Tuesday, March 22, 2011

How Does a Professional Athlete Get a Pulmonary Embolism???

Upon hearing that Serena Williams got a Deep Vein Thrombosis(DVT), it was easy for me to call on my medical knowledge and understand how this happened. I teach a lecture on DVT and Pulmonary Embolism (PE- a blood clot in the lung) for nurses new to critical care. This is my thing. Though I work in cardiology, I take often take care of patients with PE. When the lungs are impacted by a large blood clot, the heart is under stress. This can cause symptoms similar to a heart attack. So I figured I would write a blog on the topic since what is obvious to me might not be to those in other lines of work.

Disclaimer- I am a Nurse Practitioner, and work in cardiology, but the purpose of this blog is not to provide diagnosis. I am happy to provide references for any of the information provided. If you have any of the symptoms listed, please contact your medical provider or go to your local Emergency Department if they are severe.

Understanding the terminology:
DVT (Deep Vein Thrombosis)- a blood clot in a deep vein, usually in the leg or arm, which obstructs blood flow. This eventually causes impaired circulation and swelling.
PE (Pulmonary Embolism)- a DVT that dislodges and moves to the lung. This often causes difficulty breathing, and in instances of massive PE can cause cardiac arrest.
VTE (Venous Thromboembolism)- the "catch phrase" for DVT and PE

Some alarming statistics:
- 900,000 people in the US have an initial or recurrent DVT or PE each year
- An estimated 200,000-300,000 people die each year from PE
- 25% of PEs present as sudden cardiac death
- PE has a "Golden Hour". In 2/3 of fatal PE cases, cardiac arrest will occur in the first 1-2 hours
- PE causes more deaths each year than AIDS, breast cancer, and motor vehicle collisions combined

How does someone develop a PE?
Three major risk factors (Virchows Triad) predispose people to DVT and PE:

1. Venous Stasis (aka poor blood flow)- anyone who has surgery, illness, is on bedrest, is hospitalized has venous stasis. Even prolonged periods of inactivity can lead to venous stasis. It isn't just long plane flights, but also long car rides, and periods of immobility at your desk or on your couch.

2. Hypercoaguability- I always think about this as "sludgy blood". Things that dehydrate you make your blood thick, as well as some other factors. Dehydration, oral contraceptives (ever wonder why they tell you not to take birth control bills and smoke? Huge increase in DVT risk), pregnancy, tumors/cancer, blood clotting disorders are among the causes of hypercoaguability.

3. Vascular Damage- Surgery, trauma, burns. Anything that damages the blood vessel walls increases the risk of clots.

What are the symptoms of DVT/PE?
Symptoms of DVT include:
- Pain/discomfort in one or both of the legs (or arm)
- Swelling/Redness/warmth in one or both of the legs (or arm)
- Reduced ability to tolerate walking/exercise

Symptoms of a PE are often difficult to diagnose. When the PE is small in a healthy person, the symptoms are vague. When severe, the symptoms can mimic a heart attack.
- Sudden onset of shortness of breath, pain associated with breathing fatigue, decreased tolerance for activity, cough (sometimes coughing up pink foam).
- Massive PE may lead to low blood pressure, abnormal heart rhythms, and
- Again, the presentation can be vague. It is often the patient history that provides a hint to the diagnosis.

How are DVT/PE diagnosed?
Ultrasound of the affected limb is used to diagnose DVT.
CT Scan of the lung is used to diagnose DVT/PE. A different scan called a "V/Q Scan" can be used to diagnose PE in patients who have contraindication to CT Scan.

How are DVT/PE treated?
Patients are given blood thinners. These prevent further clot formation and allow the body's natural clot-busting system to do its job and break up the clot. This does not happen quickly. The body may take several weeks to dissolve a clot. In some instances of massive PE, patients may be given a clot-busting drug (similar to those given for strokes and heart attacks).
There are also surgical procedures for patients who cannot receive blood thinners or clot busters. A filter can also be placed to "catch" the clot before it gets to the lung in some patients.

How can you prevent DVT/PE?
- PE is the leading cause of preventable death in hospitalized patients. If you are hospitalized, ensure you are ambulating regularly, or ask what you are being given for DVT prophylaxis. You may receive shots in the abdomen, or "leg squeezers" (pumps that mimic the circulation changes with walking) to prevent DVT.
- If you are going on a long trip, hydrate, get up and walk around at least every two hours. Remember that this includes car trips. You can also use compression socks, and pump your legs if you aren't able to get up and walk around.

So how does a "healthy person have a DVT"?
I am not privy to Serena Williams' medical records, but from listening to interviews it is easy to figure out.
1. She gets a cut on her foot. Vessel Damage
2. She travels a lot. She is also at an age where she might possibly be on oral contraceptives. Venous Stasis

Listening to her interview on the Today Show, she thought she was just out of shape. Her symptoms were vague.

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She was eventually taken to the Emergency Room and diagnosed with PE. To treat this, she was placed on a blood thinner (shots in the belly). As a result of the blood thinner, she developed a hematoma (collection of blood) in her abdomen. Who would have thought????

David Bloom, the NBC reporter, died of a PE after ignoring the symptoms of DVT. He was embedded with troops in Iraq, spending lots of time immobile in a tank. He described symptoms of a DVT to physicians, who urged him to get treatment. He was driven to continue with his work, and suffered a fatal PE.

Whew- a long post! So what is the point? While hospitalized patients are at higher risk, healthy people who suffer injury (or even just travel a lot)are at risk, too. So if you took a minute (or ten) to read this, perhaps it will come in handy if you or someone you know have these symptoms.
Thanks for reading.

Sunday, March 13, 2011

No Answers...Time to Move Forward

So I write this post knowing that in comparison to what is going on in Japan, my health issues are completely manageable. Completely. I'm glad it is me and not a member of my family, and so far nothing is life-threatening. That being said, I haven't blogged in several weeks. There have been a couple of (very random) things going on for me.

Hearing Loss
I woke up three weeks ago with sudden hearing loss in my left ear. It feels like I am hearing under water. There is no infection/fluid/pressure in the ear. The hearing test two weeks ago showed that I lost hearing at the highest pitch in my left ear. They aren't sure what is causing it. The leading diagnosis is a viral infection of the nerve in my ear. I saw a Neurologist who is also an Ear/Nose/Throat specialist. No answers there- just orders for an MRI, a CT scan, and two more hearing tests.

As treatment for a potential nerve infection, they put me on steroids. It took about four days, and then I made the Energizer Bunny look lethargic. I was downright manic for two days. Both my sister and my partner at work wanted me to stay on the steroids (Mere so I can help her paint her walls, and Patricia because I was a data-collecting fool at work). Tommy was probably ready for them to stop! (I talk a lot to begin with...me on steroids annoyed even me!). Unfortunately, the steroids didn't fix the hearing loss. I continue to feel like I have water in my ear, challenges with hearing in noisy places, and intermittent ringing in that ear. In the grand scheme, I will deal with it, but definitely frustrating.

SVT (Supraventricular Tachycardia)
Since the hearing issue is out of my control, Today was my EP (Electrophysiology) Study. In preparation (as only a nurse would do), I painted my toenails (who wants skanky toenails when you are in a hospital gown?!). You can read more about the procedure here (if you are really that interested). The bottom line is, they put three catheters in the vein in my leg (ok-groin) and tried to induce the abnormal heart rhythm. My bartender (aka anesthesiologist) was incredible. He had me asleep before they even stuck my leg with a needle. Of course they had to wake me up during the procedure because they were having trouble inducing the rhythm.

When I run hard, my heart rate (normal rhythm) is in the 190s. With Isuprel (a medication) and a pacemaker, they were only able to get it up to the 170s-180s, and they couldn't cause the abnormal rhythm. I coughed, which was the only thing I could do. If only they had let me run on the treadmill or bend over and stand up...hard to do with huge catheters in the groin. They know I have two pathways for electricity, but couldn't burn on of them without inducing the rhythm (if they got the normal one, I would end up with a pacemaker). So from here I think it is just watch and wait. See if and when it happens again (frustrating because it isn't predictable), and consider a different medication. The first medication I was on (a beta blocker) really made me fatigued and down...I could not tolerate it for more than a week. (Of course I was on this the week before the steroids, so I went from loooow to hyper).

So no answers on the ear or the heart. I am a planner...I have pre-printed packing lists, and calendars, and like to PLAN. Apparently someone is teaching me a lesson. I'm going with the flow. I don't know if my hearing will come back, and I don't know if I will end up on another medicine for my heart rate. Again, in the grand scheme these are not insurmountable. They are just annoyances, and beyond anything I need to keep perspective. I said I would have my pity party today and then suck it up and move on.

I am so thankful for my husband, for never complaining about my issues and picking up my slack. He truly is my best friend. I'm also thankful for my wonderful family, friends, and teammates, who give me a boost when I need it (and sometimes a kick in the pants!). I got a nice email from my teammate Ryan today. His business motto is always at the bottom of his emails, and today it definitely resonated. "Don't look back....forward motion is everything." Time to move forward.