Five Deadly Sins

I roasted coffee for many years. Kaladi Bros Coffee, in Denver Colorado was a job that was much more than a job, in many ways. Since the day I started working at KBC, in August of 2003, I have been a daily coffee drinker. Perhaps the number of days without coffee, or, at least caffeine of some kind can be counted on one hand.

Out of all the vices available for perusement in the world, coffee drinking, if even a vice, would the one I would least want to be rid of. These days there are not many other vices I have either the time nor the capacity to indulge in.

In the hospital, the consequence of a given vice are glaringly apparent. This is less a discussion of the psychology and pathology of how a person is given to a certain vice, but a frank examination of the disease processes that I deal with as a direct consequence of the small, but powerful list below.

Gluttony

Definitely the most widely engaged in deadly sin, and usually the one with the most hard to hide consequences.

One one hand I'm all in with the "body positive" movement, in that our identity should not be caught up in our aesthetic prowess, or, lack thereof. On the other hand, obesity definitely has negative health consequences -- there is no doubt about it. Early morbidity is all but guaranteed for obese people relative to a their life lived as a person with less adipose tissue.

If you heart is forced to pump blood through more tissue than it was "designed" to do, it will allow for this by becoming stronger. Specifically, the left ventricle of the heart will get bigger. This is the chamber that pushes blood into the aorta. LVH -- left ventricular hypertrophy is a cause of heart failure. The walls of the ventricle, made up of specialized cardiac muscle cells, will grow to such a size that the actual chamber becomes is compromised. It can get so small that the heart actually can't do it's function -- to pump blood. I do find it fascinating that this disease is a direct result of the heart trying to be stronger, and in doing so grows so big to cause it's own demise. We call this diastolic congestive heart failure. It is the direct result of hypertension (high blood pressure) over the years, and that hypertension is a direct result of obesity. Simply to many pipes for the pump as originally made to maintain pressure as needed.

Previously I've written about osteoarthritis. I tried to illustrate the simple relationship of increased force placed on connective tissue in the knee, for instance, and the process in which osteoarthritis is increased. This is not the only factor in developing OA, but it is the largest factor, by far and the one that can be modified. 

Circling back to hypertension. Long standing elevated blood pressure can also serve to blow your kidneys out. I see people, relatively young people on hemodialysis because they had uncontrolled hypertension. A decade or two and next thing they know, they have a fistula built and they're spending three hours at the dialysis clinic three times a week and have a severely restricted diet.

I would be remiss to miss the cardiovascular disease that goes part and parcel with obesity. Best case scenario, claudication, which is a fancy word for muscle pain in the lower extremities when walking due to decreased blood flow in the setting of unhealthy, calcified  and stenosed arteries in the legs. Heart attacks and strokes are definitely a concern. Forthcoming is a whole post on cardiovascular disease, specifically myocardial infarctions, so I'll leave the juicy details for that time.

Perhaps because obesity is so prevalent and the consequences so entrenched in the way we practice medicine and manage patients that it actually plays a large part in almost every post I write. It is worth mentioning this. Also, and I say this while acknowledging how psychologically traumatic it can be to be obese, that losing weight and decreasing one's BMI can do wonders for a psychological disposition. Maybe it is the increased exercise. Improved diet. Maybe it is the body rejoicing for the decreased burden required for locomotive enterprise. Whatever it is, I can say anecdotally and through patient experience that this is a true thing.

Cigarette Smokers

Fifteen year old me thought I could get away with smoking cigarettes without my family knowing. I now realize how much that smoke smell stink is a dead give away.

Heroin and tobacco. I believe these are the two most terribly addictive substances in the world. Tobacco, smoking and nicotine now and heroin later.

As the numbers of smokers in the US continues to decline, smoking has become something of a rarity. I have a theory about this. The older folks who still smoke are the ones I see mostly. Younger people who it seems make up an increasing ratio of the smoking population (for two reasons: self limiting population in that smoking kills people and many youthful smokers stop as they age) and they're still healthy, and I don't see younger people as much, in general.

The three largest areas where cigarette smoking will get ya are:

1. Atherosclerotic cardiovascular disease
2. Lung cancer
3. Chronic obstructive pulmonary disease (COPD)

There are plenty of other issues that arise from a long standing smoking habit. One that I saw first hand during a recent rotation, comes to mind. Sebaceous cysts. 

Dr. Pimple Popper. A superstar. A genius who has tapped into the fascination and satisfaction that comes from squeezing stuff out of our skin -- or, watching it come out of someone else's skin. 

Cigarette smoking is correlated with a much higher rate of sebaceous cysts, officially we call them "epidermoid cysts." These things aren't usually very painful, but can become annoying. Unsightly. Perhaps there are those who smoke in hopes of developing these bad boys so they can go to Dr. Pimple Popper's office. Dr Sandra Lee is her real name, and she seems like a competent doctor with a great personality. 

In undergrad I had a great biochemistry instructor. I remember learning from him what some of the real life applications of some of the esoteric concepts that the fundamental, hard sciences involve. 

This article outlines one of the things I remember him teaching us. Certain fertilizers have radioactive components and when used in tobacco fields these stick to the sticky underside of the tobacco plant. The radionuclides are naturally occuring radon, which is all around us, and radon gas is even a problem in some basements. Inhaling radon is bad. 

This radiation exposure is probably not the worst, or most damaging aspect of cigarette smoking. The combination of the inhaled foreign material in conjunction with the effects of nicotine and vasoconstriction is the most damaging aspects over time. 

It is no surprise, I trust, that nicotine is the substance holding addictive power over the human chemistries. Nicotinic cholinergic receptors (nACHr's) stereoselectively bind to the (s)isomer of nicotine, which is a tertiary amine consisting of a pyrimidine and a pyrrolidine ring. 

All that to say that the nicotine is a substance that binds to neurotransmission receptors. When these receptors bind with the ligand (nicotine) we know that certain cascades occur. Dopamine secretion increases. 

Think of dopamine's presence in the brain causing the sensation of pleasure. Over time our brain alters the chemistry involved with having extra dopamine involved. It stands to reason that when this new chemistry is asked to function in the absence of extra dopamine, the brain will complain. This is a very simplified explanation of biochemical etiologies of physiological chemical addiction.  

It is this idea, that chemical changes in our brain from exogenous psychoactive agent ingestion over time leads to what we call addiction. Think of nicotine as manipulative; it seeks a codependent relationship with the your brain. The brain seeks neurotransmitter equilibrium.  Nicotine floods the brain, all day, day after day, Month after month. What does it do? It builds more nACHr's so that all the hot little nicotine has a port of call. 

This is the crux of what addiction is. It is to change our neurotransmitter architecture so that it is dependent on a chemical from outside itself. 

https://www.uptodate.com/contents/image?imageKey=ONC%2F57169&topicKey=PC%2F16706&source=see_linkion

I'm not going to explore the cancers in this post. I have a cancer centric post coming up, discussing the fascinating and varied ways that cancer can develop. 

I've heard that there are medical schools that are not using cadavers for their anatomy curriculum. This is a shame, if true. Some of those anatomy labs spent dissecting a cadaver still stick with me and are vivid memories. The lung's lymph system is self contained. This is in contrast to the lymphatic vascular system which dumps into the blood. Not one set of lungs were completely pink in any of the cadavers. I think we had 40 or 50 of them each year. We breath in stuff all the time, whether pollution in the city or dust in the country, there is no getting around it. It collects, and stays in the lungs. 

As a smoker ages they usually can be observed to follow to general paths: blue bloater or pink puffer. 

These somewhat insensitive terms, I admit, refer to the main two ways that our lungs try to cope with smoking. 

Emphysema is not diagnosed by a chest X-ray but as you can see in the XR above, the elongated chest and pleural cavity. This is a hallmark of this type of lung disease. COPD is a tough way to go. My father in law, who quit smoking cold turkey after decades of smoking was an already tall and thin man who suffered from emphysema. Miss you, Bill.

Nicotine has many other fun and exciting things it can do in your body! In just the cardiovascular system it can cause coronary vasoconstriction leading to angina and even MI, increased hypercoagulability (making clots that can go to the lungs, brain or heart) and dyslipidemia -- a fancy way of saying screwed up lipids and cholesterol. Oh, and endothelial dysfunction, meaning that the walls of the arteries become super angry and plaques can form, and with the increased risk for forming clots, it's easy to see why PE's (pulmonary embolism), strokes and heart attacks are so prominent with smokers. 

Speaking of Bill, my very much missed father in law, he also had an abdominal aortic aneurysm (AAA). He survived -- a testament to how tough he was. The only people who are recommended to be screened for a AAA are men, with any duration of smoking history and who are over 65. 

Infections are also of higher frequency. Specifically, tuberculosis, pneumococcal pneumonia, legionnaires disease, meningococcal disease, influenza and the common cold. A lot of these are simple inhibition of barriers in the respiratory immune system. Cilia, the little window wipers of the throat are killed off by the smoke. 

Cilia and flagella have a conserved 9+2 arrangement. Humans have one type of cell that have a flagella -- the spermatozoa. Bacteria have flagella though. Same type of motor. Interesting. Another topic for another day. 

Diabetes risk is up. Nicotine seems to accelerate the development of insulin resistance. 

Smoking also speeds up bone loss and is a major risk for hip fractures, especially in women. 

Pregnancies are complicated by smoking. Spontaneous abortion. Ectopic pregnancy. Lower than average birth weight. All associated with smoking. It can hasten the arrival of menopause. Erectile dysfunction -- big time. And general subfertility with both men and women is significantly correlated with smoking. 

Gingivitis and periodontitis. 

Postoperative complications. Some surgeons won't do elective procedures if a patient smokes. Decreased wound healing ability is a problem I've dealt with many times in the hospital. 

Nicotine withdrawal symptoms are powerful. After the last cigarette it takes about three days for things to hit their climax of terribleness. After that they slowly subside over three to four weeks. 

• Increased appetite, often causing weight gain
• Dysphoria (general dissatisfaction with life), depressed mood, anhedonia (inability to feel pleasure)
• Insomnia
• Irritability, frustration and anger
• Anxiety
• Difficulty concentrating
• Restlessness

It should be known that I tried hard to be a cigarette smoker when I was a teenager. It's been about three or four years since I've taken even a puff of a cigarette. I may have smoked ten cigarettes between now and the age of twenty, the last time I was sincere in my wanting to be a smoker. 

More than anything, smoking made me nauseous. Often I would be with my friends, either hanging out, or going to work and we would have a morning cigarette and sometimes I would puke, it made me so ill. In fact the only time I really enjoyed a cigarette was (besides, that, you perv) when I was having a drink. And I'm not a big drinker, and never really was. 

I count myself lucky that I am not a smoker today, and due to wisdom or intelligence. A shame that a decision in our youth can have such a life altering power. This is life, however and it matters not if we're 14 or 40, some decisions carry a weight heftier than others. 

For the smokers out there who are reading this, know that this clinician has empathy and an understanding of what it means to be a smoker. What it means to be unable to quit. I'm fortunate enough to train in a clinic where it is less judgmental and more frank acknowledgement that quitting is damn hard and it often takes multiple tries. We want to partner with you; through the failures and triumphs. 

There are various tools and ways to help people. Nothing replaces white-knuckled determination. It doesn't have to be the only weapon in the armory, though. 

Boozers

My first drink, was at my friend's house, who's father made wine. A couple of drinks and I puked into the ditch by the road. This is how it has gone for me. Some drink to excess and love every minute; I approach excess and I become sick. I don't think I've ever blacked out thankfully. Blacking out -- being so drunk you don't recall your actions, ever, is a hallmark of an alcoholic. I love wine and beer but these days I go weeks without a drink.

Again, I count myself lucky, and not wise or intelligent as I tried my hand at becoming an alcoholic for a brief stint in my early twenties. Partying, drinking. I couldn't keep up with those who seemed to be professional drinkers. Even in my hayday, drinking two nights in a row seemed so physically taxing that it didn't seem worth it.

EtOH -- ethanol. I've gained experience in managing patients who are spread throughout the spectrum of EtOH-ism, as I often write in the chart. Acute drunkenness, while it can kill a person, is usually not life threatening in and of itself.

I am fascinated by the history and cultural place that alcohol claims in history and cultures. Unfortunately, this is not for this post. Pathology due to long term EtOH-sim is what's on tap.

But not before a quick tour through the short term effects that we all know and love. A BAC (blood alcohol concentration) of .03 to 0.12% is really the sweet spot.

0.18 to 0.30% is the range where profound confusion sets in. Black outs are here.

0.25 on up to 0.40% is where things get real serious, real quick. The lucky ones will vomit while conscious enough to be face down, or just lucky enough to be face down. Even so aspiration is a real danger even if you don't cut off your airway and choke to death on the vomitus. Respiratory depression can occur in this range.

You drank so much that your brain forgot to breath.

0.35 - .80%. If one makes it this far they are in immediate danger. Coma and respiratory arrest will happen.

How about a tour of the life threatening disease processes owing to long standing heavy drinking? We'll start at the top of the head and work our way south. 

The brain really takes a beating. 

Wernicke-Korsakoff syndrome. It is a complex process by which the brain undergoes metabolic deficiencies and damage. Wernicke's encephalopathy and alcoholic Korsakoff syndrome are separate things. They are lumped together because with one, you usually get the other, Wernicke's is the acute, earlier process followed by chronic and eventually debilitating korsakoff. Both are seen primarily in alcoholics. 

Wernicke's encephalopathy is characterized by this triad of symptoms:

• Occular disturbances (ophthalmoplegia)
• Changes in mental state (confusion)
• Unsteadiness and deranged gait (ataxia) 

I've had to manage a number of patients through this acute phase, usually followed by withdrawal.

The DSM-V lists these criteria needed to meet a diagnosis of alcoholic korsakoff syndrome:

• Anterograde amnesia
• Variable presentation of retrograde amnesia

And at least one of the following:

• Aphasia -- can't formulate language nor comprehend it.
• Apraxia -- can't plan to move, and movement is uncoordinated and herky jerky
• Agnosia -- can't perceive sensation. Hearing, vision, touch, whatever. 
• A deficit in executive functions -- conscious thoughts that turn into action. 

I have no data other than experience to back this up, but I feel like in order for a person to meet maker through chronic brain pickling their other organ systems must be top performers. Moving from the head down to the chest cavity where we find the heart. 

Alcoholic dilated cardiomyopathy. A fancy term for what happens when the myocytes -- the heart muscle cells are soaked in alcohol. The walls become thin and floppy. The left ventricle, the biggest, most powerful chamber, the one that pushes the blood from the chest to the head to the toes basically shrivels, and can't pump. 

I saw a lot of this during the three months I trained at Alameda Highland Hospital, which is in the heart of Oakland, California. Interestingly enough, the patients in Oakland seemed to favor liquor over methamphetamine (which we'll get to next) which is not the case where I am now. I do see a lot of alcohol related disease, but dilated cardiomyopathy is in the minority, say, compared to liver failure, etc. I'm going to save the details of what dilated cardiomyopathy means for the tweaker section, because this EtOH section is lengthy. 

Just know that alcoholic dilated cardiomyopathy will kill you. 

Next up, the liver. 

Ethanol and its metabolites are toxic . It's presence will destroy cells if given time. 

Even now, after years of undergraduate biology and chemistry instruction, four years of medical school and a couple years of practicing as a doctor, I'm amazed at what the liver is capable of. 

This dark red peact of homogenous meat -- like a patte that lives in our gut. One of its well known duties is metabolizing alcohol. It tries its best for years. Decades even. But other things come up here and there, and the liver must attend to them. And if the alcohol is always present, sometimes it has to wait its turn. 

The liver will die, eventually. When it dies so much that it can't heal itself, which it does to an amazing degree, we call it a cirrhosis. 

With cirrhosis the liver can't do what it needs to do. What is something that the liver does that will show immediate and devastating impact when shut down?

That's right. Albumin production. Albumin is a protein-y fluid that works to maintain osmotic pressure in the blood. Basically, if you remember osmosis, water is so needy and codependent, that it follows the "stuff." If the blood doesn't have enough "stuff," or, protein in it, the water will leak into areas that do have stuff. The abdominal cavity has stuff in it. In liver failure the blood doesn't have stuff and the water moves into the abdominal cavity. Liters and liters of the liquid. 

I've done a number of pleurocentesis procedures to get this fluid off a liver failure patient. 

Clotting factors are also made in the liver. If you can't clot, you gonna bleed. Eight liters of fluid in the belly, making it hard to breath and even sit comfortably along with pooping and puking blood until you die. This is part of dying from liver failure. Of note, this is the picture with liver failure from any etiology of liver failure. 

A special treat with alcoholic cirrhosis is portal hypertension. In short the veins coming down with the throat become swollen with blood because the larger veins in the liver are no longer flexible, pliable, healthy blood vessels. The swollen blood vessels in the throat can bleed. This is very common, actually. Esophageal varices is what this is called. 

Those are the things that an alcoholic has to look forward to if they don't get caught in a bad spot and meet their demise in an acute, sudden fashion. 

Tweakers

I believe that most drugs and substances that people derive pleasure through their ingestion is based on borrowing from one's future self. Methamphetamine functions to steal time from the future. A junky steals pleasure and self-respect from their future self.

The methamphetamine addict has immense stores of energy, and can go days without sleep.

Before we get into the nitty gritty of the surprises and treats that await a professional tweaker we need to take a step back.

We have a sympathetic nervous system. We have a parasympathetic nervous system.

Besides being the material of my favorite memory tool (penile erections are mediated by the parasympathetic nervous system, and the sympathetic nervous system drives ejaculation. How does a med student remember this? Point and Shoot) there are a few important things to know about these systems.

The sympathetic system is known by the "four f's" which are:

• Fighting
• Fleeing 
• Fear
• F#@king 

This is important because methamphetamine, through manipulation of neurotransmitters, puts the sympathetic system on steroids and puts its foot on the neck of the parasympathetic system. Oh, the parasympathetic system, when activated, acts to relax a homey.

When was the last time you got really angry. Like, so angry you could just do something really irrational and damaging. Most of us let that moment pass and we don't punch the brick wall, shattering our hand. The feeling though is something we've all felt.

When was the last time you had a rush of adrenalin that left you breathless? Maybe it was one you were angry. Maybe it was when you hit that point when there was no turning back on that new skateboard during the zoo-bomb. 

When was the last time you had really good sex? Okay, okay, settle down -- keep it to yourself. Thanks.

And what about the last time you were truly afraid?

All of these emotions are "on" for the tweaker.

It is understandably not so healthy for the mind to be in this state. Psychosis is not far from any meth head; meth monsters are a real thing, in the minds of millions, at least.

Similar in how we discussed nicotine and the receptors in the brain, the rearranging of neurotransmitter production and management changes with meth use. Chronic, long standing use will leave a person unable to mount much of a sympathetic response to much anything.

Methamphetamine (in contrast with amphetamines) are direct neurotoxins, as well. Not a good combination. Since we already are talking about the brain, let us go down the body as we did above.

The infamous meth mouth.

I knew teenagers with meth mouth. Looking back, what a tragedy. In essence those children traded a lifetime of human experience for a handful of years of nonstop, crazy, jet fueled living. Good chance that many of those people are not alive any longer.

I never really knew why this happens. I now know. Being a doctor has its perks, I got to learn why meth mouth happens. Inhibition of saliva production is the primary reason. Upregulation of the sympathetic nervous system leads to a chronically dry mouth. Saliva protects the teeth. No saliva, no teeth.

I remember being so disappointed when I learned this. I was hoping for some exotic, elegant reason.

It also serves to deeply illustrate that our bodies, while on one hand awe inspiringly adaptive and sturdy. On the other, a delicate balance that when off kilter, a cascade of calamity can follow.

Further in and further down. The heart.

While the journey to methamphetamine associated cardiomyopathy is different than alcohol dilated cardiomyopathy, the end result and clinical implications are essentially identical.

Alcohol directly kills the cells, methamphetamine burns out the cells with a hormone and neurotransmitter barrage.

When this is so severe that the heart struggles to pump because it is so weak, the patient is at dire risk of cardiac arrest. The muscle cells of the heart just can't keep going. They've been burnt out.

An implantable cardioverter defibrillator (ICD) is often surgically dug into the chest so that when these hearts go into ventricular tachycardia or ventricular fibrillation, it shocks the heart.

I've spoken to patients who tell me getting shocked by their ICD who describe it as getting kicked in the chest by a horse. Others say they don't even notice it. Hard to imagine. 

Skin, like meth mouth, remains dry. Also, whether it be through psychosis, or imagined parasitic infections, skin picking is very common.

Meth addicts chose a path that is more swift and terrible than those examined thus far. At a certain point, the person seems like a sort of zombie. Rotting skin. Rotting mouth. Eyes that seem to harbor no soul. Abundant energy and stubbornness.

I do find it difficult to muster sympathy for the tweaker relative to patients who suffer from other chemical addictions. I do my best.

Junkies

In contrast to all of the above, opioid addiction has less attributable unique fatal disease processes. Many of the deaths are due to acute respiratory arrest due to an overdose. Or, means of delivery of the drug, less the drug itself. Shooting drugs into one's veins is not a good idea. Infection is so common in IV drug abusers.

Endocarditis is bacterial growing on and destroying the valves of the heart. Often these bugs are introduced through needle injections. Abscesses are rampant. Paraspinal abscesses specifically. That will ruin your day.

Opioid dependence over time will change your perception of pain. I have patients in the hospital who need opioids just to not be in pain at baseline. Withdrawal is always around the corner.

A proper discussion examining the current so called "opioid crisis" is warranted, but for a different day.

All of the above are heavily biased by my own experience; pre and post doctorness. Whether it be gluttony (I identify with this struggle) or a tweaker looking through the cupboards of the ED room for stuff to steal, I try to drill down past the emotional firewall that most patients have.

Often what the patient considers best for themselves is in sharp opposition of what I think is best for them. This is especially true for very sick patients who are in the hospital and are struggling possibly withdrawal.

A patient who has pneumonia and already has compromised respiration, loading up on an opioid, which depresses respiration, is probably not good for the patient. I used to be surprised when a patient, after hearing the explanation of why more pain meds cannot be given, says something along the lines of, "just give me the narcan if I OD."

Alcohol and benzodiazepine withdrawal may be fatal. Interestingly, opioid withdrawal is not fatal, although the addicts often wish they were dead while struggling through it.

There are those who do succeed in getting and staying clean, whether it be eating too many blue corn tortilla chips, or shooting heroin. Even more who try, fail and try again. This post is dedicated to those who are in the struggle and are fighting to live outside the strangling grip of addiction.

Keep fighting, it is worth it.