The other carbon gas problem

No it's not another blog about carbon dioxide and the environment. Today I want to talk about CO - carbon monoxide.

Most people realize it is not a good idea to turn the car on in the garage with the door closed. Some people realize that having a detector near the furnace room is smart. What few people realize is how bad a toxin carbon monoxide actually is.

For instance, did you know that prolonged low grade exposure to CO can lead to dementia? There is a story going around about someone who stayed inside the BIOSPHERE 2 dome in Arizona for two years after it was declared a failure. There were known to be high carbon monoxide levels in the biosphere 2. The individual in question developed parkinson like symptoms after two years.

It apparently causes a lot of its toxic effects through release of nitric oxide which causes vasodilatation among other things (this is what causes the hypotension and headaches).

The long and the short of it is to think of CO poisoning when ever someone presents with a headache. Especially on a cold day when people are heating there homes and have all the house sealed up.

Winter and Yellowknife's Climate.

Well it snowed some more last night. Like many days in Yellowknife I am tempted to say the weather is not usually like this. Isn't it supposed to be a semi arid climate? Anyways, winter has arrived... Really it has (although they're calling for rain tomorrow).

It makes me think we should have a few more words for winter in English. They say the Inuit have many words for snow. I suggest we should have at least three words for winter.

Maybe I'll just make them up - loosely borrowing from some other languages. In Italian and Spanish they use the term Inverno or invierno. In Russian they say Zima (pronouce the i like in the word pig) - kind of cool sounding. The local dogrib call it Zahk'e!

The Celts had an interesting idea of dividing the year into eight (2 equinoxes, 2 solstices and 4 midpoints). This fits the best for the climate in Yellowknife:

ZAHK'E: Hallowe'en to Winter Solstice - feels mostly like a real southern Canadian Winter with a few colder days.

WINTER: Winter Solstice to St Brigid's Day (aka Imbulc) - this is the depth of winter - cold and dark.

ZIMA: Imbulc to Spring Equinox: cold but getting clear, bright and lighter all the time.

SPRING: Spring Equinox to May Day (Beltane) - winter is ending, skiing is fun, it's warmer and the ice is thick; great time for winter sports.

SPRING THAW: May Day to Summer Solstice: The great thaw; itching to get boats in; warmer days finally coming; lots and lots of light all the time.

SUMMER: Summer Solstice to Mid Summer's eve: This is the yellowknife summer with loads of light, swimming, sunshine and warmth.

AUTUMN: Midsummer's eve to Fall equinox: I would call this our autumn. It can still be in the 20s but the feeling is that winter is around the corner.

FALL: Fall equinox to Halloween. Snow shows up and may melt. No lakes frozen enough to walk on. Maybe some rain.

Well, I haven't firmed up on the names of these seasons but if you have any ideas let me know!

Back in the Knife!

So, the Critical Care Forum in Toronto is a wrap. Here are a few highlights:

1) Fluids: Liberal use of fluids in the ICU seems to decrease lung injury (more than 2 L per day over baseline). So there's some evidence for the old "fluids and rest" approach to illness. Maybe gramma's chicken soup will turn out to be the ultimate fluid!

Albumin still sucks (although people still use it).

Plasmalyte may be the best fluid as it most closely resembles our normal plasma. Ringer's is good but not in head trauma as it is hypotonic. Normal saline isn't normal after all...

2) Pain and Sedation: There really needs to be alot more attention givne to pain in the ICU setting. About half of ICU patients recall it being a terribly painful experience (maybe even to the point of PTSD). We need to pay more attention to pain. Being sedated does not mean being pain free.

3) Delirium - there is no evidence for anti psychotics in the ICU. The best approach is to treat the delirium. Try to regulate a normal sleep wake cycle. Read to the patients. Give them some stimulus that makes sense. We do not need our patients to be in a drug induced coma.

3) Traumatic head Injuries - Nimodipine prophylaxis to prevent vasospasm (60 mg q4h). Bolus 7.5% saline 250 mL for increase ICP. Mannitol is OK but not likely to do much. Hyperventillation is just plain bad! Consider MgSO4 16g per day and pravastatin 40 mg / day in all head injured patients. If you suspect vasospasm order a CTA with CT perfusion. Give norepi for MAP goal of > 120 mmHg.

The food was great. Especially at the reception on the top floor of the Sheraton.

Just Finished the Sick Kids Emergency Medicine Conference

The conference at the Old Mill in Toronto was a success. Aside from the usual updates in hot topics in pediatric medicine we were entertained by many of the keynote speakers. There were some impressive stats presented by Dr Marianne Gausche-Hill from UCLA. Her talk was about pre-hospital care.

First she spoke about ALTEs (Apparent Life Threatening Events). These events are characterized by some combination of apnea, colour change, marked change in muscle tone, choking or gagging. Her data showed that 48% of these kids had a serious / life threatening illness at ED evaluation!

Another issue she brought up was about whether kids undergoing severe trauma should be sent to the nearest center vs the nearest trauma center. Although the care could be better at the trauma center - most of these kids will do better just getting to the closest ER. Another stat she brough to us was the abysmal survival of kids undergoing cardiac arrest after trauma - out of 601 cardiac arrests, 29% had return of spontaneous circulation and only 5% survived (all with poor neurologic outcomes).

There were lots of other cool presenters. Kevin Chan from Sick Kids spoke about the evaluation of febrile infants in the post Prevnar era. The bottom line is that the old approach with the Rochester criteria etc is likely not needed. The number of positive cultures have fallen off the map in the past few years. In one study, the number of positive strep cultures dropped 84% since 1998 to 2003. All 27 patients with positive cultures had UTIs. A WBC greater than 15000 had a NPV of 99.5%! However - all of these studies are in kids > 3 months. The jury is still out on the kids from 1 to 3 months.

Otitis media is practically all viral now - there really is no HIB or Pneumococcus in the inner ear anymore in Prevnar vaccinated kids.

The last pearl was the new consensus statement on clearing C-spines in kids. The main point is the vast majority with injuries will have a C1 to C3 injury. If you need to CT - CTing these is all you need with a normal xray.

Vaccine vacillation

So there are all these ideas out there floating around about vaccines. Some wonder if the testing process has gone far enough. Other's wonder why there are preservatives in the vaccines that contain mercury. Other's still say it is some sort of mass mind control chemical plot. That's enough to make any skeptic stand back and ask "what if I just skipped this?" After all, who likes needles anyway?

Well, the facts speak loudly in favour of vaccines. Take bacterial meningitis: not too long ago, many children got minor ear infections with Haemophilus influenzae type b that proceeded into full blown meningitis. Some died; other's developed life long complications. Yet now, with the addition of a vaccine against H flu - we rarely see this disease.

We have a vaccine for the seasonal flu and even for H1N1. There's the new vaccine for HPV (human papilloma virus) - the virus that causes most cases of cervical cancer. There is even now some minor progress on a vaccine for HIV. We have a vaccine for the seasonal flu and even for H1N1. There's the new vaccine for HPV (human papilloma virus) - the virus that causes most cases of cervical cancer.

There is very little evidence that the claims of mind control are true (although paranoid conspiracy theories can be a lot of fun to discuss). If this were true, I think most parents would demand to be let in on the secret to control their kids!

The study that tried to associate vaccinations and autism has long since been refuted and even debunked by its author.

I guess it all comes down to risks and benefits. There is considerable risk in not vaccinating and very large benefits in getting many of the available vaccines. Maybe you dont need a vaccine against a rare tropical disease if you dont plan to go to the tropics but would you rather have a needle in the shoulder or hepatitis B and maybe a liver transplant (Hepatitis B vaccines have been used successfully for years)?

Comtemplating Bali on a Snowy Day

Well, the snow has fallen again in Yellowknife - blanketing everything in white. It sure makes things look nice and clean.

On the other hand, putting on the winter boots always makes me wonder about life in warmer places. One such place that has been on my mind is the Green School in Bali. The ideas behind this school are amazing. I first heard about it reading about it in Time. The basic idea is that they have designed a school for kids that exemplifies sustainability and tries to provide a solid education for the 21st century global village.

In some ways it seems like it is trying to be too much - a recipe for failure possibly. When you build up high expectations it is easy to disappoint. On the other hand it really seems to be getting off the ground.

Maybe we'll take the kids there some time.

The Eigenharp, A New Electronic Musical Instrument

Eigenlabs Eigenharp.

The teaser video showcases the sexy construction; the video below shows the bizarre Eigenharp in action on a cover of Moby’s take on the classic James Bond Theme:

ILI - or was it just too much turkey

Yesterday a very good paper came out in JAMA summarizing the Canadian ICU experience with H1N1 (what we're calling the Hiney Flu - cause it's a pain in the backside for ER docs). It seems to say that Canadian women who are getting this disease are getting much sicker than Canadian men with H1N1. So far, we've been seeing more women than men with severe ILI (influenza like illness) in our ER.

One strange thing that is happening is that there seems to be more people showing up without fevers but with a lot of other ILI symptoms including gastrointestinal upset. Whether these people come back as H1N1 positive is anyone's guess.

A White Thanksgiving

Well - who'ld a thunk it - it snowed in Yellowknife already and the white stuff is sticking to the ground. We've had a few people turn up to the ER who slipped on the ice (always good for a few Colles wrist fractures). One guy hit his head when he slipped (another case for helmets!).

Another thing we'll all have to get ready for is the inevitable "I've got some Turkey stuck in my esophagus" syndrome. Let's all remember to chew well tonight.

The sky has cleared and we're seeing a bit of sunshine today. It could be a great night for northern lights.

John Lennon b. Oct 9 1940 - Instant Karma

Things that go bump in the night

The north is a good place to wear a helmet. I am not kidding. Here in Yellowknife, head injuries have got to be way out of proportion to the rest of Canada. We see very little highway trauma, very little penetrating trauma but the number of subdurals, epidurals, subarachnoid bleeds, etc is incredible.

There are no helmet laws. People love skidoos and ATVs. People like to drink booze up here too.

Come to think of it, maybe there should be a helmet law for people who go to bars too...