of chronic pain has moved to dampening down an overactive neural system, e.g. anti-epileptic drugs.
- Modifications of animal venom produce painkillers 50x as potent and morphine in pain relief.
- Nausea is such a bad feeling it is usually the worst mothers recall from pregnancy, not even childbirth itself surpasses it.
- Nausea during pregnancy can be protective because some natural foods that are safe for adults can harm the embryo. This is why pregnant women suffer the most nausea in the first trimester, when the embryo is the most vulnerable, and why the naturally crave bland foods that don't spoil and dislike strong smells and tastes.
- Women with moderate to severe morning sickness have a lower rate of miscarriage than women with little to none.
- Motor sickness occurs when there is a conflict between the motion we experience and we expect to experience. We evolved where this unfamiliar motion was only caused by poisons and toxic hallucinogens, venom, alcohol so we have a standard system to expel these products and to nurture an avoidance of them.
- Palliative medicine - the scientific study of suffering.
-"A doctor can still help a patient even when medications have failed to do so. Simply understanding - knowing the source of misery, seeing its meaning in a different way, understanding that we cannot always tame nature, can be enough to control the suffering." - Atul Gawande
- Why do we blush? Blushing is a moral emotion, it shows that the person knows he has crossed some boundary, and it provides some sort of apology, keeping us in a good standing in the world.
- Sleep apnea: When excessive fat accumulates in the tongue and soft tissues of the upper airway, it causes breathing to stop every 30 minutes or so and the person to asphyxiate and wake up, sleep becomes impossible.
- The most common pattern of overeating is "rapid intake". When food enters the stomach and duodenum, it triggers street receptors, protein receptors, and fat receptors that signal the hypothalamus to induce satiety. Fat causes that reaction the fastest, it reaches the duodenum and causes eating to stop. So why do we overeat? Speed. The mouth also has receptors triggered by fat, that accelerate our intake before the gut shuts it down. The tastier the food, the faster we eat. So how heavy we become is determined in part by how the hypothalamus and brain stem adjudicate the conflicting signals from the mouth and the gut.