BIOENGINEERING AND WORLD HEALTH
BIOENGINEERING AND WORLD HEALTH BIOE 301
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This 45 page Class Notes was uploaded by Lavonne Streich on Monday October 19, 2015. The Class Notes belongs to BIOE 301 at Rice University taught by Richards-Kortum in Fall. Since its upload, it has received 20 views. For similar materials see /class/224924/bioe-301-rice-university in Bioengineering at Rice University.
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Paul Maliakkal Kortum 22 March 2006 BIOE 301 Complications A Surgeon s Note on an Imperfect Science by Atul Gawande Each day in the life of a training surgeon involves a broad variety of patient cases Physicians are equipped with a wealth of information about the human body and associated disorders Years of practice prepare physicians to handle each patient with skill and con dence In Complications A Surgeon s Notes on an Imperfect Science surgeon Atul Gawande recounts numerous instances in which he and other physicians were confronted with patient cases far from textbook In such situations quick decision making improvisation and even gut instinct often make up for imperfections in the science of practicing medicine In his captivating account of years spent treating patients Gawande openly invites the reader to scrub in and enter the operating room through detailed accounts of surgical procedures and a glimpse into the minds of physicians who are challenged every day to make the right decisions when a patient s life is on the line Gawande translates the jargon of complex medical interventions into plain terms that help present to the average reader both technical and human aspects of his practice The first part of the book is a discussion of the fallibility of even the most experienced physicians Gawande presents a sensitive ethical issue involved in the necessary training of physicians novices can only truly learn by practicing on patients The cycle of learning medical procedures follows the saying See one do one teach one While the chance of procedural error is much greater under the scalpel of an inexperienced resident Gawande defends the controversial training with real patients as the only means of gaining skill and experience Gawande also addresses issues relevant to bioengineering in his discussion of the fallibility of a physician screening patients for heart attack risk He describes the continuous drive in medicine to automate diagnosis and procedures to reduce the inevitable problem of human error In one example Gawande illustrates inescapable human fallibility by describing a EKG interpreting machine that could detect heart attacks with twenty percent greater sensitivity than an experienced cardiologist In the next portion of his book Gawande describes the hidden mystery of the human body in unexplainable symptoms of various patients For example a seemingly healthy patient with no radiology detectable physical damage experienced unbearable back pain that greatly puzzled the physicians he visited Despite a strong base of knowledge for the causes of physical pain Gawande demonstrates that patient symptoms often evade the understanding of even the most qualified specialists The final part of Gawande s book is an elaboration on the uncertainty of diagnosis and the frightening frequency of false positive and false negative results In one case Gawande describes a patient with an extended history of heart failure and bypass operations When the patient died suddenly one morning Gawande reprimands a physician for giving the patient vitamin K which Gawande with great certainty presumed had caused a pulmonary embolism and subsequent death On the contrary an autopsy revealed that the patient had in fact ruptured an aortic aneurysm which caused a fatal internal bleeding and nearly instant death Gawande s f1rstperson account of the truth behind misconceptions of medicine serves as a direct portal into a misunderstood field Atul Gawande reveals that medicine is a dynamic practice with a comprehensiveness limited by unforeseeable and at times unexplainable patient cases All in all Complications A Surgeon s Notes on an Imperfect Science is an excellent gripping masterpiece that leaves readers with a greater appreciation for a developing science BME 301 Lecture Seventeen Outline The burden of heart disease The cardiovascular system How do heart attacks happen I How do we treat atherosclerosis Open heart surgery Angioplasty Stents What is heart failure How do we treat heart failure Heart transplant I Left ventricular assist devices Arti cial heart Burden of Heart Disease US and Worldwide Global BurdenCardiovascular Disease In 1999 CVD contributed to a third of global deaths In 2003 n 167 million deaths due to CVD By 2010 CVD is estimated to be the leading cause of death in developing countries m2 W dwmde M rta mty Monalily adults aged 15 59 Mortality 7 adults aged 60 2 n c Se Dead1x000 Rank Cause Demhs 000 HNmns 2279 7 xsz aerm eavtuseass Smaemm mart 752352 evemvasm ar wsease an n evm 0575 u 3 Guam nbstmdwe puhnnnary msease 2399 4 Read traf c Wun es m 4 Lawev vesphamry mfemans 7395 s arehmvascu ar Mm 783 5 Trarhea hmndws hmg ancevs 928 s Sewnnmed wunes 572 7 vmence 473 7 H enenswe heart msease 735 a when uf the Way 382 a Stumam mm 605 9 Luwenesmramw mfenmns 352 9 Tubevcu asxs A95 70 Chmmmbsuuztwe nu munavy Mm 343 70 man and 72mm anms 477 Figuve 51 Deaths attributable tn 15 leading causes in develnping muntries 1001 I avthuvasuavd59ase Ma mam neup asms Manes Respwatory mfemons hmmz vespvatmy mseases s Pennata andmuns Dwanhaea dwstases TuhEKu osis Dwgestwe mseases mama dwseases Ma ana Dwahe es me htus Dwseases at the gemtummavy system N Matema ondmuns 1 Luwnmnamy deve upmg munmes nghrmmtamy deve upmg aunmes 6000 Deaths mm 8000 m 000 United States CVD a meet 611 milliheh Ameheehe etnimegi39t We eff ligehuteitteh heve CMD a Aeeemte fer mete theh t eliH teeth a 3 The meth tehme th CW9 11 teehemte dteeeee f Shake techemtc Heart dtseese a Leedth eeee eeth h US a g 1pgtehnfmemeht epx1ty emehgg wethhg edh te Stroke 1 Ther Heeethg et deeth th the US of CVD dteeeeezz E 3 httteh I 209 hittth fer heetth care quot e 142 When her eet from deem and dteeibt ltty Us Burden of Heart Attack a Hermes 0f Escheth heart disease by rrarrerrrrrrg at the earerraray that surgery breast heart r a Each year m mitten 0 K 5 Ln W 7 r r 4691 n a tease Caesar wrtarm 11L hear at sirrasterth eras aerate reames aespirta Early Detection of CVD Risk Factors Tobacco use Low levels of physical activity Inappropriate diet High blood pressure Over 70 not under control I High cholesterol Over 80 not under control Screening for CVD Measure BP annually 1213 point reduction in blood pressure can reduce heart attacks by 21 Check cholesterol every 5 years n 10 drop in cholesterol can reduce heart attacks by 30 af x 7quot w x a i w H quot yquotquot W ith High Percentage of Americans with Uncentreiled High Blend Pressure by Race and Ethnicity 3990 BU E 3 xx gig 23 ke 13 Atrial1 i39v lexiean quotquotu39hite Tetal US An ierlrzan American Pepul atlen D Pressure My Mood pressure 10368 3 We higher sysitprr re member represepts the presspre wp e peeri peer pg a We U X p7 e1r39fli aS QWC member reprres rris the pressure when quotripe peert resprrg Normal lbll pressure a r39rpm rp ppre re mrppte 11 Verr with rp e Sheep be mm Hg fer ep epp39rt rPrehyperrensrorr 1 preps pressure eet hemveep Hypertension a greed eppwe mm rip H0 D0 Measure IBIP m Sphygmemanometer a Mf f pli EYSSU Ml l t gmregewe a Bi ood ow into arm Stope a we hen eui f pr pressure 1 Bli i beggme e ew J 1 t e Higher them quoty We pl 5g am 1 v 99 g 1 Hleef Kelre kei f seemed w th twbw emt ew threwgh a When cu f preesure diieetemc lpreeeurer a A ew He me a M S gmu E C aura u pms mean I wandlzomm g y L 1 z s l f lt l i Serum Ciioiesteroi Leveis Teiiei LDL HiDL Opiimei under 100 above 60 Desiiaibie iiimeiei under 1 Bordieiiiiie iBQQiSQ Abnormai eiiei over 160 beiow 35 LDL caiisee ciioiesieioi i0 ibiiiidi up inside ibin HDL actuaiiy removes cineiesterol from the wails oi biood vessels and brings it back it tine livei to be safeiy excreted The Cardiovascular System Diaphragm The heart is on the ventral side oi the thoracic cavity sandwiched between the ungs mule that carry welloxygenmed bland an red Ihon wim lest weiloxyqanaiad blood are blue Fig M 7 ad rThe Cardiovascuiar System Siiverthom 2 Ed Fulmonlry mllum valve Left quotquotm mam nulmonnrv quot r IMI H c 39 fr r I 39 V 397 v cmleka 7 r blwlpldvllve chom Cupul rlghuv imamI Mcuwld39IVINI The venlrlcles occupy the bulk arm 5 nerlesandvelnsall anachloule baseufme heart ehunlumwed vul I Dmayllwlhmugmh in two mm htt wwwinnerbod com anim hearthtm LI l II thQ I II I I I I hfml Silverthorn 2quot Ed Fig 147 eh The Cardiovascular system Amman 5mm m cm mm nanmm mm mm m m pg 1417 Genera anatomy of me cwrcu atory system SHvenhom 2quotd Ed Quantifying Heart Performance Heart Rate HR Number of heart beats per minute Normal value is 6090 bpm at rest Stroke Volume 5V Amount of blood pumped by ventricle with each heart beat Normal value is 6080 ml Cardiac output C0 Total volume of blood pumped by ventricle per minute I CO HR X 5V Normal value is 48 Lmin Blood volume Total volume of blood in circulatory system Normal value is 5 L Total volume of blood is pumped through our heart each minute Quantifying Heart Performance I Ejection Fraction EF I Fraction of blood pumped out of ventricle relative to total volume at end diastole I EF SVEDV I Normal value gt 60 I Measured using echocardiography I Normal echocardiogram I Dilated cardiomyopathy Heart Attacks Pathophysiology Diagnosis Treatment Heart Attacks Pathophysiology El Ei Case Study Three months roiliowin his first visit to your office iin Soiornon presents to the ER in e eariy morning with chest pain of one hour duratith Mn soiornon describesthe as being severe and Wiilke someone was sitting on his chest T pain iocated in the tower part of my breast bone awakened him from his seen Aithough he tried to reiieve the pain by changing positions in bed sitting up and drinking water it remained unchanged hie did not steep weili because i had an upset stomach an acid burning ieeiihgj w He attributed symptoms to over eatng and drinking at a ristnras party He has no pain or discomfort in his arms but says he has an macheness in his iett jaw which he attributes to Wbad teethW Physical examination reveals the patient to be anxious bate diaphoretic and in obvious discomfort tie is unshajven and accompaniedby his wife tie tries to reiieve his pain by beichingg He coughs occasionaiiyg Mrr soiornon says the u has been oing around the orifice and i ve had a iittie cough and fever air week caseZiCasejrhtrn Ea y El Shartrr 3 Signs of Heart Attack Maday heart attacks Start stawty symptome may came an go Chest discomfart Meat heart trwahe temmtaht th the ehter at Cheat that rar mare thah tear mrhatea array aha tahheaa r hath Discomfort th other areas at the Upper body 13 rhthrdte path gtr dracamtart th ahe r hath arma the heat hath jam r etahrach of breath a tteh atahg with theet il reearhtarto Bat rt ah eater herare lretahrart Other symptams L m 1 May thetade hreahthg eat th eatd er tight hireaaeeheaa Heart Attack Signs httpwwwnhlbinihqovactintimevideo htm LuIl Main Emory M15 LizE I irnmfquothzx mm Lt interim DWEMIM Amew Lumen Tunica media Tunica adventitia Wm mm me mummy a mumm gm httpwwwmedimagerycompatho logpreg Heart Attack Video httpwwwheart1comattackquidantcf m Heart Attacks Treatment of Acute Occlusion tPA Tissue iDiasminogen Actvator Tissue piasminogem activator tPA g timirsmbsiiv tis sigsimt m iisssivs bimd a Psijsptswsd is it si isiim psitisiits imsvimg ihssii t if stirsss Ciinicai Studies a iitisr ilstcsisssivimg isdii tits sm gtiiiit st dismst t this itsstt mtissis smcd T39s ibis imswrs bsgiii 11 tiimiigii iiitiswsmiis W iiiis iii aim isy tisspitsi psts msi witiiiii 9 miiiiitss i psim i it 3iifi i iiiiii ii v mipstssi L pstisiits wits titsispy miimiitss l 1 Thrombolytics Risks of thrombolytics Intracranial hemorrhage Increased risk in those gt age 70 Patients may require further intervention Costs of thrombolytics I tPA 2300 Streptokinase 320 Effectiveness of Th rpmhoiytics Ciinicai Triai a in 15 pauntniee and rear hcapitaie r r patiente with evening nnypeairuiiai intarptipn u tainpipnniy ta 4 iiiiierent u Streptutinaae and subcutaneous heparin r Streptokinaee and IV heparin n Acceierated tissue piaarninpgen activator item and iv heparin e Combo at atreptutinaee piue tePA with IV heparin 1 trimary end paint nae meniaiity Result n CO WCLTJO oi lbotii with W h Ev a a n taint 1W heparin 3772 gt CastaEhiectivehess at Thramiboiytics Therapy Patient Group per yr iiie saved tPA Past iii high risk 36d tPA Acute iviiii iarge infarct 242dd treatment started gt2 hears past Caiihseiihg Srrraikihg 13d0e3900 CABG Two vessei disease 9200a425 severe arrgrra Heart Attacks Diagnosis of Atherosclerosis Detecton of Atherosceross uni Gunman Wm 1