Low blood sugar caused a fatal accident!

Betty Diaz, 39, of Lake Forest, is accused of failing to take proper care of her blood sugar level, triggering an episode of hypoglycemia in which she lost control of the Suburban.

Kyung "Connie" Chung was killed in a head-on collision July 3, 2007.

Diaz is accused of taking insulin on an empty stomach, dropping her blood sugar to a dangerously low level.

On July 3, 2007 around 2:15 p.m., Diaz was driving with 8- and 9-year-old children in the SUV when she lost control, veering across a center divider and into oncoming traffic on the northbound side of Irvine Center Drive.

The Suburban crashed straight into the Camry, fatally injuring its driver, 70-year-old Kyung "Connie" Chung. Chung died at a nearby hospital.

Diaz and the two children had to be treated for lesser injuries.

According to a medical evaluation in court records, Diaz has had Type 1 diabetes for 22 years.

Diabetics who are prescribed insulin are told to take it before meals to keep blood sugar from spiking. On an empty stomach, insulin can cause blood sugar to drop to dangerous lows, triggering hypoglycemia.

Hypoglycemia causes dizziness, shaking, sweating, and confusion, and in serious cases, even seizures and fainting.

Diaz told the doctor that she took insulin on an empty stomach that morning. Her last meal before the accident was between 7 and 8 p.m. the day before, according to the evaluation.

She told the doctor that she had tested at dangerously high blood sugar levels -- four times the normal -- the night before the accident. If that's so, then in trying to bring her blood sugar down, Diaz apparently overdid it

The evaluation found that she had likely suffered an episode of severe hypoglycemia.

Diaz has been charged with one felony count of vehicular manslaughter with gross negligence and two felony counts of child endangerment.

The pre-trial hearing at Harbor Justice Center in Newport Beach is her eighteenth since she was charged 15 months ago.

Epilepsy: Causes and Symptoms

Epilepsy is a grouping of related disorders characterized by a tendency for recurrent seizures. There are different types of epilepsy and seizures. Epilepsy does drugs are dictated to control seizures, and rarely operation is essential if medicines are ineffective.

Causes of Epilepsy

Head trauma is an important reason of seizures and epilepsy.

Although it's generally accepted that a remote injury (i.e., one which happened at once in the past) can cause epilepsy, there's no agreement on how extensive or of what type that injury must be. It's known that the danger for epilepsy increases substantially if there are open or penetrating lesions, however.

Tonic-clonic seizures (grand mal)

The biggest of whole types of seizures, these are characterized by a loss of consciousness, body stiffening and shivering, and some of the times tongue biting or loss of bladder control.

If all areas of the mind are affected by the abnormal electric action, a generalized seizure may result. This means that consciousness is lost or impaired. Often complete the individual arms and legs stiffen and then jerk rhythmically.

Symptoms of Epilepsy

Simple partial seizures are further divided into 4 classes according to the nature of their symptoms: motor, autonomic, sensory or psychological. Motor symptoms include movements such jerking and stiffening.

Generalized seizures

This is the type of seize each time, so the symptoms will be much related from episode to episode.

But some people have several different types of seizures, with different symptoms each time.

Treatments of Epilepsy

Surgical therapy

New advancements in diagnostic technology and surgical methods have led to a raising use of surgical treatment of epilepsy.

Pharmacotherapy

It's newly been shown that early on effectual treatment with anti epileptic drugs will control seizures in up to 70% of newly-diagnosed grownups and kids.

Alternate Treatments

Many alternate treatments are widely encouraged for epilepsy, including bio feedback and vitamins. But their effectiveness is largely unproven.

Medications

More than a 12 medicines are presently sanctioned to treat epilepsy. To each one medicine has does well and side effects, and another medicines are suitable for a different types of epilepsy. No one medicine is examined to be the better treatment for epilepsy.

First of all, let me tell that I'm NOT a fan of the Atkins diet (as a few suggest for epilepsy) and many of its characteristics run counter to what other people recommend for a diet that helps with epilepsy most important of which is the avoidance of animal protein. Beyond that, it's my feeling (shared by a great several other people) that Atkins got a good deal correct but his diet was ultimately fatally flawed once the marketing became centered around the easy and unhealthful formula of basically eliminating crabs and eating just about anything else you needed including junk food and extravagant unhealthful fats. A few carbohydrates are essential for good wellness and I'm one of the ones who trust it was saying when the autopsy conducted on Atkins (and later covered up) revealed important problems and major deterioration of virtually every his major organs and systems. Strict adherence to his diet will indeed result in weight loss, but it may come with the cost of development chronic problems that can eventually be life shortening if not life threatening.

Dietary recommendations:

Eat sour milk products like organic yogurt and kefir.

Include beet greens, chard, eggs, green leafy vegetables, raw cheese, raw milk, raw nuts, and seeds and fermented soy products such miso, tempeh and natto.

Drink fresh juices made from beets, carrots, green beans, green leafy vegetables, peas, red grapes, and seaweed for concentrated nutrients.

Eat little meals, don't drink large measures of liquids at a time, and take two tablespoons of olive oil every day.

Avoid alcoholic beverages, animal protein, fried foods, and artificial sweetening's such as Aspartame, caffeine, and nicotine. Avoid refined foods and sugar.

SOME OF THE most important VITAMINS AND MINERALS FOR EPILEPSY:

Vitamin B Complex

Niacin HERBS FOR EPILEPSY INCLUDE:

• DMG
• L- Carnitine
• L- Tyrosine
• Magnesium
• Oxygen enhancing products (Such as OxyGen)
• Selenium
• Taurine
• Vitamin B Complex
• Extra Vitamin B3 Niacin
• Folic Acid
• Pantothenic Acid
• Calcium
• Zinc

• IMPORTAN HERBS FOR EPILEPSY INCLUDE:

• Alfalfa
• Black cohosh, hyssop and lobelia (for best results use on a rotating basis)

Sex doesn't cause seizures!

During the summer before her senior year at Northwestern, Christine Haselhorst spent three weeks studying eight hours a day for the Medical College Admissions Test. After finishing the exhausting exam, Christine returned home, finally able to relax and release her stressful preoccupation with science jargon and practice tests. Her celebratory dinner with friends, however, was cut short. That evening, Christine, a Weinberg senior, had five seizures in a row, the most she has ever had in a single day. While one episode per week had become normal for her, this extensive sequence of seizures shocked Christine, sent her to the hospital and reminded her—yet again— of the tight grip epilepsy had on her life.

Christine had her first seizure at 12 years old. Electric impulses shot through the left temporal lobe of her brain causing her to lose consciousness. For nearly one minute, her facial muscles twitched and her entire body stiffened and jerked. After eight years with no seizures, Christine began experiencing them again the summer before her junior year. Now, two years and more than 20 seizures later, Christine is still hoping for an effective treatment option. Despite medication, her episodes now occur weekly and, paired with her prescription side effects, they have started to drain Christine emotionally. As her team of neurologists searches for the perfect drug combination, Christine avoids behaviors the medical community has identified as potential triggers, such as sleep deprivation, stress and alcohol use. “Medication is the only solution they have, so I’m trying to do everything else I can,” she says. “Sometimes, though, you don’t want to be that person in the corner. But I guess I’m just not a normal college student.”

Like Christine, many people experience the practical challenges, emotional strain and stigma of epilepsy, a neurological disorder affecting approximately 3 million Americans. For the 150,000 college students with epilepsy, however, life can be especially frustrating. These young adults must establish a new network of support and learn how to manage their condition, while juggling their social life and academic responsibilities. Besides giving up activities that characterize the college experience, epileptics must consider their seizure and health risks when facing typical dilemmas, like sharing a dorm room, making new friends, choosing a major and partying. “College isn’t an obstacle, but people with seizures need to be aware and mature enough to take good care of themselves,” says Eileen Whelihan, a licensed clinical social worker at the Indiana Comprehensive Epilepsy Center. “Personal responsibility goes a long way, but I know it’s frustrating for that age group because they just want to be like their peers."

Epilepsy is a group of disorders characterized by recurrent and spontaneous seizures. These episodes of disturbed brain function cause strange sensations, emotions and behavior, and sometimes convulsions, muscle spasms and loss of consciousness. Although one in 100 people will have a seizure in their lifetime, epilepsy is only diagnosed when a person has had more than one seizure unprovoked by a fever, metabolic disorder or severe head injury. Many people associate epilepsy with convulsive fits, but the disorder can manifest itself in different ways. People can experience absence seizures, characterized by brief staring spells, myoclonic seizures, massive muscle jerks, or the more recognizable tonic-clonic or grand mal seizures, which cause the body to convulse.

While there is no cure, more than a dozen types of antiepileptic drugs available. Treatment is highly individualized though and similar medications can produce different results and side effects. For patients whose seizures cannot be controlled by medications, neurologists may propose brain surgery, vagus nerve stimulation (where a device similar to a pacemaker is implanted in the brain) or investigational therapies, like the ketogenic program, a high-fat, low-carb diet. Although most cases of epilepsy can be controlled with just a few pills each morning, more than 30 percent of patients will continue to experience seizures despite aggressive drug treatment or other interventions. “At least half the time, the first medication works pretty well,” said Dr. Douglas Nordli, neurologist and director of the Comprehensive Epilepsy Center at Children’s Memorial in Chicago. “But for others, it’s a process of trial and error.”

The highest incidence of epilepsy occurs in the first year of life and older than 65 years old. However, there is a slight blip that can account for the forms of epilepsy that emerge in teenage and young adult years. Although treated with similar measures, epilepsy among this age group may have different causes, manifestations and outcomes.

“The fundamental difference is that it is epilepsy in the context of a developing brain,” said Dr. Nordli. “So we have great concerns about brain function and how the patient is doing from a cognitive, developmental, behavioral and psychiatric standpoint.” Repeated seizures can increase the likelihood of social and learning disabilities, brain damage—and even death. According to the National Institute of Neurological Diseases and Strokes, the center primarily responsible for funding epilepsy research, sudden unexplained death from epilepsy is a research priority. Recent studies suggest the risk of death in epileptics may be 25 times higher for those in their 20s to 40s–an especially frightening find for young adults.

Although the underlying causes of epilepsy are often unclear, medical professionals have found that sleep deprivation, heavy alcohol or drug use and stress are common and potent triggers for seizures. Neurologists advise patients to avoid these behaviors and to identify their personal triggers, which can include caffeine, flashing lights and hyperventilation. Fortunately, it’s a myth that sex can cause a seizure. “If you learn that you drink more of anything caffeinated and you start to have seizures, then maybe that’s a trigger for you,” says Eileen Whelihan, a licensed clinical social worker. “It’s a way of learning. The important thing we tell them is that if you find something is true for you then you need to pay attention to it.”

Dorm life, frat parties and classes packed with hundreds of new faces can overwhelm any undergrad. A study the Journal of Adolescent Health revealed that stresses from the daily routine of school and life keep 68 percent of college students awake at night. “So many kids just fall apart in college with the incredible suddenness of freedom,” says Maureen Tillman, licensed clinical social worker and creator of College with Confidence, a counseling service for parents and young adults. “There are so many different kinds of stresses, and it is not a very stable environment.” Free from nagging parents and the daily routine of high school, the university setting requires epileptics to adapt to a life where weekends start on Thursdays and study sessions can last until sunrise. “At home, I never would pull an all-nighter,” says Samantha Gassell, 20, a junior at Emerson College who began having myoclonic seizures in middle school. “But at college, everyone does their homework all night rather than right after school, and I just couldn’t do that.”

Gassell joined a sorority at Emerson College but quickly realized how hard it was to maintain a healthy sleep schedule. After being encouraged to attend late-night activities, she had to explain to her new sorority sisters that she couldn’t participate. “People don’t always understand how the severity of things like stress, drinking and sleep can really affect me,” Gassel says.

Christine has also had to learn how to reduce her exposure to seizure triggers. She tries to stay relaxed by using her free time during the day and writing down everything she needs to get done. (She carries a pocket calendar, keeps a Google Calendar and regularly scribbles “to do” lists on Post-Its.) Christine is also active in the University Chapel Choir, which allows her to pursue her love of singing and, as she declares, keep her sanity. But Christine knows her limits and her sleep requirement: eight hours. “I’ve always been a student first and foremost, so to have to change that is really weird for me,” she says. “Now I have to sacrifice school work for actual sleeping.” Driving can also be a challenge to independence since each state has different laws regarding epileptics. Christine, who is required by Illinois law to be seizure-free for six months before she can legally drive, plans to live in a city or near public transportation when she graduates. “Unless I have driver or maybe a limousine,” she adds with a smile.

Unlike other triggers, doctors understand how consuming alcohol can induce a seizure. Alcohol affects an inhibitory transmitter that reduces neural activity and sedates the brain. After a person has stopped drinking, however, the nervous system becomes irritable and excited, which can trigger a seizure. Since alcohol can also affect the stress hormone system and be dangerous to mix with medications, epileptics are instructed not to drink or to have no more than two drinks.

While most college students could make wiser choices about alcohol, many young adults with epilepsy feel that they miss out by abstaining. Previously, Christine drank in moderation but after she had three seizures following a night of drinking while studying abroad in South Africa, she stopped completely. The risk wasn’t worth the fun.

“I still go out with my friends but I sort of stay on the sidelines and watch. Inside, it’s still hard not to be able to participate fully,” says Christine. “I’m 21 years old and it sucks that I can’t go out and just have fun with my friends.”

In addition to managing a chronic illness, people living with a seizure disorder must develop a deep awareness and familiarity with their body. This can help them realize if they are pushing their limits or if they are experiencing an “aura,” the often indescribable feeling or strange sensation that can precede a seizure. For many, this requires making it routine to be hypersensitive to how they feel.

“If I’ve been out with friends, I’ll wake up the next day and just be super anxious and aware the entire day,” said Hannah Niequist, a dance teacher who has been seizure-free for several years. “It’s like I’m tricking myself into feeling that aura. I’m so just aware if I drink or am stressed or didn’t get enough sleep that it makes me feel uncomfortable and unsettled.”

People with seizure disorders also have to make decisions about telling others about their condition. Although no one can be legally forced to share their condition with a university, roommate, professor or employer, preparing others can make the situation less frightening and easier to manage. Tracy Schultz, community education coordinator for the Epilepsy Foundation, often reminds her clients their safety and academic success could be at risk. Depending on the severity and frequency of seizures, some people with epilepsy will tell friends not to call 911 since that can be expensive and unnecessary. For example, Christine, who wears a medical alert bracelet, tells friends to make sure she doesn’t hurt herself while seizing and wait for her to come out of it.

Still, it can be difficult to talk about epilepsy or to explain a seizure to a group of friends. While Christine has never had a seizure during class, students who have had seizures in a public place often feel embarrassed. (Some did not even want their name or story included in this article). “They may be hesitant to disclose for fear of sticking out or being different from their peers,” says Michelle Grace, health services director at the College of Lake County in Illinois. Nicole Roman, 23, who hasn’t had a full seizure for almost three years, still worries people will treat her differently. “I don’t want my friends to think they can’t come out with me or that they have to watch over me like a mom,” says Roman, who won’t always tell prospective bosses initially. “I just get afraid that there are some employers who don’t understand epilepsy and will disregard me for the job. But I don’t want anyone else choosing my path for me.” Other epileptics feel comfortable telling people about their seizures and view it as a way of educating others and sharing a significant aspect of their life. Most recently, disclosure has become even more important as the central theme of the Epilepsy Foundation’s “Talk About It” public education campaign. By collaborating with celebrities like Gregory Grunberg from the television series “Heroes,” this nationwide initiative hopes to raise awareness about epilepsy and increase funding for research. In 2005, NIH funding per patient with epilepsy was $39, while other conditions like multiple sclerosis, Parkinson’s and Alzheimer’s disease received more than $100 per patient. “When you look at research dollars, it seems markedly disproportional compared to other diseases that are far less common,” says Dr. Douglas Nordli. “Epilepsy is still in the shadows and there need to be more public awareness about how common it is.”

In college, disclosure can be especially important if students want academic assistance. The Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act protect persons with disabilities from discrimination and ensure accommodations are available. But in the college setting, students must self-advocate.

“Once they graduate high school, they kind of fall through the cracks when it comes to assistance,” says Schultz. “Before college, they have a case manager or school psychologist helping them to navigate the system for specialized education. But when they graduate, they’re on their own.”

Many students seek help from university disability services. These offices can help draft letters to professors, provide assistive technology, like a note-taker or laptop, grant extra time or a separate space to complete assignments, and allow early course registration. While these offices can be a great resource, students who miss classes because of seizures must take the lead in getting the help they need.

“Some schools have great programs for students with disabilities but there are some schools where the disability office is one staff member,” says Schultz. “Sometimes they won’t even know what they’re dealing with since many people don’t understand epilepsy as much as they understand other disabilities.”

With auras, academics, stress, sleep and other issues to juggle, it’s not surprising that depression is the most frequent comorbid psychiatric disorder in people with epilepsy, affecting between 20 and 50 percent of patients. When Christine began experiencing weekly seizures, during what she calls the worst summer of her life, her condition began to affect her emotionally. “She has a different life,” says Christine’s mother, Maria Defilippis, who thinks the seizures and medications have changed her daughter’s personality. “Before she was always in control, nothing and no one could stand in her way. But now epilepsy has got her under control.” Christine faces additional frustrations because her epilepsy is not yet controlled. Despite taking medication and changing her lifestyle, she has not been able to fix her brain, and doctors haven’t either. For a week in July, she stayed in the hospital for a series of tests and scans. The findings, however, only confirmed neurologists’ predictions that she was ineligible for brain surgery since her seizures are not localized. Christine is also dealing with the debilitating side effects of her antiepileptic drugs, which cause blurred vision, vertigo and nausea. Since it is harder for her to read, test and write papers, she is stuck between wanting to up her dosage and living with the side effects. But Christine has not given up. At the end of the summer, she began a three-month clinical trial conducted by researchers at Johns Hopkins University to examine the impact of a modified Atkins diet on seizure frequency. While she thinks it may be working, Christine, who now eats pecans portioned out in small plastic baggies, is not sure how much longer she can go without carbohydrates. With the support of her parents and three younger sisters, Christine tries to assure herself that the weekly seizures will end and that she won’t be like this forever. In December, Christine visited MayoClinic, a prestigious medical center in Minnesota, for a second opinion and new treatment options. “We went through all the stages, like death. You’re shocked, then you’re in denial, and then you cry. And now I’m just mad as hell,” says Christine’s mother, who has found it hard to watch her daughter struggle to manage things she once handled with ease. It has been especially disheartening to see Christine consider giving up her life-long dream of becoming a doctor out of fear she won’t be able to handle the stress. Juggling college, a potential medical career and her search for a cure, Christine faces responsibilities and pressures beyond the average young adult. Besides learning the nuances of telling formal dates she’ll pass on the mixed drink, Christine has realized that the small things are not worth stressing about and life is not something she can plan. “The hardest part for me is trying to be a normal college student and still having to deal with this,” says Christine. “You want to be able to go out with your friends and have a good time but this is always in the back of your head — literally and figuratively.”

A young boy suffering from a rare seizure disorder brings joy to other sick children

Jordan Corvin has seen his share of hospitals.

Jordan suffers from Ehlers-Danlos Syndrome, a disorder affecting connective tissues that causes acid reflux and seizures. He goes to Philadelphia’s Children’s Hospital every four months for potassium treatments. And it was during one of his stays there where, in his own words, “I saw kids being lonely in beds and some were crying.”

Nine-year-old Jordan felt he had to do something. Putting his own illness aside three years ago, Jordan and mom and dad April and Matthew Corvin started a program called Jordan’s Wish – put together with their own funds and the donations of time, gifts, and money from local families.

Essentially, Jordan fills a satchel of small presents that would make Santa proud. Then during the Christmas and New Year’s holidays, he takes them around to hospitals to give to kids and adults. And their response is rewarding for Jordan.
“It’s good. It’s nice. It gives me a happy smile,” said this generous young man.

His benefactors over the years have been Westchester Medical, Kingston and Benedictine hospitals, North Dutchess, and now Columbia Memorial where he recently off-loaded a ton of small gifts before Christmas. In fact, he had so many gifts that he left an additional goody bag to be distributed at the hospital during the New Year’s week.

Dressed in a holiday green Mickey Mouse sweater, Jordan walked the halls of Columbia Memorial with his snowflake decorated blue bag dispensing cheer and goodies that brightened a lot of faces.

Two-year-old Nathan Fulton, dressed in yellow pajamas and sucking on a bright red pacifier wasn’t sure what to make of the Santa-hatted youngster walking into his room. But his mother understood and let the young Jordan give a small Santa bag to her son. Nathan tugged at the bag as Jordan looked on approvingly, his arm warmly draped around the little boy’s shoulders.

“It’s good to give,” said Jordan.

“And it makes my heart feel good.”

Some fertilizers contain toxins that can trigger seizures

The practice of adding hazardous materials to fertilizers had been a serious issue since 1997. Industries have found a way to get rid of toxic wastes, including industrial wastes and pesticides by putting them in fertilizers.

According to Sen. Miriam Defensor Santiago, some tests done on fertilizers show the presence of numerous heavy metals and other contaminants.

She said these toxic fertilizers have been shown to have caused the contamination and loss of agricultural lands, death of livestock, contamination of groundwater or drinking water and potentially allowed toxic substances to end up in food supplies.

She said some of the toxins which have been found in commercial fertilizers include lead which causes seizures, mental retardation and behavioral disorders, cadmium which is known to cause cancer, kidney disease, neurological dysfunction, immune system changes and birth defects, and arsenic which is a known carcinogen.

Santiago said this is precisely why she is pushing for the passage of a bill, Senate Bill 3556, which calls for an immediate halt to the practice of adding toxic and hazardous materials to fertilizers.

“The Constitution, Article 2, Section 16 which states that the government “shall protect and advance the right of the people to a balanced and healthful ecology in accord with the rhythm and harmony of nature,” Santiago stated in the measure.

“The purpose of this bill is to stop the practice of adding toxic and hazardous materials to fertilizers immediately,” she added.

The measure would be termed as “Fertilizer Content Act” and would primarily ban fertilizers that poses substantial or potential threats to public health and environment and generally exhibits carcinogenic, ignitable, oxidant, corrosive, toxic, radioactive or explosive characteristics.

Under the bill, the Department of Trade and Industry (DTI) is mandated to analyze samples of all commercial fertilizers for the presence of hazardous wastes or hazardous substances.

The Department of Health (DOH) will assist the DTI in conducting these tests. The Secretary of Trade and Industry will publish a list of fertilizer products containing hazardous wastes or substances and will annually report the results of the sampling and analysis to the legislature.

Serotonin Syndrome vs. Seizures in obese patients

This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.

Learning Objectives

• Identify obesity-related health problems and discuss their impact on the health and well-being of obese individuals.
• Identify the two clinical approaches to weight loss.
• Identify actions, precautions and side effects of adrenergic, serotonergic and alternative weight loss medications.
• Identify and differentiate three classifications of bariatric surgery and the common complications of each.
• Describe and explain various components of a bariatric response plan.

Key Terms
Adrenergic: Pertaining to the fibers of the sympathetic nervous system that use epinephrine (adrenalin) as a neurotransmitter.

Anastomosis: Surgical joining of two vessels, ducts or bowel segments.

Benzodiazepines: A class of psychotropic drugs used for sedation, anxiety, seizures, muscle spasm and amnesia, and which includes Valium.

Cardiac sphincter: The muscular fibers at the junction of the lower esophagus and stomach that prevent backward movement of food from the stomach into the esophagus.

Deep vein thrombosis: A thrombus (blood clot) in one of the deep veins of the body.

Ephedrine: A stimulant drug used to suppress appetite and enhance weight loss and concentration.

Fentanyl (sublimaze): A synthetic narcotic used to control moderate to severe pain.

Gastroesophageal reflux: A condition in which food travels backward from the stomach to the esophagus, causing irritation of the esophagus.

Innervated: A state in which a body part has been supplied with nerves or nervous stimuli.

Laparoscopic surgery: A minimally invasive surgical procedure performed with only small incisions.

Leptin: A protein hormone that regulates energy intake and usage, including appetite and metabolism.

Methamphetamine: A drug class that stimulates the central nervous system.

Obesogenic: An environment and its components that contribute to obesity.

Phentermine: A stimulant medication used for weight loss that mimics the actions of the sympathetic nervous system.

Pulmonary hypertension: Abnormally high pressure in pulmonary circulation.

Roux-en-Y gastric bypass (RYGB): An invasive procedure used for morbid obesity that decreases stomach size through creation of a pouch. This procedure also separates the small intestine into two arms, rerouting the jejunum to the stomach and the duodenum to the distal ileum.

Stomal stenosis: An abnormal constriction or narrowing of an opening or passageway (stoma).

Thermogenesis: Production of heat, especially at the cellular level.

Ventricular gallop: In adults, an extra heart sound (S3) that indicates the presence of myocardial failure.

The dispatch report was for a "woman passed out." Everyone on the rescue squad knew the address. It was Dorothy, a 38-year-old bariatric patient who weighed about 300 pounds and had a history of deep vein thrombosis.

On scene, Dorothy’s roommate explained that Dorothy was post-op from a Roux-en-Y gastric bypass (RYGB). When asked what happened, the roommate said Dorothy was having a small bowl of chocolate ice cream to celebrate coming home. After Dorothy started to have severe abdominal cramping and suddenly passed out, her roommate called 9-1-1.

As the crew proceeded into the bedroom, they could hear the arrival of the engine company, whose help would be needed if the crew were to safely care for the patient. After ensuring the patient’s airway and breathing were adequate, the EMT obtained a blood sugar reading, which was low. Although Dorothy was awake and able to maintain her airway independently, the paramedic knew that oral glucose might not be the best choice and elected to immediately administer IV glucose. With assistance, Dorothy was able to walk to the stretcher in the living room, and she agreed to be taken to the hospital. Talking to the emergency department attending later, the EMT and paramedic found out that Dorothy was sent to a dietician for education about how to live with her gastric bypass.

Obesity & Complications
It has been estimated that one-third of Americans are obese, and some of those people are morbidly obese, or greater than 100 pounds over their healthy body weight. Although such people are at increased risk for complications related to obesity, many don’t see themselves as being at risk for obesity-related health conditions. In one survey by Shape Up America, a nonprofit organization founded by former Surgeon General C. Everett Koop, MD, seven out of 10 overweight Americans didn’t consider themselves unhealthy or think their weight posed a risk to their health. Further, Malcolm K. Robinson, MD, of Harvard Medical School, suggests that not only will obesity impact the health and well-being of the patient but the patient may also expect to lose up to 20 years of life expectancy.

Although health problems associated with obesity are numerous (see Table 1, p. 44), some people take action to reduce their weight and address these conditions using a variety of methods. If successful, some patients can look forward to a reversal of many of these illnesses and a return to good health. But these weight-loss interventions aren’t without risk, too.

Adrenergic Agents & Side Effects
At its core, obesity is an imbalance between food intake and energy expenditure. Weight loss measures must be taken to correct this. The clinical approaches to weight loss fall into two categories: medical or surgical. It’s important for EMS providers to understand these bariatric therapies and the problems they can cause.

The earliest medical approaches focused on increasing energy expenditure. Adipose tissue, or fat, is a form of energy storage for the body. Lipids within fat are released for energy when needed, in part by the sympathetic nervous system.

Adipose tissue is highly innervated with sympathetic nerves for adrenergic stimulation. Epinephrine (aka, adrenaline) attaches to beta 3 sympathetic receptors in fat and activates lipolysis, the division of fat into fatty acids, fatty acids being used for energy.

Stimulation of beta 3 adrenergic receptors is usually responsible for thermogenesis, an example of which would be heat production from shivering. Bariatric medications seek to stimulate these beta 3 adrenergic receptors to raise the resting metabolic rate and thereby adjust the ratio of intake versus expenditure to create a caloric deficit and ultimately weight loss.

Used since the 1930s, amphetamines are the earliest examples of these stimulants or adrenergic medications for weight loss, but they were frequently abused. Newer agents, such as phentermine, first approved by the FDA as a diet suppression medication in 1959, have less abuse potential and cause less severe central nervous stimulation.

However, this class of drugs is not without risks. As an adrenergic stimulant, these "diet pills" can lead to hypertension, palpitations and tachydysrhythmias. The effect is even more pronounced if the patient is concurrently being treated for depression and has been prescribed a monoamine oxidase inhibitor (MAOI) class antidepressant. Most medical authorities recommend a two-week "wash-out" period between the end of MAOI use and the start of the adrenergic agent. Without that wash-out period, the combination of MAOIs and adrenergic stimulants can lead to potentially life-threatening hypertensive crises and strokes. Similarly, using such illicit drugs as cocaine or methamphetamine in tandem with these adrenergic stimulants can lead to hypertensive crisis.

Because diet pills have potential for abuse, the FDA has classified these medications as controlled substances under the Controlled Substances Act. Table 2 (p. 46) lists some of the drugs in the adrenergic classification by generic name, trade name and schedule.

Another major side effect attributed to this class of bariatric medications is primary pulmonary hypertension. Pulmonary hypertension’s effect on the bariatric patient is twofold. First, pulmonary hypertension decreases the heart’s ability to increase cardiac output, especially during times of exertion, leading to shortness of breath and fatigue. Second, pulmonary hypertension will eventually cause the right ventricle to fail, a condition called cor pulmonale . Coupled with left-sided heart failure secondary to increased systemic vascular resistance caused by obesity, the patient will go into complete heart failure.

Compounding these complications is the fact that many bariatric patients are also diabetic. Adrenergic stimulants may decrease the patient’s insulin need. Without an adjustment of their insulin dose, a patient may inadvertently overdose on insulin, leading to hypoglycemia.

For a variety of reasons, increasing numbers of patients are turning to alternative or complementary medicine for weight loss. Such weight loss supplements include chromium picolinate, ma huang and white willow bark. These substances are thought to be adrenergic—similar to ephedrine or caffeine. When combined with drugs from the adrenergic class of bariatric medications, these substances pose a great risk for hypertension-related medical emergencies.

Selective Serotonin Reuptake Inhibitors
The other class of bariatric medications seeing greater use is serotonergic agents. Like the adrenergic agent epinephrine, serotonin is a central nervous system (CNS) neurotransmitter that impacts mood and appetite. Originally used as antidepressants, serotonin agents are also prescribed as an appetite suppressant, impacting the intake side of the energy imbalance. They work by either increasing the amount of serotonin available or by inhibiting the reuptake and destruction of serotonin in the distal neuron.

This latter action forms the basis for the effect of selective serotonin reuptake inhibitors (SSRI). SSRI medications allow serotonin to remain in the synapse longer, thereby continuing to stimulate the nerves. Examples include fluoxetine (Prozac) and sibutramine (Merida).

Both Prozac and Merida can cause dizziness, nausea, insomnia and significant increases in blood pressure. The latter is cause for concern. Most physicians won’t prescribe these medications if the patient has a history of coronary artery disease (CAD) or congestive heart failure (CHF). Unfortunately, in many cases, one of the long-term outcomes of obesity is CHF and many of the signs of CHF (such as ventricular gallop, peripheral edema, rales or crackles in the base of the lungs, are obscured in the obese patient).

Serotonin syndrome is a potentially life-threatening side effect of SSRI; it occurs when excessive amounts of serotonin build up in the CNS. This stimulation of the CNS also leads to increased adrenergic activity and is causes the signs associated with serotonin syndrome, which include fever (without infection), clonus (shivering without cold), agitation, tremors and sweating. Serotonin syndrome may result from normal therapeutic levels of SSRI and interactions with MAOIs, tricyclic antidepressants, fentanyl, phentermine, methamphetamine and cocaine. These medications combine synergistically with SSRI to cause serotonin syndrome.

Untreated serotonin syndrome can lead to seizures, hypotension and dysrhythmia. Prehospital care is largely supportive. Benzodiazepines are used to control tremors and clonus.

Bariatric Surgery
Bariatric surgery has become an increasingly popular method of permanent weight reduction, especially with the advent of laparoscopic surgery. It’s estimated that more than 140,000 patients had bariatric surgery in 2004 and that greater than 50% of those surgeries were laparoscopic.

Although the mortality associated with this type of surgery is low (0.1% to 2% depending on the procedure), the complications usually necessitate EMS.

There are three classifications of bariatric surgery: restrictive, malabsorptive and combination. All three bariatric surgeries are intended to block the patient’s intake of excess calories, impacting the energy formula on the intake side.

Restrictive bariatric surgery procedures include gastric banding and gastroplasty. The FDA approved gastric banding, also known as lap banding, in 2001. Lap banding is a minimally invasive laparoscopic procedure that places an inflatable ring at the neck of the stomach near the fundus and proximal to the cardiac sphincter. This inflatable ring creates a small pouch and limits the amount of food the patient can eat.

The alternative to gastric banding is vertical banded gastroplasty (VBG), aka, stomach stapling. Like lap banding, gastric banding creates a small pouch but the procedure also includes a double row of staples that isolates the majority of the stomach from the pouch.

Gastric bypass is an example of a malabsorptive procedure. These procedures involve bypassing the stomach entirely and even removing as much as two-thirds of the stomach. Because of a number of nutritional complications, this procedure is discouraged in favor the RYGB combination procedure.

RYGB may be the most common bariatric surgery in the U.S., but it’s quickly being eclipsed by gastric banding (laparoscopic RYGB trials are being conducted). In such a procedure, the bariatric surgeon creates a one-ounce pouch at the stomach’s inlet and then detaches the small intestine at the jejunum and attaches it to the stomach at the pouch. The remaining arm of the duodenum is also attached to the distal ileum, creating a Y-shaped circuit.

RYGB has a proven record of sustained weight loss but is not without complications. Obvious complications include those common to all abdominal surgeries, including dehiscence (a spontaneous opening at the wound with or without evisceration) and hernia.

Other adverse effects include surgical complications at the site of the connections, or anastomosis. Some 20% of RYGB patients experience leakage of stomach contents into the abdominal cavity as a result of force from overeating at the staple line. These spilled stomach contents can lead to peritonitis. The symptom pattern associated with peritonitis includes dyspnea, tachycardia, abdominal pain and general restlessness.

Approximately 20% of patients who undergo RYGB may experience stomal stenosis, a narrowing of the stomach inlet that results in post-prandial epigastric pain, not dissimilar to the pain felt with gastroesophageal reflux after eating. A key sign of stomal stenosis is regurgitation of undigested food.

Dumping Syndrome
Gastric dumping syndrome is a form of rapid gastric emptying that occurs when a concentrated carbohydrate, such as sugar, enters the digestive tract. The higher osmolarity of the carbohydrates in the small intestines causes fluid shifts in the intestine. These fluid shifts are often accompanied by pain and nausea, and patients experiencing them often complain of feeling bloated or experience diarrhea.

The sugar spike also results in hyperglycemia and a subsequent rise in circulating insulin. As the fluid rapidly passes through the digestive system, the patient becomes hypoglycemic. The symptom pattern associated with hypoglycemia includes lightheadedness, weakness and even syncope. The EMS provider must be alert to the possibility of hypoglycemia induced by dumping syndrome even if the patient has just finished eating.

Treatment, Transport & Sensitivity
There’s a stigma surrounding obesity. In studies, even overweight people reported feeling obesity was unattractive. This "weight bias" can translate into subtle and sometimes not so subtle behaviors that patients can detect.

A greater sensitivity toward obesity comes from understanding that it has a complex etiology. Some believe that obesity is biological, a problem created by protein receptors in the lateral hypothalamus. Others believe that the cause of obesity may be genetic and point to research on the leptin gene. Still others believe that Americans live in an "obesogenic society where increased portions, sedentary lifestyles and unhealthy food lead to obesity.

Regardless of the etiology of obesity, the problem isn’t going to be solved in the field. Perhaps more importantly, if the patient has a negative experience with an EMS provider, they may be less inclined to seek help from other health-care providers. The EMS provider would be well served by maintaining a professional demeanor and acknowledging the difficulty of the patient’s situation.

In EMS terms, a patient is obese when they exceed the load-carrying capacity of the equipment or crew. In those cases, special resources should be brought to the scene.

Special response to bariatric patients should be thought of as a risk-control strategy. By utilizing specialized protocols and procedures, the responding department or agency can decrease their worker’s compensation claims and retain workers longer.

Some crews use specialized lift teams, which combine special tools, such as pneumatic lift devices, and training to move large patients with a minimum of effort. Some agencies have outfitted specialized bariatric ambulances. These agencies may stock large-body stretchers that can carry patients who weigh up to 700 pounds and have extra handholds that permit multiple EMS providers a grip point to help with lifting. These ambulances may also come equipped with ramps and winches to pull the patient into the ambulance.

Conclusion
EMS providers are duty-bound to act when called to the scene of a bariatric patient and may have other duties to that patient that dictated by the Americans with Disabilities Act. Therefore, every EMS system should have a bariatric response plan in place.

But more importantly, EMS providers should see bariatric patients not as a burden, but as another special population of patients deserving of our care and compassion. JEMS

Richard Beebe, MS, RN, NREMT-P, is the paramedic program director for Bassett Healthcare’s Center for Rural Emergency Medical Services Education, clinical assistant professor at the State University of New York at Cobleskill and a practicing paramedic in the town of Guilderland, N.Y. He has been an EMT since 1974 and an EMS educator since 1987. Mr. Beebe is the also the co-author of Fundamentals of Basic Emergency Care (third edition) and the Professional Paramedic Series.

References

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Illegal substances are party poopers for party goers as they may cause seizures or worse

PARTYGOERS are being warned not to spoil their festive celebrations by taking illegal substances.

Some 'legal high' drugs have now been relabelled as illegal. But at least one highly dangerous substance is still within the law.

And police are urging revellers to steer clear.

Just before Christmas, a group of what were termed 'legal highs' were classified as Class B and C drugs - making them illegal.

Force drugs co-ordinator Bryan Dent said: "The government became so concerned about the adverse health effects of a number of substances, they have made them illegal to possess or supply."

Recently, a smoking/ herbal mixture known as SPICE became popular. SPICE has been found to have been treated with a chemical which mimics the effects of THC – the ingredient found in cannabis.

Mr Dent said: "SPICE was legal to sell and possess, usually from Head Shops and the internet. But now anyone found selling or in possession of SPICE which has been treated with certain chemicals is committing an offence for which they can be arrested. SPICE has become a Class B drug."

GBL (Gamma – Butyrolactone ) – although this colourless, oily liquid has a bona fide industrial use as a paint/varnish stripper and stain remover, it has also become popular on the recreational scene.

Mr Dent said: "Possessing or selling GBL for human consumption is now a criminal offence. Its effects when taken can be deadly – especially alongside alcohol."

Other substances now illegal to possess and sell include BZP and certain anabolic steroids.

Mr Dent said: "We want party goers to enjoy themselves, but also stay healthy. We don't get pleasure from informing parents and loved ones that their son or daughter has become seriously ill or died because they have been consuming drugs thought to be harmless. There is no such thing as a harmless drug."

Mephedrone, also known as M Cat or Meow, is also giving police cause for concern.

It is usually a white powder but is in fact plant food. It can be taken orally or snorted, but it is harsh on the nostrils and causes severe nose bleeds. It can cause blurred vision, increased perspiration and increased risks of fits and seizures, breathlessness and high blood pressure.

Mr Dent said: "Although it is not a controlled drug, in other words not illegal to possess, it is dangerous for humans to consume. A number of people have taken it and ended up in hospital."