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DR. STEMMLER’S MONTHLY TEACHING ROUNDS

AUGUST, 2000

Clinical Story of the Month         

(Copyright Stemmler 2000)

A Tummy Ache Leads to Surgery and Surgery Leads to a Tummy Ache

Terry McLaughlin had just turned 60. A big birthday party out on his familyís Texas ranch brought over 100 friends and family members together. A well-known Houston restaurant catered a lavish Lone Star BBQ: brisket, pork, chicken, sausage, potato salad, cole slaw, baked beans and the finest chili, North of the border. And, of course, all the beer a big keg could hold.

The men went to an early morning hunting trip Ė "just quail," as Mr. McLaughlin put it to me, but the real fun was in the camaraderie, the walk with the dogs, and just being out on a crisp spring morning, before the heat of the summer would keep everybody Ėeven the dogs Ė inside.

Mr. McLaughlin loved his birthday party, but the pain was always in the way. A pain he had endured for 30 years, since two feet of his small intestine were removed during an emergency surgery to "unblock his intestines." Twenty years later a second surgery was done to remove 2 more feet of his small intestine in order to excise his "adhesions," the sticky scarring that often forms after surgery, especially after abdominal or pelvic surgery, a situation that often leads to chronic pain. Now, ten years later, Mr. McLaughlin lived with abdominal pain, day and night, in addition to having around 8-10 bowel movements a day Ė hardly a situation that would make a birthday party a fine experience. And recently a most annoying symptom had added to his misery: pain on the tip of his penis and in his testicles.

When I first saw Mr. McLaughlin he looked chronically debilitated. A kind man with a twinkle in his blue eyes and a beautiful smile, his fatigue was revealed in his voice, in the examination of his pulses and tongue, and in the coldness and weakness of his abdominal wall. He loved airplanes, and I had many stories to tell him while distracting him during the needle insertions. A well-educated, logical man, he initially wondered what acupuncture could do for "adhesions," since this seemed to be a mechanical problem. Judging from his general status, though, I felt that the adhesions were just partially causing his pain. Most likely his pain was due to a long-standing "stagnation of Qi," which originally may have even led to the intestinal obstruction and later, after each surgery, had progressively worsened. Pain over 30 years has a debilitating effect by itself, and it will further compromise the healthy circulation of "Qi." So I decided to work on strengthening his "Qi" and thus improve his pain. I planned 12-20 sessions and predicted good chances for great improvement, but, because of adhesions after 2 surgeries, perhaps a 100% resolution was not possible. On the first treatment I used both Chinese body points and Korean hand points, heating all of them with a moxa stick. The patient was also instructed in the use of moxibustion at home, especially on some of his abdominal points. I also suggested he use a hot water bottle against his abdomen during the night, since his sleep was often disturbed by the pain. His type of pain (Yin type or "cold") will often worsen during the night, when the Yin curve (dark, cold, quiet) of the Yin-Yang-night-day cycle, (where Yang is its bright, hot, active opposite and in balance), dominates over Yang. In addition, Mr. McLaughlin was also given a Chinese herbal combination to help with the "blood stagnation in his abdomen." When he returned the next day, he reported not having any pain after his treatment and was sleeping through the night. His testicular symptoms had changed from a pain into a "discomfort." After 3 treatments his testicular pain as well as the pain in the tip of his penis had completely resolved, to never come back. He began to feel better, yet continuing to have frequent bowel movements and abdominal pain, although less intense. A second herbal combination was added at his 6th visit, which had "tonifying" qualities. In the mean time the patient maintained his moxa treatments at home, once or twice a day, as instructed. By the 8th visit he reported doing "much better," and after 9 visits he began to show signs of "strengthening Qi:" a four-pound weight gain, not feeling as cold, less frequent and less intense abdominal pain, and a decrease in the frequency of his bowel movements from 8-10 to 5-6 formed stools per day. Having lost 4 feet. of his intestine, the patient would most likely always have more bowel movements than a normal person. From my perspective he looked better and his voice was stronger on that visit. The patient expressed great satisfaction and pronounced that "he could live with this." Of course, he was coming from a Western medicine background where any improvement counts, often even as modest as 10-30%. I reassured him that he did not need to settle for what he had accomplished so far, however fantastic it might appear to him as compared to his years of suffering. Instead, I suggested he could expect a much better outcome with this approach.

On the 11th visit he was happy to report that he ate chili and still felt well, an unusual gastronomic experience for him. By the 12th visit he said he felt "80% better" and, again, mentioned he knew "he had to live with a little bit of pain." "Perhaps," I said, "but we can do better than 80%." After 14 visits his pain no longer occurred daily; only "occasionally, much less intense and in short bouts." I suggested we should aim at 90% and then consider a maintenance program. After 18 visits he was delighted to report to be "90% + better." We had three more treatments and then planned a tapering schedule (from 2 times per week, to 1 time per week, to once every 2 weeks, to once every 3 weeks and, finally, once every month) with a goal of either keeping him at 90% improvement or even slowly raising this outcome to 93 or 95%.

As many patients who feel better, Mr. McLaughlin did not return for his maintenance program. I had proposed 12-20 sessions and he indeed completed 20 treatments. A follow-up call to him 3 months after his last treatment found him in good health, and looking forward to his next birthday cook-out, where he could join his family and friends in uninterrupted conversations and the pleasures of a good Texas BBQ.

WHATíS NEW IN MEDICINE

(COPYRIGHT STEMMLER, 2000)

"Cardiopulmonary resuscitation by chest compression alone, rather than with mouth-to-mouth ventilation, results in higher survival"

Two hundred forty-one patients with an out-of-hospital cardiac arrest were assigned to receive chest compression alone, and 279 patients with the same condition were assigned to receive chest compression plus mouth-to-mouth ventilation. Both procedures were performed by bystanders at the scene, following instructions given by telephone dispatchers from an emergency medical care system in Seattle, WA.

According to the results of the study, the outcomes of both approaches were similar, but the authors suggest that chest compression alone may be the preferred approach for bystanders inexperienced in CPR.

(From: Hallstrom, A. et al. "Cardiopulmonary Resuscitation by Chest Compression Alone or with Mouth-to-Mouth Ventilation." New England Journal of Medicine. 2000; 342: 1546-53, and from : Ewy, G.A. Editorial, "Cardiopulmonary Resuscitation: Strengthening the Links in the Chain of Survival." New England Journal of Medicine. 2000; 342: 1599-1600.)

COMMENTS:

Most out-of-hospital cardiac arrests result from an abnormal cardiac rhythm, known as "ventricular fibrillation," which is a common consequence of the heart muscle being starved of oxygen, as it happens in a heart attack. It has been established that if CPR is initiated within 4 minutes of the event, 43% of the patients survive and are able to leave the hospital at a later date. Yet, if the CPR is not initiated until 8 minutes, only 7% of patients survive and, after 16 minutes with CPR, no patients survive.

As soon as paramedics arrive, the most effective treatment for a patient in cardiac arrest is electrical defibrillation. But such an intervention is useless, unless the patientís heart and brain have received enough blood circulation to benefit from such defibrillation. The traditional basic CPR protocol was as follows:

    1. Patient flat on his back, chest stripped, operator kneeling by his side.

    2. Nose pinched, chin lifted, head bent back.

    3. Operatorís mouth covers patientís mouth and 2 deep breaths are blown into the patientís lungs.

    4. Heel of one hand on center of patientís chest, between nipples Ė second hand on top of 1st hand. Pump chest 15 times, pushing down on heels of hands1-2 inches deep.

    5. Repeat steps 2 and 3.

    6. Repeat 4 and so on.

Such "breathing gaps" in between 15 pumping cycles often result in only 39 compressions per minute, versus 84 compressions per minute with chest compression alone, which is much closer to a "normal pulse rate" and more efficient heart activity and brain preservation. One incident shows how this difference is perceived from a bystanderís perspective. According to a report mentioned in the 2nd article from the above references, a female bystander performing CPR on a man in cardiac arrest, following the traditional chest compression and mouth-to-mouth protocol, asked her dispatcher, "Why is it every time I press on his chest he opens his eyes, and every time I stop to breathe for him he goes back to sleep?" Obviously the man was slipping into unconsciousness anytime pumping was interrupted. It is therefore now recommended that if you find yourself in a situation where you have to perform CPR, you follow step 1 and just lift the patientís chin and bend his head back, after which you start active chest compressions to a count of 50. Then take a quick break and make sure the airway (chin up, head back) is still open. Resume pumping.

Donít ever shy away; go ahead and pump! You may save somebodyís parent or child by this simplified CPR approach. Good luck and thank you so much!

Christina Stemmler, M.D.


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