From our anonymous insider…
Lectures detailed the absorption mechanisms of the gastrointestinal system. The sodium-potassium ATPase pump creates the electrochemical gradient that energizes transport of glucose and amino acids. (See next week for how the kidneys use almost the exact same proteins to get rid of waste.)
Stretch and presence of food causes G-cells in the Antrum of the stomach to secrete the peptide hormone gastrin. Gastrin acts directly on parietal cells to secrete hydrochloric acid into the stomach lumen. In case those cells don’t respond adequately, gastrin also acts via intermediary enterochromaffin-like (ECL) cells that release histamine, which in turns activates parietal acid secretions. Eating complex macromolecules, rather than simple refined sugars, may activate more levels of regulation for processing.
Every day before anatomy lab, Jane and I watch the corresponding Acland videos, fascinating dissections by Robert Acland, the late surgeon and clinical anatomist who developed important microsurgery techniques. We get so enthralled by these that we have to stop ourselves from watching too far beyond the upcoming dissection.
This week we opened the peritoneal cavity, revealing the stomach, intestines, liver, pancreas, and spleen. Several cadavers, including mine, had appendectomies. My group’s liver felt rock solid due to cirrhosis. One cadaver had sigmoid colon volvulus: her sigmoid colon had twisted around itself, causing pressure to build up and stretching the typical 1.5-foot section to three times the normal diameter and twice the length. It looked like a massive caterpillar. One student stepped out due to nausea as her group accidentally sliced the colon, causing feces to ooze out. That’s something we didn’t see Robert Acland do.
A pediatric surgeon joined my anatomy group. She was was wonderfully helpful with a story to go along with every structure. She commented that our cadaver had been good for GI surgeons, with at least three abdominal surgeries: appendectomy, hysterectomy, bariatric surgery (stomach stapling). Darwin was interested in the origin of species; GI surgeons look at the “origin of appendixes.” Surgeons look for an odd triangular fat fold at the ileocecal fold to locate the appendix during appendectomies.
I stayed late with the surgeon to dissect the vessels near the pancreas, which is nestled in among the stomach, spleen, and transverse colon. “Never touch the pancreas,” she explained. “In surgery, all those pancreatic digestive enzymes can leak out and start digesting organs.” I cut the pancreas to reveal the deep structures behind. I saw how the splenic artery runs with the pancreas to the spleen. The splenic vein then travels across the pancreas to fuse with the inferior and superior mesenteric veins to form the massive portal vein. Working in the cramped space gave me an appreciation for why pancreatic cancer is so difficult to remove surgically.
Our patient case: “George,” a 55-year-old combat veteran with a history of alcohol abuse, pancreatitis (inflammation of the pancreas), and liver cirrhosis. He presented with jaundice, clay stool bowel movements and dark orange urine. These symptoms pointed to issues with the liver and pancreas for our differential diagnosis. Blood work showed vitamin deficiency and anemia. An x-ray revealed a pancreatic tumor mass obstructing the Ampulla of Vater. This prevented pancreatic enzymes and bile from being secreted into the duodenum of the small intestine. In a healthy person, bilirubin, the toxic product formed from recycling red blood cells’ hemoglobin, is transferred into the duodenum with bile from the liver. Gut bacteria convert this into stercobilin which is excreted in feces giving it its characteristic dark color. George’s obstruction caused a buildup of bilirubin in extracellular tissue, blood and urine. The tumor was inoperable and he was referred to hospice care, where he passed away after eight months.
George’s wife came in to discuss her experience along with a nurse and a social worker who had managed George’s “home-care hospice” case. The nurse manages 10-15 patients and makes up to 5 home visits per day. Many of these visits are pain management emergencies. A student asked if there was ever an issue with opioid abuse? She responded, “We err on the side of the patient. If the patient tells us there is an issue we listen. The prescriptions are for two-week periods.” She explained that prescription is typically methadone, a slow-release opioid which has less addiction potential, but in the last year the hospice facility has tried to tighten control of opioids. “I dealt with one case this year where the family was stealing pain pills from granny.”
“You are the gateway to hospice care,” continued the nurse. “Saying there is nothing more I can do as a physician for a patient that you may have been caring for decades is heartbreaking. The patient transitioning from aggressive care with hope to comfort care is similarly heartbreaking for the family.”
George’s wife described how helpful hospice care was for her family. She described being crushed by the immense requirements for medical appointments and medications during chemotherapy. “We had no time to think about what comes next. We had no chance to enjoy the time he had left.” George was able to live at home for his last eight months. The case manager described how hospice care allows families to plan and come together: “When the white flag goes up people have time to adjust. An estranged brother or daughter will travel to reconnect with the family.” The nurse added, “People think someone in hospice care is going to die within a week. That is simply not the case. Most are there for several months to even one-and-a-half years.”
The case manager added that hospice centers have coordinated care with other facilities to meet a patient’s needs. “If a patient’s last wish is to go to the beach, we’ll coordinate care with a local facility.” The team will typically attend a patient’s funeral.
One student asked about assisted suicide. Although illegal in this state, the nurse believed it should be a terminally ill patient’s choice. Some do ask about getting transported to Michigan or other states where it is legal. The nurse commented how one Huntington’s patient made the decision to starve to death. George’s wife commented how George considered assisted suicide. “He would never take his own life but he did ask about assisted suicide. If it wasn’t for me and his son, I believe he would have done it.” The panel concluded by stressing the need to have end-of-life discussions with patients early, before terminal disease states, and promoting patients to have an advanced directive (or living will).
At lunch our class discussed the cost and quality of end-of-life care. More than 80 percent of patients living with a chronic disease claim they want to avoid hospitalization and intensive care during the terminal portion of their illness. However, in 2005 the CDC estimates that only 25 percent of deceased died in their own home. In 2008, Medicare spent $55 billion for the last two months of patients’ lives (CBS). One-quarter of Medicare expenditures are for care in a beneficiary’s last year of life, an unchanged ratio from twenty years ago.
The next day, the state’s chief medical examiner gave a lecture on opioid abuse. “Sherry” is a trained pathologist who conducts autopsies on suspect deaths and public health crises (at a much lower salary than if she were practicing).
According to Sherry, heroin use became widespread in the 1960s when addicted Vietnam veterans returned home. Poppies were cultivated in Vietnam. The 1980s cocaine boom caused a decline in heroin. “We have Kurt Cobain to thank for bringing back heroin with 90s Grunge.”
“You will quickly realize that today’s opioids are nothing like yesterday’s heroin when you go on your ED [emergency department] clinical rotation,” explained Sherry. “You’ll see several ODs in a given night.” In 2013, drug overdoses became the U.S.’s number one cause of unintentional death. Heroin is found in urban centers whereas pills are found in more rural and suburban areas.
“Street” heroin used to be cut to 6-7 percent purity, thus requiring intravenous injection to get high. This drove Hepatitis C infections, which Sherry said have declined due to access to clean insulin needles from Walmart and the increasing purity of heroin. Today’s 20-percent-pure heroin can be snorted: “Without the needles there is no social stigma.” Sherry said that students are trying heroin in the same way that older generations might have tried alcohol and marijuana. 1 in 13 high school students in our area admitted to using heroin.
“Do not touch any bag or foil you might find in the ED!” Sherry exclaimed. “If you touch it, you could overdose and die.” Synthetic opioids are now so powerful that some act through absorption through the skin. Pure heroin is about twice as potent an agonist (binds to mu-receptor producing “high” response) as morphine. Fentanyl, quite widespread now, is 100 times as potent as morphine. “The new rave is carfentanil. Addicts are quite excited about this one, 10,000 times as potent as morphine and used to put elephants down. Drug labs and health workers are petitioning for access to the opioid-blocker Narcan in case of skin contact with carfentanil.”
“Drug dealers are actually quite brilliant businessmen,” Sherry explained. “They realized the demand does not go away after the prescriptions are cut off. Police try to suppress the names of individuals who overdose because users will look for his or her dealer. The overdose means that the product must have been good.Some dealers purposefully overdose a client because it boosts sales.”
A student asked what she would recommend doing to prevent this epidemic. “Death penalty for heroin dealers,” she laughed and continued, “Loved ones see the signs of drug abuse but they do not realize how serious they are. With the potency and variability of drugs these days, you can overdose on the first high, or the hundredth high.” She also cautioned us that the gateway to addiction is frequently prescriptions from physicians. The individual who overdoses is on several prescriptions: antidepressants, anti-anxiety, sleep. “These are people connected to the healthcare system. These mental illnesses present as physical pain such as back pain. It takes one doctor to overlook the mental cause and prescribe painkillers for the physical pain.”
Sherry said that prescription opioid abuse has been reduced by prescription monitoring networks. “A few years ago, drug addicts were able to state-hop because these monitoring networks would not talk across state lines.”
Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 1 night. Example fun: drinks at classmate’s apartment with about 10 other students, followed by the downtown bar scene (everyone else) and home (me and Jane).
For the life of me, I cannot understand how we live in a country where opioids so powerful that skin contact can kill you are part of a high-fatality opioid epidemic, yet apparently it’s becoming impossible for the government procure the drugs with which to exercise the death penalty “safely”. How on earth can both things be true?