Proper blood pressure taking technique and what is an auscultatory gap??

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In my second quarter of year two med school we are covering the cardiac system (2nd time since last year, but in more depth). We learned how to take a blood pressure last year and did some extensive practicing fall quarter this year, but we’re back at it again for the cardiac system. One step of the blood pressure taking technique we are taught is after applying the cuff we are to take the patient’s wrist and check for their pulse. We are to continue checking the pulse as we inflate the cuff so we know when the cuff is at the point where it is blocking the flow of blood. Inflate the cuff another 20 mmHg of pressure then listen with the stethoscope on the brachial artery as the cuff slowly deflates. We are listening for the blood as it begins to flow again as the cuff is deflating.3712792250_472cd5fa9c_z

 

 

 

 

 

 

 

 

What was surprising to me was that most clinicians that have taken my BP have not checked the pulse while inflating the cuff. Talking with my peers and instructors we found we’ve shared this experience. I’ve watched a clinician taking my BP pick a random number on the BP dial and inflate to that number. Here’s where the problem can come in: if there’s an auscultatory gap. An auscultatory gap is the temporary disappearance of the blood flow sounds while the cuff is deflating.

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It is most often seen in older patients and it is strongly associated with hardening of the arteries. The problem with not checking the pulse while inflating the cuff is that the patient’s blood pressure could be grossly underestimated if the reading is unintentionally begun in the gap. Checking the pulse ensures that the top, and true, systolic pressure is reached before beginning the reading.

 

 

 

 

 

 

mind-the-gap

References:

Frech, T. M., Penrod, J., Battistone, M. J., Sawitzke, A. D., & Stults, B. M. (2012). The prevalence and clinical correlates of an auscultatory gap in systemic sclerosis patients. International Journal of Rheumatology, 2012, 590845. doi:10.1155/2012/590845

Cavallini, M. C., Roman, M. J., Blank, S. G., Pini, R., Pickering, T. G., & Devereux, R. B. (1996). Association of the auscultatory gap with vascular disease in hypertensive patients. Annals of Internal Medicine, 124(10), 877–883.

Drinking liquids during meals… is it healthy?

I’ve been thinking about this topic for awhile. Actually, since one day in my physiology class last year. We were talking about gastrointestinal motility patterns.  And why would that be the one on my mind recently? While we were learning about how fast different meals empty from the stomach I was thinking about something that I had heard about back in my days of reading random things on health and nutrition. Somewhere there emerged an idea that drinking water with meals was detrimental to digestion.Bella eating zucchini bread

The suggestion was that the water would lower the pH level of the stomach and dilute the digestive enzymes, thus making food harder to digest. According to the internet this could cause indigestion, heartburn, irritability, bloating, lethargy, headaches, insatiable cravings, inability to determine hunger, depression. I’m wondering if it also caused the dust all over my house and those pesky lost socks!

I never could get truly into this way of eating because I quickly found that telling myself that I couldn’t have liquids during meals made me want them that much more! Not to mention there are several foods that are a challenge for me to swallow without liquid.article-2238428-005CD67400000258-197_233x423

What we learned in physiology that day was that the rate that liquids empty the stomach is faster than any other component of a meal.

Gastric emptying

The figure to the right shows that liquid empties from the stomach in about 20 minutes, much faster than the semisolid or solid foods, which take from 60-100 minutes. So, the liquid isn’t going to be in the stomach for long, messing with your stomach pH. Second, the pH of the stomach is LOW, about 0.7 to 3.8 which is very acidic. So acidic that there isn’t much that can change that except food, which only brings it up a small amount.

In my undergrad I did some experiments in chemistry with making an acidic solution less acidic (more basic), and I can tell you without a doubt  that water alone is not going to change the acidity of a mixture.  The other thing happening in your body is what physiologists call the cephalic and gastric phases of digestion. In the cephalic phase we are thinking about and anticipating eating. As you are preparing your meal and just about to sit down to eat it you are anticipating eating it and this is releasing gastric juices in your stomach. The gastric phase is while we are eating and our body releases more gastric juices.

The summation of all this is that drinking liquids during your meal is not going to lower your stomach acidity. You are still going to make plenty of stomach acid (providing things are working correctly in that area in the first place), and none of the liquid you are going to normally drink is going to change the pH level of that stomach acid.

So if you want feel free to enjoy your beverage with your meal again!Flash-Chill-TAKEYA-Iced-Tea-Beverage-System

References:

Rhoades and Bell,  2013, Medical Physiology: Principles for Clinical Medicine, fourth edition, (pgs 494-495, 509)

Elderberry syrup

Something that is well known for this time of year is the flu, the upper respiratory flu, not the stomach flu. I’ve decided to write a post about this for several reasons: 1) it’s usually on everyone’s minds during pre-winter and winter season, 2) it’s going around in the Seattle area right now based on this article, 3) I happened to learn a few things about it in Botanical Medicine lab fall quarter. We had a final project requirement of preparing two herbal preparations (one internal, and one external) to target a specific health condition. I chose to target influenza A because I had read some research in the past about Elderberry extract having a significant impact on the duration and severity of symptoms of influenza. I became slightly obsessed this summer with wild harvesting my own elderberries on one of our trips to Eastern Washington and making my own elderberry syrup. So it was natural that I decided to make one of my preparations for this project elderberry syrup.

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I’ll share with you part of my write up for my project.

“Influenza is caused by an orthomyxovirus, an RNA virus that infects the upper respiratory tract. Most influenza is caused by influenza virus type A, and although some illnesses are caused by type B, type A is more severe and is more commonly seen. Influenza is typically characterized by fever, myalgia, headache, sore throat and cough. Although the illness is typically self-limiting in 5-7 days, it is nevertheless important to address due to its ease of communicability(it’s easy to catch), short incubation period (doesn’t take long from the time you’re exposed to getting symptoms), related loss of productivity(can’t get to work, school, etc), and risk of morbidity in certain at-risk patients.

The elderberry syrup I made consisted of Sambucus nigra ssp. cerulea, also known as Blue Elderberry. This was the main herb for my target condition because I have known for some time the research showing Sambucus nigra extract having powerful antiviral effects, and the ability to shorten the duration of influenza. I also knew it was possible to wild harvest it in Eastern Washington during the late summer. Since it was my main herb I chose for addressing influenza I will share some extra information about it.  Sambucus nigra, black elder, has been used for centuries in folk medicine as treatment for colds, influenza and sinusitis. The berries of elder contain high levels of flavonoids that have been shown to have antiviral activity against several different viruses, including influenza virus. The main flavonoids in elderberries are the anthocyanins cyanidin 3-glucoside and cyanidin 3-sambubioside, and it has recently been demonstrated that these substances are detectable in blood plasma after oral ingestion of elderberry extract. Raw honey is used to increase shelf life, flavor, and for its antiviral properties. Clove and fresh ginger are added to enhance the flavor profile.

I chose a syrup because it is tasty, easy to take, and quick and easy to prepare. The syrup can be made in a fairly large quantity if you are able to wild harvest many quarts of fresh elderberries. The syrup can be made up and it will last for about 3 months with refrigeration, and can also be frozen. Also, the berries can be frozen and the syrup made up as needed.”

I’ll include my recipe write up from my project, which is also available in the below references from Rosemary Gladstar’s book. I used honey since that’s what she recommended but I’ve noticed syrups on the market use vegetable glycerin, and since I have that I’ll try that next time. Please never give honey to infants under the age of 2.

Rather than making syrup in the past I have purchased encapsulated elderberry extract. That might be something to look into if making your own doesn’t work for you. Check with your health care provider before making any decisions about your health and check my disclaimer here.

Elderberry Syrup  

Supplies:

  • Large pot
  • Fine mesh metal strainer
  • Sterile canning jars or container of choice
  • Tongue depressor or chopstick

Ingredients:

  • 2 quarts fresh ripe elderberries, Sambucus nigra, Caprifoliaceae family; (I wild harvested Sambucus nigra ssp. cerulea found commonly in Eastern Washington)
  • ¼ cup water
  • ¼ ounce freshly grated gingerroot, Zingiber officinalis, Zingiberaceae family
  • ½ teaspoon ground clove flower buds, Syzygium aromaticum, Myrtaceae family
  • Honey

Directions:

  1. Combine elderberries with ¼ cup water in large pot and simmer over medium heat until soft.
  2. Strain out pulp, reserving liquid
  3. Return liquid to pot, composting pulp
  4. Using tongue depressor or chopstick measure amount of liquid, marking level on tongue depressor or chopstick
  5. Add ginger and cloves and simmer, uncovered, until liquid reduces to half its original volume (use marked tongue depressor to check)
  6. Pour juice into measuring cup and note volume
  7. Return to pot and add equal amount of honey, stirring to combine thoroughly
  8. Let cool, then store in sterile bottles in refrigerator
  9. Use within 12 weeks or freeze

References

Couch, Robert B. “Medical Microbiology.” 1996. ncbi.nim.nhi.gov. 6 December 2014. <http://www.ncbi.nlm.nih.gov/books/NBK8611/&gt;.

Gladstar, Rosemary. Medicinal Herbs A Beginner’s Guide. Storey Publishing, 2012.

Kinoshita, et al. (2012). Anti-influenza virus effects of elderberry juice and its fractions. Bioscience, Biotechnology, and Biochemistry, 76(9), 1633–8. doi:10.1271/bbb.120112

Krawitz, et al. “Inhibitory activity of a standardized elderberry liquid extract against clinically-relevant human respiratory bacterial pathogens and influenza A and B.” BMC Complementary and Alternative Medicine (2011): 11:16.

Zakay-Rones, Z., Thom, E., Wollan, T., & Wadstein, J. “Randomized Study of the Efficacy and Safety of Oral Elderberry Extract in the Treatment  of Influenza A and B Virus Infections.” Journal of International Medical Research (2004): 132–140.

Surviving Gross Anatomy Lab

I think this is the class that marks a student’s entrance into medical school. I know for me this is the class that made me feel like I was a real medical student. Some people are pretty nervous and squeamish about cadaver lab.  I was not one of those people. I was super excited and couldn’t wait to get started! At Bastyr we are expected to wear a thick, reusable hazmat suit and ventilator mask with filters graded for formaldehyde. There’s been some unfortunate criticism of Bastyr for this policy. There’s been opinions expressed that our cadaver lab is old, outdated, not well ventilated and a definite negative to the school.  I did not find any of these rumors to be true. It’s possible that the lab might seem “old”; the building is older, but I don’t find that a negative. We have everything we need in the lab to make it useful. The ventilation is up to standard, it is approved by OSHA as having safe levels of formaldehyde exposure to medical students.  The hazmat suit and mask are required to protect the health (especially the liver) of the student.  The room has a bank of window on one side that bring in lots of natural light. Additionally, the professor that runs the lab keeps ferns growing all over the lab to make it less sterile feeling and to enhance filtration of the air. All that said, I wouldn’t spend much time in the lab without my suit and mask. I found it much easier to dissect when I didn’t need to worry about anything soaking into my clothes. The more covered you are the less likely you are to smell of formaldehyde once you leave the lab.

As far as studying for and learning gross anatomy: lectures in the theory part of gross anatomy were slightly helpful, although just studying from the competencies seemed sufficient if I couldn’t make the lecture.  The gross lab instructor held optional tutorials once a week, both outside of lab which were lecture/drawing style, and a tutorial inside the lab where we could see the parts on a prosection. I found both of these immensely helpful.  The other option provided, and highly suggested, is to go into the lab at times other than your normal lab time and go through the structures you are currently learning. I found this the least helpful, partly because during the majority of the year I was in gross lab these were only allowed at specific times and there were usually a lot of people in the lab, especially right before midterms or finals. I found it hard to concentrate with so many people walking around and talking and discussing. Often I found that I would think one thing and someone would tell me it was something else. It seems like every time that happened it would turn out with later checking that I was right and they were misleading me.  Not a big deal, but frustrating for me when I was on the right track and was convinced I was wrong.  So the lesson is trust your instincts if you think you may  be right. The other study techniques that I found most helpful were studying from Rohen’s Color Atlas of Anatomy. I would go through the pertinent pages and quiz myself based on the photos. This might not work for everyone, you have to be able to think and imagine in 3D for this to be highly successful. I found it worked quite well for me. The other techniques I used were drawing, lots and lots of drawing! You don’t have to be good at drawing, as long as it makes sense to you it’s going to help.

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This is a great drawing, not mine! But something to give you inspiration.

My first quarter of ND medical school

I’m in my 2nd year of Naturopathic Medical school at Bastyr University. I plan on writing more posts about classes I’ve taken and my suggestions for how to succeed. I also plan on writing about my experiences in seeing naturopathic medicine at work in the clinic where I observe. At the end of my 2nd year I will be what was formerly known as a secondary student clinician. More on that later… For now I want to start at the beginning.

My first experience with ND medical school was the pre-quarter before first year. This was over a year ago in July of 2013.  I opted to take some of my fall classes the summer before. I had taken time off beforehand so I was ready for classes. I didn’t want to wait any longer before jumping in since I’d already had some time off.  My first classes were Integrated Structure and Function, Research Design, and Constitutional Assessment. 12.5 credits.

ISF – This is an integrated class meaning they attempt to combine Histology, embryology and biochemistry teaching all three separate but trying, where possible, to integrate concepts across molecular, cellular, and tissue levels. At this point it didn’t seem very integrated. I think it’s difficult to integrate all these different studies exactly. The integration aspect was much more obvious with the later classes in fall and beyond.

Overall you will be learning the basics in all three disciplines. Histology in the summer quarter included a lab time. This was great and from what I understand it was not offered in the fall quarter. I feel lucky that I had this lab time. Our instructor was great at making the ideas and concepts come alive. She insisted we have a histology lab book where we were required to do hand drawings of the tissue types we studied. This is an excellent way to learn. My biggest and most important piece of advice that I can give is to draw your way through the first year.  I had hoped in my undergraduate when I had to take that art elective that my drawing class would help me later, and it did!

For this notebook we had to sketch the tissue at a certain magnification and answer a few questions. I recommend also listing the function of the tissue, how it differs from a similar looking tissue and any structural hints for recognizing it later. The other thing I did that helped me learn them very quickly was I downloaded a program called Anki. A few classmates also did this and together we would find pictures online of the tissue we were studying and paste them into Anki and make our own “intelligent” online flashcards that we could share. Anki is a simple program available for free on all platforms. This made it easy to study for a few minutes wherever I was. It also has a way of figuring out which cards you still need to study more and which you can study less. I wish I could have used it more during the year but it is time intensive to get your study set together and I just didn’t usually have time to set it up. I think the most important idea for studying is that you are building something with the material you are studying. I have notebooks full of drawing and notes, lists, structures, etc. It was the process of building these that helped me more than actually studying them. Along this line just using someone else’s notes to study from might not be enough. There were lots of people sharing beautiful, organized, highly detailed notes, but it just didn’t do it for me to passively use these to study.

Research Design class was pretty straightforward. Read the text, go to lecture, take the online quizzes. Not difficult material, especially if you’ve had any exposure to types of research. Definitely useful material that you will need to be familiar with later. Also some training in how to access research articles.

Constitutional Assessment – a very, very basic overview of different modes of assessing a patient’s constitution. From Ayurveda, to Chinese medicine, tongue diagnosis, pulse diagnosis, really basic intro to homeopathy, and humors. Really basic, easy class. Don’t expect too much and you won’t be disappointed. Gives you an idea of what you might be interested in pursuing in more detail at a later date.