In Which Dr. Baffled Tortures His Residents

In Which Dr. Baffled Tortures His Residents

I was rounding in the nursery with 2 interns today.  There are 7 babies in the nursery.  One of them had a large, hyper-pigmented nevus on his right calf.  All of the other babies have completely normal exams.  When I asked them if any of the babies had any findings on exam they said no.  I told them that one baby had a clear abnormality on the exam and they should go back in and re-examine all the babies and find it.  They examined babies and reported non-existent findings for an hour with no progress.  I then told them which baby had the findings and they then stared at that baby for 20 minutes before they found it.  The whole incident was painful to watch.

Whats the moral or the story?  A physician’s history and physical exam skills are among the most important aspects of medicine.  Without them, you’re just wandering around the diaspora throwing spaghetti at the wall and hoping something sticks.

Bookmark Printables (via Google Drive) 

Would you guys be interested in free bookmark printables?

I’ve never done these before so feedback would be appreciated (good or bad!). If you guys like these then I could maybe make a better (more pretty) series or even custom ones.   

More free printables here. 

Grapefruit Juice & Drug Metabolism

Bergamottin is a natural furanocoumarin found principally in grapefruit juice. It is also found in the oil of bergamot, from which it was first isolated and from which its name is derived.

To a lesser extent, bergamottin is also present in the essential oils of other citrus fruits. Along with the chemically related compound 6’,7’-dihydroxybergamottin, it is believed to be responsible for the grapefruit juice effect in which the consumption of the juice affects the metabolism of a variety of pharmaceutical drugs.

If someone has an 'enhanced metabolism' that processes drugs faster, is it easier or harder for them to overdose? Wouldn't they uptake more of a drug quicker, therefor making it more dangerous? I see this a lot with Captain America and Spider-man and such, where the dose of various medicines will be raised and I'm not sure that makes sense?

…oooooh you sure have opened a can of pharmacokinetic worms here….

Simply put, whether the drug never reaches therapeutic blood levels, or exceeds them, depends on 1) how the character’s metabolism works, and 2) what kind of drug they ingested (skip to the bolded part at the end of the post to get the tl;dr).

When you take a drug, the following happens (this process is sometimes denoted as “ADME” or “LADME”:

The drug must separate from the vehicle that brought it into the body (for example, a pill must disintegrate in the stomach, releasing the drug, or an IM or IV drug must separate from its solution): Liberation

The drug must be absorbed into the bloodstream (for a pill this would mean getting absorbed through the lining of the stomach or intestine, for IM injections this means getting absorbed by blood vessels running through the muscle where the drug is): Absorption

The drug must be deposited from the bloodstream into a location where it can be used: Distribution

The drug must be metabolized (broken down or changed by a biologic process, creating different chemicals called metabolites): Metabolism

The drug metabolites must be excreted from the body: Elimination

The first end of this process is largely driven by regular old chemistry. A pill has to dissolve to release the drug, and assuming that these characters have similar stomach/small intestine environments, this is not going to be different for them.

Absorption is mostly driven by a concentration gradient (substances like to be at the same concentration across membranes, so if there’s more drug in the small intestine than there is in the blood around the small intestine, the drug gets absorbed into the blood as the concentrations try to equalize), so this too is probably not going to be all that different. Even distribution is (mostly) driven by that concentration gradient, so, again, this process wouldn’t necessarily be any different from that of a normal human.

Now, the latter half of this process is a lot more dependent on a person’s specific physiology. When we talk about metabolism, we’re talking about how the body changes ingested chemicals into something excrete-able. For many drugs, this change involves enzymes in the liver.

About 6 different liver enzymes are responsible for the metabolism of about 90% of drugs. Each different enzyme is responsible for the breakdown of a different group of drugs.

Some people have genetic mutations that cause more or less of an enzyme to be produced. People who make more of an enzyme metabolize that group of drugs faster, while people who make less of them metabolize those drugs more slowly.

Through certain genetic tests, real life people can be designated one of the following for any given group of drugs:

Ultrarapid Metabolizers have the genetic wiring to produce way, way more copies of an enzyme than the typical person, and metabolize the corresponding drugs very, very quickly

Extentive Metabolizers produce more copies of the enzyme than most people

Intermediate Metabolizers produce an average number of copies

Poor Metabolizers produce significantly fewer copies than average, leaving them unable to metabolize the drugs normally

Now, remember how I said it also has to do with what kind of drug it is? There are two different kinds of drugs I’m talking about: Active Drugs and Prodrugs. Active drugs are able to be used by the body as-is. Prodrugs only have an effect once they’ve been metabolized by the body into a different substance.

Say someone is an ultrarapid metabolizer of an active drug. They take the drug, it gets absorbed and distributed like normal, but they rapidly metabolize it into inactive substances and excrete it. This person would either get no effect from a typical dose, or only a very slight one, because the drug is never allowed to build up to effective levels in their blood before getting metabolized.

But say that same person is a poor metabolizer of a different active drug. They take the drug, it gets absorbed, but they only very slowly are able to metabolize and excrete it. The drug ends up building up in their blood and staying there longer, possibly causing an overdose of the drug at a typical dose.

The situation would be reversed if the drugs were prodrugs instead. An ultrarapid metabolizer of a prodrug ends up metabolizing too much of the active substance too quickly, possibly causing overdose, while a poor metabolizer of a prodrug maybe never metabolize enough to get effective concentrations of the end substance (check out this post on the prodrug codeine).

Finally, applying this real-life precedent to Captain America, or Flash, or Spider-Man canon evidence, you would have to assume that due to their respective super powers, they all produce a metric sh*tton of liver enzymes capable of metabolizing drugs super fast and hella effective kidneys for excreting them. Typical doses of active drugs would barely work on them, while prodrugs might have a short, but incredibly strong effect on them.

R E F E R E N C E S

MEDICAL BOOKS

If you’re looking for some medical (non-textbook) books to read in your limited amount of spare time, check out some of my favorites below:

The House of God by Samuel Shem

A classic pre-medical school book. It details residency life in the 1970s. You can talk about this book with almost any medical student or attending. It is practically a medical school requirement. 

Intern: A Doctor’s Initiation by Sandeep Jauhar

A more modern look into medicine residency intern year from the perspective of Cardiologist Dr. Sandeep Jauhar. Comes with the highs and lows you can expect. After having been through 6 months of residency, I would say it is very accurate.

Gifted Hands: The Ben Carson Story by Ben Carson. Just because I find Ben Carson incompetent as a politician does not mean I do not respect him as a doctor. He is a phenomenal pediatric neurosurgeon and this book details his story.

On Doctoring: Stories, Poems, Essays by Richard Reynolds

A book of stories and poems from doctors throughout time and also from famous poets and authors depicting their views of medicine.

Private Practice: In the Early Twentieth-Century Medical Office of Dr. Richard Cabot by Christopher Crenner

An interesting look into a Boston medicine clinic from the early 1900′s. With excerpts from old patient notes which I found very interesting. 

And if you have an interest is something more dark:

Blind Eye by James B. Stewart

The real story of a doctor murderer from the 1990′s who killed multiple patients without getting caught for several years.

Devil in the White City by Erik Larson 

The story of the World’s Fair in Chicago in the late 1800′s. A great look into the history of Chicago and the murderous doctor who roamed its streets.

And lastly:

The Hitchhiker’s Guide to the Galaxy by Douglas Adams. Just a great book in general. My favorite.

Suggested by other users:

The Making of a Woman Surgeon by Dr. Elizabeth Morgan

Suggested by http://thetay-in-the-757.tumblr.com

This book is my all time favorite, as I am a female aspiring to work in the healthcare system myself. Dr. Morgan chronicles her own journey in the male-dominated arena of medicine in the 1970s and 1980s, as she struggles to maintain an appropriate balance between remaining empathetic towards her patients and yet must toe the line of not becoming too emotionally involved with her patients so that she burns out, as well as maintaining her own femininity in a man’s world.

When Breath Become Air by Dr. Paul Kalanithi

Suggested by http://nandemokandemo.tumblr.com

When Breath Becomes Air is an autobiography written by an esteemed neurosurgeon who discovers he has Stage IV lung cancer in his final stages of residency. It appeals to not only medical students, with his profound impressions of cadaver dissection and his first life and deaths, but also to current medical professionals by questioning philosophical domains of mortality and what a meaningful life is, as well as to non-medical professionals with moving thoughts on family, life, death and meaning. It is not a novel to be missed by any person.

Granny: No printer, just fax!