Women were left confused and the medical community divided by the new government guidelines for mammograms released Monday by the U.S. Preventative Services Task Force. The task force went against the grain and ignored the American Cancer Societies earmark of age 40 and age 35 for high risk women.
Bloggers went wild over the announcement - physicians and lay people alike questioned the consequences of this decision. One very well know blogger Dr. Manny Alvarez is the Managing Editor of foxnewshealth.com.
In his blog he criticized the decision openly: ...the only thing I can conclude from their statements is that they’re playing a numbers game and based on their theoretical statistical analysis and data from some European countries such as Sweden...Saving someone from cancer should not be a numbers game, but unfortunately, this seems to be the trend coming to America. Save dollars, and make it cost effective.
This discontent reverberated through the medical community. Mark J. Pascuzzi, MD said it well - And so it begins. Even before the government take-over of Healthcare they are efforting to circumvent the relationship that you and I (a fellow member of ACOG) have with our patients. Let the micromanagement begin!
This practice will save millions of dollars for the insurance companies and boost their profits into the billions. I would like to see the insurance companies roll the money over to cover a few experimental treatments currently not covered: Surgery to cure Diabetes Type II, Implanting of permanent lenses, Stem cell treatments, and bone marrow transplants for cancer.
Tuesday, December 1, 2009
Tuesday, November 17, 2009
Neurological Emergency Care: Stroke - Brain Attack
An emergent crisis in the neurological system can be the most challenging to monitor and evaluate, perhaps because of our inability to control it as easily as we do a cardiopulmonary event. The neurological system is virtually out of control when it is injured. Neurological crisis are the most frustrating cases for nurses because we are accustomed to being able to monitor, chart progress, report to physicians when changes occur and carry out orders to improve conditions whereas declines in neuro status are often not fixable and we are obliged to make the patient comfortable, watch the condition worsen, and many times allow them to die. The most common neurological emergent crisis is Stroke (Cerebral Vascular Accident or Brain Attack as it is referred to today.) Neurological assessment includes interview, physical exam, and condition specific tests.
Stroke Animation
In many cases the patient is unable to answer and we must rely on family or friends to describe onset and development of symptoms. It is important to make sure there is a clear understanding of information being provided. The time of onset of symptoms is paramount. When investigating onset be sure to ask questions to review a patients earlier behavior. Ask if there is a history of past neurological disorders and document initial symptoms of the current event . Use caution not to suggest symptoms and use open ended questions, You can ask specific questions for clarification purposes. Document any progression of symptoms and be sure to ask if there have been any recent illnesses that may influence the current status, such as a head cold, sore throat, falls, or any accident involving the head. Include inquiry into any recent change in prescription medication, over the counter medications, and herbal remedies.
Include a review of current medications when taking a history and make sure the patient has been compliant with prescribed medications especially if they are taking an anti-seizure medication. Failure to take prescribed amounts can cause anything from a focal seizure to a more severe grand mal seizure. If the patient is over medicating he may experience mental slowing, drowsiness, lethargy and more seriously non responsive states. There are many underlying conditions that can affect the nervous system: diabetes mellitus, pernicious anemia, cancer, chronic infections, thyroid disease, substance abuse, renal failure, hypertension, dehydration, alcoholism and a host of others.
A physical examination should follow with a focused neurological exam including the Glascow Coma Scale. Laboratory tests should include routine blood tests especially electrolytes and blood sugar to rule out any physiological abnormality that can be treated and would reverse the neurological symptoms. Computerized Tomography and Magnetic Resonance Imaging can be done to visualize blood vessels, brain edema, infarction, identify blood accumulation or tumor presence. If the situation warrants, a lumbar puncture should be done. All of the data collected may give enough information to determine the cause of the insult.
Golden hour of Treatment
Stroke Assessment
Points to remember.
A score of 15 is the highest and 3 is the lowest.
A score of 7 or less indicates coma.
Abnormal flexion, or decorticate posturing is evidenced by adducted and flexed arms with wrists and fingers flexed in the chest.
In extension , or decerebrate posturing, the arms are adducted and extended with wrists and hands pronated and the fingers flexed.
An easy way to remember the difference between the two terms is that decorticate is toward the core or center of the body and the arms are also bent inward toward the core.
Decorticate vs. Decerebrate
5 Point Neuro Check
Syncope
What’s new in Acute Stroke Care
Stroke Animation
In many cases the patient is unable to answer and we must rely on family or friends to describe onset and development of symptoms. It is important to make sure there is a clear understanding of information being provided. The time of onset of symptoms is paramount. When investigating onset be sure to ask questions to review a patients earlier behavior. Ask if there is a history of past neurological disorders and document initial symptoms of the current event . Use caution not to suggest symptoms and use open ended questions, You can ask specific questions for clarification purposes. Document any progression of symptoms and be sure to ask if there have been any recent illnesses that may influence the current status, such as a head cold, sore throat, falls, or any accident involving the head. Include inquiry into any recent change in prescription medication, over the counter medications, and herbal remedies.
Include a review of current medications when taking a history and make sure the patient has been compliant with prescribed medications especially if they are taking an anti-seizure medication. Failure to take prescribed amounts can cause anything from a focal seizure to a more severe grand mal seizure. If the patient is over medicating he may experience mental slowing, drowsiness, lethargy and more seriously non responsive states. There are many underlying conditions that can affect the nervous system: diabetes mellitus, pernicious anemia, cancer, chronic infections, thyroid disease, substance abuse, renal failure, hypertension, dehydration, alcoholism and a host of others.
A physical examination should follow with a focused neurological exam including the Glascow Coma Scale. Laboratory tests should include routine blood tests especially electrolytes and blood sugar to rule out any physiological abnormality that can be treated and would reverse the neurological symptoms. Computerized Tomography and Magnetic Resonance Imaging can be done to visualize blood vessels, brain edema, infarction, identify blood accumulation or tumor presence. If the situation warrants, a lumbar puncture should be done. All of the data collected may give enough information to determine the cause of the insult.
Golden hour of Treatment
Stroke Assessment
Glascow Coma Scale
| Opening eyes | Spontaneous--open with blinking at baseline | 4 |
| Opens to verbal command, speech, or shout | 3 | |
| Opens to pain, not applied to face | 2 | |
| None | 1 | |
| Verbal Response | Oriented | 5 |
| Confused conversation, but able to answer questions | 4 | |
| Inappropriate responses, words discernible | 3 | |
| Incomprehensible speech | 2 | |
| None | 1 | |
| Motor Response | Obeys commands for movement | 6 |
| Purposeful movement to painful stimulus | 5 | |
| Withdraws from pain | 4 | |
| Abnormal (spastic) flexion, decorticate posture | 3 | |
| Extensor (rigid) response, decerebrate posture | 2 | |
| None | 1 |
For children under 5 the verbal response criteria is adjusted as follows
| SCORE | 2 to 5 YRS | 0 TO 23 Mos. |
| 5 | Appropriate words or phrases | Smiles or coos appropriately |
| 4 | Inappropriate words | Cries and consolable |
| 3 | Persistent cries and/or screams | Persistent inappropriate crying &/or screaming |
| 2 | Grunts | Grunts or is agitated or restless |
| 1 | No response | No response |
Points to remember.
A score of 15 is the highest and 3 is the lowest.
A score of 7 or less indicates coma.
Abnormal flexion, or decorticate posturing is evidenced by adducted and flexed arms with wrists and fingers flexed in the chest.
In extension , or decerebrate posturing, the arms are adducted and extended with wrists and hands pronated and the fingers flexed.
An easy way to remember the difference between the two terms is that decorticate is toward the core or center of the body and the arms are also bent inward toward the core.
Decorticate vs. Decerebrate
Cranial Nerves
| Nerves in Order | Modality | Function |
| Olfactory | Special Sensory | Smell |
| Optic | Special Sensory | Vision |
| Oculo-motor | Somatic Motor Visceral Motor | Levator palpebrae, superioris, superior, medial & inferior recti muscles Parasympathetic to ciliary & pupillary constrictor muscles |
| Trochlear | Somatic Motor | Superior oblique muscle |
| Trigeminal | Branchial Motor General Sensory | Muscles of mastication Sensory for head/neck, sinuses, meninges, & external surface of tympanic membrane |
| Abducens | Somatic Motor | Lateral rectus muscle |
| Facial | Branchial Motor Visceral Motor General Sensory Special Sensory | Muscles of facial expression Parasympathetic to all glands of head except the parotid Sensory for ear and tympanic membrane Taste anterior two-thirds of tongue |
| Vestibulo-cochlear | Special Sensory | Hearing and Balance |
| Glosso-pharyngeal | Branchial Motor Visceral Motor Visceral Sensory General Sensory Special Sensory | Stylopharyngeus muscle Parotid Gland Carotid Body Sensation posterior one-third tongue & internal surface of tympanic membrane. Taste posterior one-third tongue |
| Vagus | Branchial Motor Visceral Motor Visceral Sensory Special Sensory | Muscles pharynx & larynx Parasympathetic to neck, thorax, & abdomen Sensory from pharynx, larynx & viscera Sensory from external ear |
| Spinal Accessory | Branchial Motor | Trapezius & sternocleidomastoid muscles |
| Hypo-glossal | Somatic Motor | Tongue muscles except palatoglossal |
5 Point Neuro Check
Syncope
What’s new in Acute Stroke Care
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