Heart Surgery 101

In 2005, I was asked to write a piece for KnowledgeNews.net. This piece is copied below, with a few minor additions. It was prompted by the fact that former President Bill Clinton was undergoing a second open heart procedure. The piece was titled Bill Clinton’s Heart* and began like this:

“Today former President Bill Clinton will reenter the operating room, and surgeons will reenter his chest-fixing problems created when they did coronary bypass surgery last year. Surgeons are never happy about revisiting previous work sites. Once violated, your body’s tissues heal with scarring, and scar tissue obliterates the nice, neat, anatomical planes that make most surgical operations predictable.”

It’s purpose was to answer this question:

“How will President Clinton’s doctors do their delicate work? How does heart surgery really work?” Here is how, and even 17 years later the setting and procedures are pretty much the same, though the technology and materials have all continued to improve.

Setting the stage

The patient lies in the middle of the cardiac surgical suite, flat on his back under bright lights, painted with an ochre iodine solution from neck to knees, then draped in multiple layers of sterile plastic and cotton. A vertical screen separates his head and neck from the site of the surgical action.

Behind this screen, the anesthesiologist does his magic, infusing a cocktail of oblivion­ inducing drugs into the patient’s veins, inserting a tube down the windpipe, and ventilating him with a mixture of gases that keep consciousness mercifully at bay. On the patient’s left side, the pump team sets up shop, with a technician seated behind a low, rectangular stainless steel machine the size of a large desk. He’s all about plumbing, preparing the tubes that, within the hour, will carry blood from the patient’s stilled heart to the machine, through a cylinder where the dark purple blood picks up oxygen and turns cherry red, and then back again to the patient’s aorta for distribution to the body. Raised over the end of the table is a mammoth tray of tools–surgical hardware.

Getting in

The surgeon and scrub nurse wait on the patient’s right, the surgical assistant on the left. With one vertical slice down the middle of the chest and a buzz of the saw down the center of the breastbone, or sternum, the chest wall is breached.

The surgeon wedges a nifty little tool into the sternal split, and proceeds to crank open the chest. (At the end of the surgery, he will use something that looks like a meat hook to wind up the wire sutures that pull the edges of the bone back together. And later write a prescription for enough narcotics for several weeks.) As the bone comes apart, a shiny pink pillow puffs up from below, filling the gap. This is the lung, protected in a slippery, clear envelope called the pleura, which lines the inside of the chest wall and the outside of each lung, letting the lung slide friction-free as it expands and contracts.

With the bony gap widened to six or seven inches, the surgeon removes the spreader and gently pushes aside the right and left lungs, covering them in wet, protective cloths. He is now in the middle compartment of the chest, the mediastinum. There, in the center, in a protective, transparent little envelope called the pericardium, is the heart–a purplish, muscular little fist of an organ in its healthy state, pumping away with a powerful twisting contraction. Of course, since we’re doing heart surgery for a reason, it might be a pale, flabby bag, draped in yellow fat, contracting with a weak little squeeze.

Getting the Job Done

Getting in is the standard part. What happens next depends on what the patient needs. Sometimes it’s a new valve inside the heart, or maybe two. Sometimes it’s bypassing diseased coronary arteries on the surface of the heart with an artery brought down from the chest wall and attached beyond the blockage, or with a piece of a vein from the patient’s leg attached at one end to the aorta and at the other end beyond the blockage. Either way, the stitch work is so tiny that the surgeon wears glasses with little microscopes on the lenses.

Sometimes a bypass can be done without stopping the heart, and the surgeon sews in rhythm with the beat. But most times, the surgeon has to re-plumb the body, sending un-oxygenated blood from the right side of the heart out to the mechanical pump and depending on the pump technician to run the machine and send the blood back to the aorta. Then the surgeon stops the heart with a mixture of drugs, letting it lie peacefully in the center of the chest while the repairs get done.

Getting Out

Going on the pump and coming off the pump can be white-knuckle times. Sometimes there is trouble restarting the heart. Sometimes the patient has to go back on the pump. But if all goes well, backing out is largely the reverse of getting in, with many checks in place. All the tools and all the gauze sponges used for mopping up must be back where they belong (it’s surprisingly easy to lose things in a blood-soaked operating field). The inside of the chest has to be dry (no leaking of blood from anywhere). Even then, tubes are left in place in the chest to let oozing fluids drain to the outside for the first few days of healing. These come out several days later, with a hard yank and a stitch or two to close the hole. Then the sternum gets pulled back together with wire – it stays in there permanently. If the surgeon likes music in the operating room, and all has gone smoothly, the music sometimes gets changed to something a little livelier, and the skin gets sewn up. The surgeon’s work, he hopes, is done. It’s nature’s time to go to work and smooth over all the cuts and stitches.

*KnowledgeNews, Thursday, March 10, 2005

Anxiety: A Protective Emotion

“…Kids are different today, ” I hear every mother say
Mother needs something today to calm her down
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of her mother’s little helper
And it helps her on her way, gets her through her busy day…”

                                  Mother’s Little Helper, The Rolling Stones

    In 1966, a bluesy rock song penned by Keith Richards of The Rolling Stones paid homage to the tranquilizing drugs which had become the rage, in an age of anxiety defined by the “rat race” and by the development of the psychopharmacologic approach to life’s problems. The title of the song, Mother’s Little Helper, reflects the predominance of women as the recipients of drugs that treated anxiety and the lyrics are a succinct representation of the dilemma of the diagnosis of anxiety. Is anxiety a mental illness, and, if not, what is it?

    Anxiety has been defined in many ways over thousands of years. For the classicists of Rome and Greece, the words used to describe anxiety as illness were nuanced.  Some referred to a mental feeling and others to bodily sensations, and they all conveyed a sense of constriction. As far back as the oldest book in the Bible, the character Job, in his anguish, speaks of “the narrowness of my spirit.” A different aspect of anxiety appears in one of the Romance languages, in the Romanian word nelinişte, meaning unrest. Between the ancients and the modern era of psychiatry, the concept of anxiety as a unique disorder goes dormant, with the symptoms buried in other diagnoses referring to emotions, particularly melancholia and neurasthenia. But by the time of the first Diagnostic and Statistical Manual of Mental Disorders in the early 1950s, anxiety was back, categorized as a mental disorder, with progressively more sub-categorizations related to associated behaviors over the next four updates to the guide. Anxiety disorders are said to affect almost a third of US adults at some point in their lives, and are rising among children as well.

    There are clearly people for whom the emotion of anxiety is crippling, interfering with the ability to navigate in the world, to accomplish necessary tasks of daily life, and to use the potential they have to live the best life they can. For these people, anxiety is a disorder. And anxiety complicates other serious mental illnesses like depression and schizophrenia. But anxiety is also normal, a feeling of dark expectation that is part of being human. Everyone experiences anxiety intermittently. Sometimes it keeps us awake. Sometimes it interferes with plans. Sometimes it helps us avoid problems. Sometimes it lingers longer than usual. Given the very high frequency of anxious feelings, learning about why anxiety occurs and about how to cope when it appears may be very helpful.

Anxious feelings are a protective. Because we are vulnerable creatures in a world filled with danger, we evolved to recognize, respond to and figure out how to avoid things which threaten us. The parts of the brain charged with this task are the amygdalae, paired almond-shaped structures deep in the brain on each side, near the temporal lobe. The connections to and from the amygdalae are complex and extensive, and the circuits trigger two emotions when we face unfamiliar, potentially threatening situations: fear and hope. Fear focuses attention and freezes motion, while triggering the physiologic responses necessary to fight or flee. Hope is the emotion that emerges when memory scanning triggered by the amygdalae yields recognition of a pattern in the threat. Hope enables development of a plan of action. Anxiety is the dark apprehension we feel when we cannot find the way to a plan to deal with persistence of the fearful, or just plain unresolved situation.

   Anxiety has three components. First, an alarm reaches each amygdala through the senses and triggers fear and memory scanning. The alarm encounters the second component, a mixture of beliefs based on prior experiences stored in memory.  The third component is the coping behavior that emerges.  Coping behaviors may be unsuccessful in reducing the fear, or unable to resolve the situation because of conflicts with beliefs.  When coping is unsuccessful at restoring calm, anxiety carries on, a dread sense sometimes accompanied by restlessness, nervousness, tension, sweating, weakness, shaking, rapid heart rate and hyperventilation, spilling over into non-threatening situations. When normal life is compromised, or unsuccessful coping behaviors like substance abuse take over, anxiety becomes a mental disorder.

    Some of us have more anxious temperaments than others, but everyone can work to better cope with fear-provoking situations. The less chaotic our lives, the fewer the confrontations with the unknown are – but control can never be perfect and lack of control itself can cause fear and, hence, anxiety. many of the patterns we establish in our lives, such as regular habits and ordering our environments we have learned unconsciously as a means of keeping anxiety under control. Countermeasures like the techniques of cognitive behavioral therapy (CBT) are not only useful but can be done as self-help. There are numerous cognitive behavioral therapy resources available in libraries and online. They teach recognition of the common distortions of thinking that lie beneath chronic anxiety, and ways to correct them. Interestingly, CBT is quite similar to the recommendations of the classic Epicurean and Stoic philosophers who wrote about anxiety so long ago.

    When anxiety disrupts life and does not yield to attempts to change, the professional help of a cognitive behavioral therapist is in order, as well as a general medical checkup to rule out problems like hyperthyroidism or Vitamin B12 deficiency.  Sometimes a therapist will add a pharmaceutical product, usually one in the SSRI category of antidepressants. While the “mother’s little helper” class of drugs, the benzodiazepines, are very effective in reducing acute anxiety, more chronic use has led to significant, refractory addiction problems, and SSRI-type antidepressants are a better choice to begin with if drugs are going to be tried. If drugs are employed they should not be a substitute for the hard work of understanding how the interaction of personality, experience and environment lets a useful and protective emotion become untethered from its purpose. Such understanding can help the mind move forward into solutions.

Two Years In

Below I have copied a comment I wrote in January 2022 on an article published on Substack by a biologist who named Joomi Kim. Joomi’s website is linked below. The article, titled “I Was Deceived,” is robustly documented and I had begun sending a link to it to friends who wanted more information about the 2019 pandemic virus and the medical approaches to it. I wrote the comment because I have spent many hours a week for the last two years delving deep into the science behind the pandemic narrative, keeping family and friends who wanted to be informed up to date, and I was grateful have the compilation of references that were attached to Joomi’s story. The comment, in addition to being a thank you note to Joomi, is a brief description of my own conclusions about what has happened and where we stand now.

During the spring of 2020 I realized that something was very wrong in the medical world of COVID – terrible data collection and a peculiar indifference to attempting to treat patients with the infection until they were late in the illness, when they were essentially untreatable. In the summer of 2020, I sat down with my iPad, in a small town in the mountains, to investigate the PCR test which seemed to be the linchpin of the “pandemic,” the thing that defined the numbers that were being used to justify destruction of social bonds and economic activity. I got up two hours later, realizing that surely the people behind the lockdowns and the health care directives knew what I now knew, and I sadly came to the conclusion that the exercise we were enduring was not about our welfare, but about getting to the great vaccination project. I’ve learned more about virology and immunology and the psychology of crowds than I ever wanted to know, and have found all that you have written here – and more. I am afraid that the myocarditis and aggressive cancers are just the tip of a very large iceberg and I believe we are involved in the greatest public health disaster in history. I am very grateful to you for having compiled all of these links in one place and intend to give this article to anyone I come across who is beginning to wake up to what has happened.

You can find the January 15, 2022* article on Joomi’s Substack site, found at:    https://joomi.substack.com/

*The title on the author’s main page is “I Was Deceived.”I have deliberately linked to the author’s main page rather than to the article directly because its URL title is one that could be flagged by the WordPress administrators as disinformation. This is the world we live in now.

Trigeminal Neuralgia: The Worst Head Pain

Anyone who has experienced toothaches, blocked sinuses, earaches, corneal scratches or migraine headaches knows that pain arising from any part of the head can be severe. Head pain is transmitted to the brain through the fifth of twelve pairs of cranial nerves at the base of the brain, named the trigeminal nerves. The worst head pain of all is the result of one or the other of these nerves misfiring, a condition known as trigeminal neuralgia, in which hundreds of episodes a day of lightning like spasms of pain on one side of the face are triggered by trivial touch or movement or by nothing identifiable. The pain is severe enough to bring sufferers to their knees and to cause more than a few to say that if it persisted they would have to commit suicide.  The famous painting, The Scream, by Norwegian artist Edvard Munch, has been called a visual representation of the agony caused by trigeminal neuralgia.


Symptoms of trigeminal neuralgia are almost always one-sided.  Spasms of facial pain are brief and explosive and described as stabbing, electrical, or like being stuck with an ice pick. Episodes can last for weeks or months, and then disappear not to return, or they may return in similar fashion, without warning, months or years later. Pain bouts may also become chronic and associated with other duller, longer lasting pain in the same area of the face. Because light touch and facial movements such as chewing and talking can trigger pain, patients avoid eating, lose weight, become depressed and socially withdrawn and look disheveled from avoiding skin care and shaving.   

Why does it happen?

About 150,000 new cases of trigeminal neuralgia are diagnosed in the US every year, more often in women than men and usually over age 60. The ailment can appear in younger people, most often in conjunction with multiple sclerosis. As long ago as the eleventh century, an Arab physician, Jujani, suggested that a blood vessel in the head, near the nerve that served the face, caused spasmodic facial pain and anxiety, a prescient notion since one of the few risk factors for trigeminal neuralgia is high blood pressure. Chronic high blood pressure distorts and hardens arteries, and one of the most effective treatments of trigeminal neuralgia in modern times has been to pad the nerve, protecting it from the pounding of an overlying artery.

Bolstering Jujani’s theory, pathological examinations of trigeminal nerves have shown evidence of damage and repair to the sheaths surrounding individual nerve fibers, suggesting that pressure from a nearby artery or vein, causes intermittent, reversible damage. The association of trigeminal neuralgia with multiple sclerosis, an inflammatory disease which also causes myelin sheath damage, lends weight to the idea that stripping sensory nerve fibers of their myelin sheaths somehow causes them to be irritable and misfire. There is no specific test for trigeminal neuralgia, which can be diagnosed from the clinical history alone. However, sometimes CT and MRI scans are done to rule out tumors irritating the trigeminal nerve, or to look for evidence of demyelinating diseases like multiple sclerosis or other autoimmune problems. Spinal fluid analysis might be added a search for inflammatory or demyelinating marker proteins and cells.

Similar conditions

      Other conditions may produce shooting head pains. One is glossopharyngeal neuralgia, coming from irritation of a different cranial nerve and causing pain deep in the throat and ear. It is much rarer than trigeminal neuralgia, but medical treatments are similar. Another is occipital neuralgia which comes from compression of a nerve in the upper neck, at the base of the skull. This painful condition is associated with poor posture, trauma or arthritic changes. Occipital neuralgia presents itself as stabbing or shooting pains, as well as duller aching pain and general headaches in the back and sides of the head, and at times behind the eyes. Temporomandibular joint problems (the joint that hinges the jaw to the skull) may also cause shooting pain in the side of the face, along with jaw pain and locking.


    The first effective treatment of trigeminal neuralgia was based on the concept of nerve cell irritability, with the use of drugs that treated seizures, first introduced in the mid-1900s. Though not perfect, these drugs continue to provide significant relief for the majority of trigeminal neuralgia sufferers. In addition, many attempts have been made to change the input of the trigeminal nerve to the brain physically by cutting it or injecting it with chemicals that deaden it. This treatment is called neuro-ablative surgery and the relief obtained is in direct proportion to the amount of numbness in the face caused by deliberately damaging the nerve. The more numbness, the better the pain relief. However, for some people, persistent facial numbness or unpleasant sensations are almost as intolerable as the pain, so numerous variations on such procedures have been tried. There are few controlled studies of outcome. Gamma knife surgery is the latest method. Symptoms recur within three years in 20-60% of patients, in inverse proportion to the amount of numbness produced by this deliberate nerve damage. 

    Microvascular decompression surgery (MVD), as mentioned above, is the most effective surgical procedure for trigeminal neuralgia. It involves opening the skull and placing a Teflon felt pad between the trigeminal nerve and the blood vessel that lies atop it, just where the nerve enters the brain stem. In experienced hands MVD produces immediate pain relief in over 90% of cases, with relief sustained for a decade or more in over 2/3 of them. Though many patients would rather try this or other surgical procedures than be dependent on anticonvulsant drugs, they must carefully weigh the risks, which are those of general anesthesia and of opening the cranial cavity, infection and damage to delicate neural structures chief among the possibilities. Procedures such as these should be done in centers where experience levels of all involved are demonstrable.

     All the pains we suffer are reminders that our exquisitely complicated pain networks exist to guard the body, particularly the head and the brain within, against damage from the environment. Like every other part of the body, the pain systems can go awry, making life very difficult, but this is nature’s trade-off since life without pain is more dangerous. In conditions like trigeminal neuralgia we are left to try to understand the cause and to intervene as best we can without causing harm.

Restless Legs

       In 1999, Dr. William Dement, the nation’s foremost sleep researcher, lamented that 15 to 20 million Americans with Restless Leg Syndrome had fallen into a major knowledge gap in the medical care system.  Doctors simply didn’t recognize the symptoms, and, more importantly, didn’t understand the serious effects of restless legs on patients’ lives.  Dr. Dement wanted to educate patients and their doctors, but sleep medicine didn’t attract much public attention.  Then, in 2006, the pharmaceutical industry waded into the knowledge gap, launching an advertising campaign during the Superbowl for the first drug approved for the treatment of Restless Leg Syndrome, something most of the audience had never heard of.  Advertising a disorder to market a drug is not the education Dr. Dement had in mind, but at least it generates interest and curiosity, the first steps toward knowledge.

      “Syndrome” means a set of symptoms. Restless Leg Syndrome (RLS) encompasses creepy, crawly sensations in the legs (but occasionally in the trunk muscles or arms), occurring mainly in the evening, getting worse on retiring for the night, and relieved by motion, particularly walking.  The best estimates are that 5-15% of the population recognizes these symptoms as their own. More men than women are affected and frequency increases with age. The cause is unknown, but recent research suggests that iron metabolism in a tiny part of the brainstem is at fault.  

       RLS is also known as “Ekbaum’s Syndrome,” after Karl Ekbaum, who first described the problem in 1940.  Jerry Seinfeld’s script writers added “Jimmy Legs” to the RLS lexicon when they had Kramer moan about a girlfriend whose nocturnal leg movements made him crazy. Kramer was actually describing not RLS but the primary sleep disorder that often accompanies it: periodic leg movement disorder (PLMD). In contrast to restless legs, Jimmy Legs often bother bedmates more than they do the afflicted sleeper, who spends much of the night bicycling away with no memory at all of the movements or of the multiple awakenings that accompany them.

More than a sleep disorder

     Because restless legs cause insomnia and sleep deprivation, RLS is technically a sleep disorder. However, the sufferer’s waking world is also fraught with difficult situations that demand stillness. Theaters, airplanes, dental chairs – even operating tables- can be intolerable. The course of action taken for relief depends on the frequency and severity of the symptoms, balanced against the risks and side effects of the treatments considered.

     The mildest version of RLS occurs in otherwise normal people after extreme physical exertion such as running a marathon, and it responds to time, rest and energy replenishment. At the severe end of the RLS spectrum are people whose trouble falling asleep and disrupted nighttime sleep produce severe daytime sleepiness. They need accurate diagnosis and treatment, by sleep specialists if possible.  Between the mild, intermittent end of the spectrum and the severe extreme are all the rest of the RLS sufferers, including some pregnant women. These people are best served by an ongoing relationship with a doctor who understands the syndrome and the complete approach to treatment.

Diagnosis and Treatment

       Treatment begins with a good history and physical exam. Restless legs are sometimes symptoms of peripheral nerve or kidney problems, and occur in the setting of diabetes. They can also reflect side effects of drugs such as antidepressants, antihistamines, and anti-nausea medicines. Even in the absence of medical problems, a check of the serum iron is on order since long clinical experience and new research implicate iron metabolism. Iron deficiency should prompt a search for a cause – usually bleeding or dietary insufficiency. Medications to reduce stomach acid, now in widespread use, can also cause iron deficiency.

         Assuming there are no underlying medical problems, the next step is the elimination of stimulants from the diet – particularly in the latter half of the day. That means caffeine, cigarettes and alcohol – as well as any over the counter medicines of the types mentioned above. Developing mental alerting strategies to occupy the mind during times of boredom may help. When focused and occupied with games or puzzles the brain seems to suppress restless impulses. Increasing daily physical activity quiets the legs in over 50% of RLS patients.

          When sleep suffers and normal life situations such as long automobile rides are intolerable, pharmacologic intervention is often necessary. The drugs that appear to be helpful fall into four classes: the ones that increase the neurotransmitter dopamine or act like dopamine (dopamine agonists); narcotics like codeine; the benzodiazepines like Valium, and the anticonvulsant Gabapentin. All of these are serious drugs with potential side-effects, not the least of which is a phenomenon called augmentation – the worsening of symptoms over time producing the need for more drugs.  But the drugs can be true life-savers for people who are severely afflicted and in desperate need of sustained sleep and the ability to remain still.

       What of the new drug touted in Superbowl ads in 2006, and a more contenders released since then? They are dopamine agonists, some of which  have been around for years – FDA-approved for use in Parkinson’s disease, but also used “off-label” by doctors dealing with RLS patients. Their marketing focuses a light on the obscure world of sleep medicine, where devoted researchers who followed Dr. Dement continue to educate patients and doctors about the troubled sleep that generates many accidents and eats away at productivity and emotional resilience. That is a service to all.

One-Footedness: The Key to Balance

Human beings negotiate the world on two legs, a skill mastered in toddlerhood. As children we are well balanced and swift. Then one day in mid-adulthood, we look at our children and realize that they are fast out-performing us in skills that require balance. When did balance become more difficult?  Of course we cannot define that point because life sneaks up on us, nibbling away at skills we do not practice because nature works assiduously to conserve energy.  Motor and mental tasks we do not practice get put to rest.

What’s involved in balance?

We maintain balance by taking in three types of sensory input and adjusting muscular activity accordingly. The three input systems are vision, messages from hair-like projections in three fluid-filled canals set at right angles to each other in the bone of the middle ear, and continuous reporting from delicately engineered receptors in our muscles and tendons that measure stretch and tension.  We can learn to balance without the first two components of the balance system, but not the third. To demonstrate the importance of the input from the muscles and tendons, try getting up and walking after one foot has fallen densely asleep from pressure on the nerves which are the highways for sensory information on its way to the brain. Even if you can wiggle the foot because motor nerves are more resistant to pressure, you cannot use it without knowing where it is.

Use it or lose it” applies to balance

Much of modern adult life involves little more than moving from one form of sitting to another, which gives the feedback systems in the eyes, ears, and muscles and tendons little exercise. Over time, balance skills deteriorate, and eventually falling happens with simply tripping or changing position or direction. Falling is the cause of many hospitalizations and, often, the injuries incurred lead to death. Living well and independently over the decades depends in no small part on maintaining the ability to walk without falling. Fortunately, balance improves with practice, and we have ample opportunity throughout the day to engage the balance systems and give them a workout.

Waking up the eyes and ears

Eyes are easy. Look around while you walk. Off to the side, up, down, straight ahead. If you are a straight-ahead looker most of the time, looking around may make you feel a bit unsteady at first. But your brain will begin to coordinate the changes with the information coming in from the ears and the muscles, so it will get easier. Once it does you can add more head movement, following your gaze. That will add more movement of the inner ear canals, which can become very accustomed to minimal movement. Young adults taking dance lessons for the first time or grandparents taking grandchildren on park equipment might be surprised to find themselves dizzy because of long unpracticed movements that involve spinning in circles or bending over. The ears are reporting unusual movements but with practice they will re-learn and stop sounding alarms. Deliberate exercises in head tilting and turning, such as the ones widely prescribed for benign positional vertigo, can speed the process.

Waken the muscle receptors by paying attention to walking

The stretch and strain receptors in the muscles are active whenever we are upright, but also lose function – even in walking, which is the most frequent and complex motor function we perform. Walking involves the subconscious coordination of over 300 muscles in a series of controlled falls that move the 200 bones of the skeleton forward or backwards in space, sometimes with the addition of upward or downward travel on stairs or ramps. Walking requires one-footed balance, with one foot bearing the body’s entire weight while the other foot swings forward. Landing the forward moving foot prevents the body from falling as it moves forward.

As the years pass, the body’s motor system tries to conserve energy by allowing you to use fewer, large muscles rather than more numerous small ones to accomplish the task of walking. Balance suffers and it is harder to adjust quickly to uneven terrain or surprises that throw you off balance. Learning to re-engage and strengthen all the smaller muscles devoted to one-legged balance re-awakens a lot of the sensory input and improves stability in all your upright activities.

Exercises for one-footedness

A good exercise for developing one-footed balance involves standing on one foot while barefoot (elevated heels throw the center of gravity forward), lifting the other knee in front of you and using a countertop for support. The gluteal muscles in the buttock on the side of the weight bearing leg will be forced to contract to keep the pelvis from dropping on the other side. The entire foot, powered by the lower leg muscles, is the stable platform that supports the rest of the body and the big toe stays in active contact with the ground. As strength and balance improve, try moving away from the support of the counter, getting the free knee up to a right angle in front of you and then swinging it down and back and a little behind you, concentrating on keeping the pelvis level and stable and the trunk upright. Adding toe lift exercises on stairs – dropping the heels a little below the stair level and pushing up from there – adds to the strength and flexibility of the ankles and to sensory input from the many intrinsic foot muscles and lower leg muscles.

Taking the exercises out for a walk

Once you get the feel of the muscle contractions necessary for one-legged balance, then try to feel the same sequences of activity while walking.  Good, upright posture helps. Your head weighs 10-14 pounds when directly over your spine, but the weight doubles, triples and even quadruples in proportion to how far in front of the body it is. If you have the habit of jutting your head forward with a curve in the back of the neck, or looking at the ground while you walk, the work of balancing increases proportionately. Keep the chest lined up over the pelvis and engage the trunk muscles – the so-called core – by trying to lift the pubic bone upward with the front of the abdomen. The core muscles maintain proper pelvic tilt. Then, while walking, try to feel the one-footedness you practiced while standing next to the kitchen counter and the ankle motion you felt doing toe lifts.

The action in walking is at the hip, ankle, and foot. The role of the knee is to let the leg bend as necessary. As you shift your weight to one foot, the gluteals contract in the buttock to hold the pelvis and prevent the released side from dropping. In the brief phase before the supporting leg begins to push you forward, notice the entire sole of the foot. Its connection with the ground begins with the heel planting down and continues as the body weight rolls forward. The knee will be straightest when you push through and are about to plant the new foot.

Do not neglect the feeling coming from the toes – especially the big one as you push off and begin to move the other leg through. Toes add a significant amount of surface area, increasing the available sensory information fed into the motor system and they contribute to the push phase of the gait. Notice also how the ankle moves as the heel lifts off the ground. Notice all of it as your other leg is swinging through and really try to relate the sensations to the one footed balance exercises you have done to practice.  

Notice other gaits

And while you are out walking and noticing your own one-footedness, take a look at some of the gaits you see. You will begin to learn the risk factors for falling. You’ll see people using only large muscle groups, initiating the leg swing by lifting the entire side of the body, from the shoulder down. They are already off balance. Their bodies must tip to the opposite side to allow the advancing leg to clear the ground. When the new leg lands and the weight shift begins again, the gluteals are not engaged, there is no push off from the hip and the foot, and the other side begins to lift from the shoulder. On a sunny day you will see such a walker’s shadow shift from side to side. Sometimes there are physical problems that impair walking balance, but for someone in good health, without neurological disorders like neuropathy, working to make the shadow move in a straight line pays off in a longer functional life. 

The Headaches that Predict Catastrophe

One of the most treacherous problems a busy emergency room physician faces is headache.  “Headache” is a very common symptom, different from focal head pains attributable to sinus, eye or ear problems. While very painful and sometimes associated with nausea and vomiting,  the vast majority of headaches, even if frequent and debilitating, are benign.  They do not signify underlying illnesses or impending danger.   But the emergency physician cannot afford to be wrong about the rare headache that predicts oncoming catastrophe and provides a chance to intervene.

Two broad categories

Catastrophic headaches fall into two broad categories. The first category includes “space-occupying lesions” such as tumors, hemorrhages, abscesses, and hydrocephalus (known commonly as “water on the brain”).  The second category involves infectious and autoimmune problems that produce inflammation, triggering pain receptors in the membranes surrounding the brain and its blood vessels. Catastrophes avoided by successful interventions in both categories include death, permanent brain damage and blindness.  

Tumors and abscesses

The most common fear about a bad headache is that it is caused by a brain tumor, but tumors usually produce other symptoms, involving speech, thinking, coordination or vision before they produce headache. Since the brain tissue itself has no pain receptors, tumors cause headache when they distort surrounding membranes or blood vessels, which have pain receptors. Tumor-related headaches worsen with positions and activities that normally cause the pressure in the veins in the head to rise – coughing, sneezing, lying down, straining at a bowel movement or lifting something heavy. As tumor size and pressure increase, nausea and vomiting appear. Occasionally, brain abscesses – pockets of infection surrounded by capsules -may mimic tumors. They usually come from blood infections seeding bacterial or fungal organisms into the brain.

Hemorrhages in the brain

Brain hemorrhages occupy space and increase pressure in the head.  Deep small blood vessels, damaged by high blood pressure or arteriosclerosis, are usually the culprits. While these intracerebral hemorrhages can cause sudden headache, stroke-like symptoms such as paralysis, confusion, trouble speaking and loss of consciousness occur first or soon after the onset of headache.

Hemorrhages outside the brain, but inside the head

Headaches are also a symptom of epidural and subdural hematomas – collections of blood that accumulate over the surface of the brain hours to weeks after some closed head injuries (meaning no skull fracture). The history of injury, even seemingly trivial injury in an elderly patient,  is crucial to correct evaluation of these headaches and there may be no other accompanying neurological symptoms. A head blow in the temple, where the skull is the thinnest is a common history. Young children and older adults are more susceptible to epidural hematomas (located between the inner skull and the the dural membrane over the brain) than those in between those age groups. Both epidural and subdural (between the dural membrane and the surface of the brain) collections of blood usually require surgical removal, sometimes as an emergency if symptoms such as change in level consciousness appear. Actor Liam Neeson’s wife Natasha Richardson did not survive an epidural hematoma incurred in a skiing related fall in 2009.

The “sentinel headache” of the aneurysm

Bleeding from brain aneurysms – weak spots at branch points of arteries – can be immediately catastrophic, even causing sudden death. But a tiny, warning leak before an aneurysm actually ruptures may cause a “sentinel headache” which allows time for life-saving surgical repair to prevent the oncoming, big rupture which typically occurs sometime in the next 10 days.  A sentinel headache is sudden and severe pain involving all or part of the head, It is sometimes described like a “thunderclap.”  As the little warning squirt of blood dissipates in the spinal fluid around the base of the brain, the headache dulls but a peculiar, longer-lasting pain may appear in the middle of the upper back, usually worsened with movement and probably indicating irritation from blood in the spinal fluid around the spinal cord. Diagnosis involves brain imaging with dye to study the arteries, and possibly a spinal tap to make certain bleeding has occurred. Unruptured cerebral artery aneurysms are found incidentally in 2% of autopsies so the problem is not rare.


Hydrocephalus is a rare cause of headache, but one that should never be overlooked. The rise in pressure in the head comes from spinal fluid being trapped in the ventricles, hollow structures in the center of the brain where spinal fluid is made. Normally the spinal fluid circulates out of the ventricles via a very small channel, and bathes the surface of the brain and spinal cord before being absorbed into special veins at the top of the head. If flow is blocked, the ventricles begin to enlarge putting pressure on the surrounding brain. Most times, the onset of hydrocephalus is gradual, with headache, nausea, vomiting and balance problems gradually increasing. Unrecognized and untreated, obstructed spinal fluid flow leads to lethargy, coma and death, within 24 hours if the obstruction is sudden. Causes of obstruction include congenital anatomical abnormalities, tumors blocking the ventricular outflow tracts, scarring of these passages by inflammation from past meningitis or bleeding. Hydrocephalus most often requires surgical intervention to either remove the obstruction or to place a shunt around it, allowing cerebrospinal fluid to escape from the ventricles.

Headache from infection

Headache producing infections mainly involve the meninges, the membranes covering the brain and the spinal cord and are caused by viruses, bacteria or fungi. Viral and bacterial meningitis both cause severe headache, neck pain and rigidity and photophobia – inability to tolerate bright light. Movements of head and trunk and even eye movements are painful. Someone suffering from bacterial meningitis has a high fever, looks extremely ill and deteriorates rapidly. Identification of the infection type requires spinal fluid, obtained via spinal tap – insertion of a large needle into the spinal canal in the low back.  Antibiotics are lifesaving. Viral meningitis, though painful, is less dramatic, and gets better on its own. Fungal meningitis is rare and much slower and less dramatic in its presentation than bacterial meningitis. It most often occurs in people who have impaired immune systems and requires prolonged treatment with antifungal drugs.

Non-infectious inflammatory headache: temporal arteritis

Headache from a non-infectious inflammatory condition called temporal arteritis usually presents itself in the seventh or eighth decade of life as a constant, often one-sided pain. Other symptoms that provide clues to this diagnosis are pain in the jaw muscle, especially with chewing, and tenderness of the artery just under the skin of the temple – the origin of the name for auto-immune inflammation that affects the arteries that supply the skull and brain with blood and can cause blindness and strokes. Diagnosis is confirmed when a blood test called ESR (erythrocyte sedimentation rate) is elevated and a temporal artery biopsy shows characteristic inflammatory cells in the artery wall. Treatment with steroids like prednisone, undertaken soon enough, prevents blindness and takes the headache away, but must be continued for many months.

A very useful question

One of the most useful questions an emergency room physician, or any other professional evaluating a headache complaint can ask the patient is “How worried are you about this headache?” People know themselves and have an innate sense about the nature of their symptoms. They will very often know the difference between a catastrophic headache and all the others.

Probiotics: Manipulating Your Internal Ecosystem

The human body is an ecosystem harboring numerous different species living in delicate balance, well-adapted to each other and to their physical environment. The creatures that thrive on our skin and in our noses, mouths, urogenital tracts and guts are microscopic organisms – mainly bacteria, fungi and bacteriophages (viruses carried by bacteria).  These organisms comprise the human “microbiome” and perform valuable services for us, breaking down food, making vitamins and other chemical compounds that we absorb, teaching our immune systems how to recognize invaders, and maintaining bowel health.  Their genes interact with our genes, up-regulating and down-regulating them as we change our diets.

Research relating the the invisible world of the microbiome to physical states of health and illness is still in its infancy, but has produced interesting data and useful observations about attempts to restore microbiome composition after disruption by illness and antibiotics. Outside this world of esoteric research, entrepreneurs have leapt ahead of the facts, supplying millions of people who wish to better their health with supplements called probiotics, pills containing “living microorganisms, which when administered in adequate amounts, confer health benefits on the host.

Not a new idea

The idea of manipulating the body’s microorganisms to improve health is not new. In 1908, Nobel prize winner Elie Metchnikoff, the “Father of Immunology,” theorized that the large intestine was a cesspool where putrefaction by bacteria produced autotoxins that aged the body. While some believers advocated removing the colon or administering repeated enemas to cleanse it, Metchnikoff thought that Lactobacilli, bacteria found in the yogurt consumed by long-lived Bulgarians, could  battle the putrefactive bacteria, and that consumption of the yogurt, along with other ascetic practices like avoidance of alcohol and intoxicants, would prevent dementia, illness and premature death. Like yogurt, other fermented, bacteria-laden foodstuffs such as kefir and sauerkraut have long been advocated for general good health.

Experimental evidence?

There is tantalizing experimental evidence that the interior microbial world has previously unsuspected ties to overall health. For instance, in germ-free mice, introduction of specific bacteria into the gut will alter energy usage because the bacteria digest incoming food.  The mice get fatter on the same amount of food they were fed in the germ-free state because they absorb more of it. Bacteria also produce substances which act like neurotransmitters and communicate with the brain via the gut’s neural network. And they modify the action of their genes to match the types of food we eat, which in turn modifies food absorption and immune system function.

Genetic tools speed modern microbiome research

High speed DNA analysis is the modern tool which drives microbiome research. No longer do scientists struggle with culturing and identifying the multitude of bacterial types that reside in the human body. Based on microbial DNA sequencing of samples from human bodies, we know that we carry over 3.3 million bacterial genes, vastly more than our own 22,000 genes). There is far more diversity between humans in terms of the genetics of the organisms they carry than there is in their genetic profiles – and enough stability in each person’s microbiome to create unique microbial DNA profiles, which can be identified like fingerprints on surfaces people touch. There are even identifiable differences between the fingerprint profiles from an individual’s right and left hands.

Fecal transplants: the ultimate probiotics

The best scientific information about manipulation of the microbiome in the quest for better health comes from the ultimate type of probiotic – the so-called fecal transplant. Transfer of fecal material from one person’s gut to another’s was first tried in the 1950s. In this experiment, a patient suffering severe colitis was spared surgical removal of the colon when restoration of a normal mix of bacteria, as well as everything else in contained in the stool sample used for the transplant, quelled the toxic bacteria eating away his colonic lining.  Since that time, fecal transplantation has been 90% successful in treating the severe and often recurrent colitis and diarrhea produced by the bacterium clostridium difficile.

The complex nature of fecal material

Fecal material contains bacteria, viruses, bacteriophages – the viruses that bacteria can transfer among themselves and to the host, other types of microorganisms, and all the chemical products of the metabolic processes of all these living creatures. Each stool donor has a unique microbial profile, as does each fecal transplant recipient. Donor stool is screened for drug resistant and abnormal bacteria, prepared as a slurry and introduced into the colon via colonoscope, or into the stomach or small intestine via a tube. Capsules that resist the acid and enzymatic environment of the upper GI tract also show some promise.

Probiotics: less complex mixtures of living organisms than fecal transplants

Like fecal transplants, probiotics aim to create a healthier balance of bacteria in the gut, but they are capsules containing a few types of freeze-dried bacteria harvested from cultures in labs. When swallowed and exposed to the warmth and moisture of the body’s interior they spring to life. Sold as supplements, probiotics are not subject to FDA quality control.

Probiotics have been studied as treatments for antibiotic-induced diarrhea, allergies, autism, metabolic syndrome, autoimmune ulcerative colitis, Crohn’s, disease, infectious colitis, constipation, traveler’s diarrhea, periodontal disease, and more. The studies are fraught with problems that make most of them inconclusive at best. But as preventives for antibiotic0induced diarrhea and clostridium difficile diarrhea, probiotics may be helpful and are generally not harmful for otherwise healthy people.  Theoretically, people with depressed immune systems could contract an infection from one of the organisms included in the product. There has been at least one neonatal death attributed to a contaminated probiotic.

Do the introduced bacteria survive?

A recent, carefully designed study from Israel assessed whether or not probiotic bacteria took up residence in the colon after ingestion. In some people, called persisters, the probiotic bacteria can be found in the recipient, but in others, called resisters, none of the probiotic bacteria survive. The type of bacterial populations already living in the gut make the difference. In addition, another good study demonstrated that probiotic use actually delayed the return of normal bacteria to the colon after a course of antibiotics.

Much work remains in the investigation of  the human microbiome and in attempts to improve health by manipulating it. What is clear so far is that each person’s microbiome is unique and that success in understanding and manipulating it will require individualized evaluation. Most probiotic use at this time is a one-size-fits-all approach, done for non-specific reasons. Similar to Metchnikoff’s Bulgarian yogurt.*

*modern science shows that the lactobacillus in the yogurt does not survive the trip through the gut to the colon.

Tuberculosis: The Long Pandemic

In late 2012, a Nepalese man began a three month-journey, on foot, by car and boat, and in an airplane, through South Asia, Brazil and Mexico, and into Texas. He brought with him an infection called XDR-TB, short for extensively drug resistant tuberculosis, a disease still relatively rare in the US, but one that public health officials fear because it is spreading across the world. We have become complacent about TB because it has been successfully treated with antibiotics since the 1950s and because most tuberculosis cases occur in underdeveloped countries where malnourished and sick people with weakened immune systems live in crowded and unsanitary conditions. But with easy global travel and spreading antibiotic resistance, especially on the Eastern border of Europe and in Africa, China and India, more awareness of this ancient disease is needed again in areas of the world where improved living conditions have made TB uncommon and unknown.

A long history

Three-thousand-year-old writings from China and India, passages in the Old Testament, and the writings of Hippocrates all describe the affliction we call tuberculosis. The disease became a scourge as more and more people crowded into urban centers in northern climates in the middle ages.  Between the 1500s and 1800s, hundreds of millions of people in Western Europe, England and the eastern US died of TB, then called consumption and attributed either to a “malignant miasma” in the air or to hereditary constitutional weakness. Squalid living conditions, poor indoor ventilation and malnutrition common during the early industrial revolution facilitated the spread of the disease, which in 1882 was finally proven to be caused by a bacterium, Mycobacterium tuberculosis.  When living conditions began to improve in the early 1800s the death rate began to decline, but a cure awaited the development of antibiotics in the mid-twentieth century. The goal of eradicating TB, however, has not been achieved.

Latent vs active infections? The immune system decides.

Anyone can be infected with the TB bacteria, acquired by inhaling the respiratory droplets of someone who has an active infection in their lungs. Inhaled TB bacteria are captured by cells that scour the airways for invaders. The bacteria reproduce themselves inside those cells, eventually killing them and exciting an immune response that in 90% of people will clean up the infected area, called a “tubercle,” in a process called caseating necrosis because the dead tissue resembles crumbled cheese. The tubercles may leave small scars in the lung, visible on chest X-ray, without ever having caused any symptoms of illness. Infection in these immuno-competent people, the vast majority, is called latent TB, a condition that affects almost a third of the world’s population, including 13 million people in the US.

In 10 % of people who get infected with the TB bacteria, the immune response is insufficient. Active tuberculosis is the result. Caseating tubercles may grow to large size and collapse producing cavities in the lung. Tubercles that erupt into the airways allow surviving bacteria to spread to other people in sputum and respiratory droplets. In addition, bacteria may travel to other parts of the body via the lymphatic system, setting up infectious nodes in almost any tissue.  Typical symptoms of active tuberculosis develop over weeks to months and include chronic cough, night sweats and fever, weight loss, weakness, fatigue, and skin pallor. Tubercles in various organs and lymph nodes give rise to local symptoms from swelling and inflammation.

Latent infections come alive

Latent TB can reactivate and become active TB if the carrier’s immune system weakens – a result of other disease such as HIV, drug treatment that suppresses the immune system, or just deterioration of health that accompanies drug use or poor living conditions. Ten million cases of active infection occur each worldwide year.

Before antibiotics: high altitude and collapsing lungs

In the 1840s a botany student who suffered from TB traveled to the Himalaya mountains and came home to report his cure, setting in motion the sanatorium treatment for which high altitude locations such as Davos Switzerland and Denver, Colorado became renowned. Much later, scientific work showed that the mycobacterium tuberculosis grows poorly at low oxygen pressures, a fact that may well have added to the other health and nutritional benefits of sanatorium life. Attempts to put infected parts of lungs “to rest” by collapsing them with injections of nitrogen into the chest began in the 1880s.  German Author Thomas Mann memorialized this procedure, called an artificial pneumothorax, in his novel The Magic Mountain.  The treatment method continued well into the 1940s, when the development of antibiotics finally offered a cure for TB.

Not the usual antibiotic treatment

Antibiotic treatment of TB is not easy. Patients must take two to four drugs on a strict schedule for 6-9 months and tolerate some unpleasant side effects like nausea. Until their sputum is free of TB bacteria – which can take several weeks – they must be strictly isolated. Caretakers benefit from proper mask wearing because the tuberculosis bacteria is larger than N95 mask pores.  Because drug resistance has been a result of poor compliance with the drug regimens, strict monitoring and observation of patients is necessary. Often drugs must be taken under direct observation. Once drug resistant disease occurs, treatment becomes more complicated and prolonged, requiring trials of different antibiotics, with even more need for isolation of infectious patients and close supervision throughout the entire course of treatment.

Testing and vaccines

A tuberculin skin test, when positive, indicates prior infection with tuberculosis bacteria, and therefore latent disease in someone who has no symptoms. Chest X-ray and chest CT, as well as collection of sputum for microscopic analysis and culture are the mainstays of diagnosis in active disease or if someone with a positive skin test has any suspicious symptoms.

The only vaccine for TB, used since 1921, is made from a weakened bacterium similar to the TB bacterium. Its acronym BCG is short for the virus name (Bacille Calmette Guerin). BCG reliably prevents neonatal disseminated forms of TB such as meningitis, but is much less effective in preventing the adult respiratory form of TB, which is the usual version beyond childhood. It has not been regularly administered in the US because most people handle primary infections easily. However the spread of drug resistant forms of TB may change that recommendation, especially for people regularly exposed to patients. In the meantime, work on new vaccines employing new technologies continues.

Drug resistance is spreading

TB was on the decline in the US until the 1980s, when HIV disease appeared, devastating the immune systems of its sufferers and making them susceptible to active TB.  With better treatment of HIV, TB is on the decline again, but popping up increasingly in the homeless population, particularly where they congregate indoors in crowded shelters. Recently, cases of drug resistant TB have occurred in people who had never been treated, meaning that the drug resistant bacteria are spreading, not just evolving in treated patients. In eastern Europe 30% of new TB cases are now resistant to many of the TB drugs. The traveler who appeared in Texas with XDR-TB was a warning. We need robust public health measures to monitor infectious diseases, improve sanitation and living conditions as much as we need development of new antibiotics.


Dyspnea (trouble breathing): A symptom with many causes

A baby enters to the world with collapsed, fluid filled lungs.  Within 10 seconds, he gasps, takes a noisy breath and completes his transition to the outer world. From that point, he will inhale and exhale air over 8 million times a year until he takes his last breath at death. Breathing is his link to life, much as his umbilical cord was the link when he was in the womb. As long as his heart and lungs remain healthy and the muscles and bones his chest can move normally, he will maintain a comfortable, laissez-faire relationship with his breathing, seldom paying much attention to the never-ending process of taking in oxygen and getting rid of carbon dioxide. Strenuous physical activity will make him notice his breathing and he will learn the physical limits beyond which breathing harder and faster is ineffective. While he will experience discomfort with breathing at those limits, he will not feel fear or distress because he understands that his gasping for air is a normal response and that he will recover promptly when he rests.

Words used to describe trouble breathing

But when there is trouble somewhere in the respiratory system, the act of breathing becomes distressing in ways that and prompt a variety of different descriptions: “I feel short of breath.” “I can’t catch my breath.”  “My chest is tight.”  “I’m smothering.” “I’m suffocating.” “I can’t take a deep breath.”  “I can’t breathe out all the way.” “Breathing is hard work.”  “I need to more air.”   Doctors use one word to encompass all of these descriptions – dyspnea, defined as abnormally uncomfortable awareness of breathing. Dyspnea is not a diagnosis but a symptom of many different types of respiratory problems. Diagnosis requires discovering where the trouble is in the normal chain of events that make up one breath.

The drive to breathe

The first part of a normal breath is the drive to breathe –  a message from the brain to the muscles that increase the volume of the chest. The ribs move outward and the diaphragm between the chest and the abdomen moves down. The chest cavity expands, much like a fireplace bellows, sucking air down the trachea and the bronchial tubes into the lungs. In the next step, oxygen is absorbed into the blood and carbon dioxide is expelled from it. This gas exchange takes place in the spongy tissue of the lungs, in tiny air sacs called alveoli where red blood cells flow in single file though tiny capillaries. After 3-4 seconds, the muscles relax, the chest cavity diminishes in size and air rushes back out. Normal breathing goes on automatically, beneath conscious awareness unless the body demands more gas exchange because of increased exertion.

The drive to breathe increases when the body’s demand for oxygen goes up.  “Hard breathing” from exertion is not distressing or indicative of illness unless it occurs in someone who has been very fit and previously more capable. Low oxygen pressure at high altitude also stimulates the breathing drive, but true dyspnea is a sign of altitude sickness and need for immediate treatment and evacuation to lower altitude because of fluid in the lungs.  Anxiety and fever increase respiratory drive, as does hyperthyroidism, producing variable awareness of rapid breathing, but little discomfort.

The highway air movement follows

Moving air in and out of the lungs is the next part of normal breathing and a common source of true dyspnea. Infections, chronic inflammation from allergies, cigarette smoke or other environmental toxins can narrow and partially obstruct the trachea and the bronchi. Symptoms include coughing, wheezing and faster breathing to compensate for less air moved with each breath. Breathing “seems like hard work.” Sometimes bronchial spasm from inflammation makes it difficult for people to exhale fully. They have a sense of not being able to empty the air from their lungs and as a result get the feeling that they cannot inhale enough on their next breath. Asthma is the typical illness which causes this type of dyspnea.

Muscle disorders like Lou Gehrig’s disease, overall weakness from chronic illness, or paralysis from spinal cord problems can limit air transport by limiting chest wall movement. Obesity causes breathing problems because even normal muscle may not be strong enough to move the chest wall buried under heavy weight.

The deep reaches of the lungs where the work is done

Farther down into the lungs, dyspnea comes from impaired gas exchange and feels like air hunger – no matter how fast the breathing rate is, there still seems to be insufficient air. Lung infections like viral and bacterial pneumonia, and chronic inflammatory disorders that produce lung scarring are the typical culprits.  Cough, fever and rapid onset of dyspnea are clues to pneumonia.  Gradual onset of dyspnea is more common in the inflammatory scarring and in smoking related lung disease, which causes both obstruction to air flow and loss of the alveoli where gas exchange occurs.

Poor blood flow through the lungs can be the culprit

Normal breathing also depends on the heart, which is the pump that pushes blood through the lungs for gas exchange. A failing heart makes blood flow too sluggish for adequate gas exchange during each breath, causing a sense that air flow is inadequate and making breathing rate go up. People who have cardiac dyspnea also describe feeling suffocated or smothered, especially if fluid begins to leak from the blood into the lung tissue. Gravity influences the symptoms which worsen with lying down and improve with sitting up.

Pulmonary emboli, clots that form in the legs or pelvis and break off and travel upstream, can cause severe and sudden dyspnea by lodging in and blocking major blood vessels in the lungs.  Air reaches the lung segment where the clot is lodged, but gas exchange doesn’t occur because no blood is getting through. Large clots can be fatal immediately.

Should you develop dyspnea, seek help and try to provide a good history of your symptoms.  Symptom history is very important in diagnosis and accurate diagnosis is crucial to proper treatment. The goal of treatment, of course, is a return to the comfortable lack of awareness of breathing that should accompany you from cradle to grave.

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