吃飽喝足摸了好一陣子就開始讀文章.....
今天讀了篇跟NTG舌下錠兒，就是硝化甘油(嗯吸消化或浣腸肝油球喔)相關的
首先，關於關島的行程....
第一天早上睡覺/下午聽說是city tour...(直接去海灘)
第二天早上就要跳飛機了/下午去shopping
第三天租車繞島旅行
第四天早上八點，出現在桃園 =__=
覺得關島其實是一個玩起來蠻累的地方
因為就只能很晚很晚去，很早很早回=__=著實有病
希望玩得愉快啦~~
要去住最漂亮夕陽的飯店
然後我覺得跳飛機的那個單位好厲害
因為我在EMAIL裡面就是請他打電話跟我要我的信用卡資料
然後打來的人竟然會講中文!!!!(那我幹嘛寫英文信那=__=)
會講中文早說嘛~~~
然後真是個有好的地方
台灣人可以靠身分證入境，然後靠台灣護照租車開
怎麼這麼爽...!!
下午聽到一個母校的八卦
說研究生跟老師都一起出去吃飯...老師晚上都不回家XDD
然後那個研究生就老師發paper都掛他名字....
比起老師paper都掛兒子的名字比起來...
這種驚艷的等級大概只比
" 聽到熟識的overlapping達人，在女生房間待了一陣子之後裸露上半身走出女生房門"
稍低一點
好了 今天要先睡了
昨天為了聊很多鬥爭祕辛在半夜12點喝了杯茶
之後就HIGH到今天下午
現在大概是退駕了=____=
晚安!
Nitro: Why Aren't We Prescribing It?
- 今天的文章，本來以為他要解釋為什麼醫生們不開NTG...，但竟然是在鼓勵醫師們多多開立NTG....
- NTG就是八點檔中那種突然抱著心臟，然後說快幫我拿一顆藥然後吃完以後就會好很多的那個藥，是含在舌頭底下迅速就會作用的一個血管擴張劑
以下本文開始....
- 2009年開立了400萬張有NTG的處方，AHA(American Heart Association)統計有9百萬個心絞痛患者
- 每年仍然有很多患者被診斷為CAD(coronary artery disease, 冠狀動脈疾病)、放支架、缺血性心臟病。但很多被診斷為CAD人都不曾有過一瓶NTG
- 之後他講了一個case：
- 有一個75歲老白男人，胸痛去掛兩次急診，都被診斷成hiatus hernia (橫膈膜裂孔疝氣)因為要查原因，所以住院。當時可以看不到他的血管攝影有異狀。因此沒有診斷出是冠狀血管疾病，然後他的血管攝影師就叮嚀他，下次他在胸痛就一定要馬上回來看醫生。
- 但是捏，那個放他回家的主治下午就打給她女兒，叫他要帶他老爸回來看門診。但是去看門診以後只是跟病人解釋了他的心臟正在攻擊他(誤導你們)...(是heart attack啦)，然後又再次叮嚀病人，如果你的胸痛再發作，就趕快回來。然後......病人就掛了。事情是這樣，幾天後病人又heart attack，他們打911的時候，因為都沒有NTG可以用....然後又等太久了。事後就有討論為什麼不開NTG!!!
- 作者本人對於美國醫生都不開NTG感到很驚訝，有五年狹心症病史的病人，竟然不曾拿過一瓶NTG。所以他就做了一塊廣告康棒，上面寫你有心臟病?冠心症?裝支架?請跟我們詢問關於NTG的事，下面還提醒你的NTG是不是過期啦?
- 然後作者就嗆聲說他關心病人20年，說一定要開NTG給這些高風險的病人(碎碎念那樣)應該要把NTG當坐菲比小精靈，NTG又不貴才10塊美金 (真的是在碎碎念)
- NTG的禁忌症：主動脈瓣膜狹窄，超低血壓，嚴重肥厚性心肌病，重度肺動脈高壓，嚴重脫水，或病人每日勃起功能障礙吃藥
- 碎碎念的醫生建議NTG使用
- 至少每年換一罐新的(天天宅在家的一年一次；會出門趴趴走、農作的可能半年或三個月就要換)
- 要吃NTG要坐下吃
- 如果是第一次自己吃NTG的病人，他會建議那個病人最好打電話跟一個人聊個天，以免從此再見
- 每15分鐘吃一個，吃三次還是不舒服趕快911
- NTG是一個笨藥，他緩解你的胸痛，但可能會造成頭痛（接著他就把各器官比喻成廚房客廳之類的...解釋那個藥的作用）
- 跟台灣公版衛教不一樣的就是，台灣人比較怕死，５分鐘就要吃一顆....人家是１５分鐘那樣。還有關於效期，台灣是講可以放到他上面的保存期限...
- 還有我覺得很好就是對於第一次自己吃ＮＴＧ的病人的教導，在他第一次要吃的時候打電話給一個人，以免發生甚麼不幸可以有一個人知道可以馬上幫忙叫救火
- 台灣公版衛教請參考吳火獅衛教單張
單字
- hiatus hernia (n.) 橫膈膜裂孔疝氣
- angiographer (n.) 拍血管攝影的那種放射師
- struggle (v.) 掙扎
- under visualized 可以看到的
- telemetry (n.) 遠方遙控測量
- cath-lab tech (n.) 導管室技術員
- irritated(v.) 被惹惱的
- astounded (adj.) 震驚
- laminate (v.) 劈開 (n.) 層壓版(廣告看版)
- bona fide 正牌的
Accordingly to New York Times journalist Natasha Singer, approximately four million prescriptions for nitroglycerin were written in the US in 2009[1]. The American Heart Association statistics show that approximately nine million Americans were living with angina that same year[2].Scores of patients receive a new diagnosis of coronary artery disease, suffer a heart attack, undergo a stent implant, or receive a new diagnosis of ischemic cardiomyopathy annually. If we do the math, this means that millions of coronary artery disease patients have never owned a single bottle of nitro. Many more are walking around with nitro prescriptions greater than a year old. It seems to me that nitroglycerin prescribing might be a good target for a global practice-improvement initiative. To understand why the lack of having available nitro is more than a mere inconvenience, read on.
The patient came to the ER for chest pain, not once but twice. He was a 75-year-old white man with no prior cardiac history. He was told his pain was a "hiatus hernia" at each ER visit. When he finally saw a second family physician as an outpatient, he was referred to a cardiologist. Even that didn't go well. The angiographer struggled with his newly adopted radial approach, undervisualized the coronary arteries, and sent the patient back to a telemetry bed to rest prior to discharge. A cath-lab tech told a senior partner who just happened to walk through the lab that he thought he saw a tight coronary lesion that was missed.
The senior partner reviewed the film and walked down the hall to find the patient parked in a wheelchair, waiting for hospital discharge. "You aren't going home, are you?" he asked. "Well, yes I am," replied the patient. "I've been told I'm fine, but I don't understand where the pain is coming from. Besides, the hospital says Medicare won't pay for me to stay."
The senior cardiologist replied, "If you have any more pain whatsoever, please return to the hospital immediately." The patient left with his family. Later that evening, the patient received a phone call from the senior cardiologist, who again seemed concerned, even regretful, that he had allowed him to go home. When the patient's daughter heard that the senior cardiologist had expressed concern a second time at her father's discharge, she insisted that he return to see that cardiologist the next day.
During that office visit, the troponin levels drawn from the hospital admission two days prior were confirmed as elevated. It was explained to the family that the patient had indeed suffered a heart attack. Again, concern was expressed, and plans were made for him to be recatheterized as an outpatient. "You don't mean you are sending him home again, do you?" asked the son, a bit irritated. "Well, he's not having pain now, so I think he can go home with one of you," responded the senior cardiologist. Then, turning toward the patient, he said, "Remember, if you experience any more pain, you come right back in."
That was the last time any of the patient's healthcare providers saw him alive. When the patient experienced chest pain a few days later, the family called 911. They did not deliver nitro while they waited far too long for the ambulance to arrive because they didn't have any. It was never mentioned during any of the family doctors' office visits or the two ER visits. Incredibly, it wasn't prescribed upon discharge from the hospital with leaking troponin or at the second cardiologist's office visit during which a recath was planned. The EMR system did not catch the omission. Understandably, the patient's family has lots of questions about the events surrounding his death, but one of them is simple: "Why didn't anyone prescribe nitro?" Many will correctly argue that the lack of a nitro prescription was the least of the issues with this patient's treatment plan, it's still a good question.
My wake-up call on the underuse of nitro came on the morning the World Trade Center fell in New York. I was called to see a patient with a five-year history of angina. Despite his claim of having received many stents in cath labs scattered across the US, he had never been given a single prescription of nitroglycerin. I was so astounded that I picked up the phone while standing at the patient's bedside and called my office secretary. "Please laminate eight signs that say the following: 'If you've ever had a diagnosis of angina, pain due to heart artery blockage, angioplasty, heart bypass surgery, a stent, or a heart attack, please ask us about a nitro prescription." Underneath it, the sign asks: "Is your nitro 'old'?" along with appropriate warnings not to take nitro if "Cialis, Viagra, or Levitra" have been prescribed (unless specific instructions have been given).
Those laminated signs have triggered hundreds of conversations about nitro in our office. There is no better captive audience than a bored patient in an exam room chair, staring at the wall in front of them as they've leafed through a moderately worn 2012 Time magazine for the second time. My sign has also generated a lot of conversation about erectile dysfunction. It's given my cardiac patients courage and permission to broach both subjects.
Treat Nitro Like a Furby
In my greater than 20 years of caring for patients, I've been amazed at the number of bona fide card-carrying stent patients who've never owned a bottle of nitro. On several occasions, patients have told me that their CV surgeon advised against carrying nitro "because you won't need it." (Graft failure rate is around 2% per year, so perhaps the same logic should apply to never wearing a seat belt?). I wonder how many ER visits for angina could have been avoided if the patient had just popped a sublingual dose of nitro, obtained relief, sat home to finish watching the Superbowl, and then contacted his cardiologist for a conversation the next day?
How many dollars have been wasted on hospital admissions because we didn't think to prescribe it? How often do we ask our patients if they need a refill? (Cue the tiny brown bottle coming out of a pocket or purse to be thrust into the air between the patient and the overhead light like a Ryder Cup trophy.)
Nitro is cheap, so there isn't much of an excuse not to prescribe it, except in cases of tight aortic stenosis, ultralow blood pressure, severe hypertrophic cardiomyopathy, severe pulmonary hypertension, severe dehydration, or patients on daily erectile-dysfunction meds. I ask my patients to treat nitro like it's a Furby . There are several things it doesn't tolerate, like heat, light, moisture, or being jostled around. Nitro needs to live in its own bottle, and I tell patients to be aware that it ages rapidly. That "tingle under the tongue" is not a reliable guarantee that it's working. I recommend that patients discard their nitro and get a new bottle every year, if they are sedentary, indoorsy-type patients. Jackhammer operators, farmers, and the like are instructed to change it out every six months or sooner. Most don't.
I instruct patients to be careful taking nitro if they suspect they are dehydrated, because significant blood pressure drops can occur (rarely fainting). Every patient who plans to use nitro should sit down. Those who may be prone to dizziness or syncope or who are first-time users should lie down and call someone to check on them in a few minutes or stay on the phone line with them. They should put a tablet under the tongue every 15 minutes or so, give or take depending on the impact it has on their pain. I explain the "strike three and you are out of there" rule, meaning you need to call 911 if that third nitro does not garner relief.
When I prescribe nitro to my male patients, I tell them, "Don't give it to your friends if they are taking erectile-dysfunction meds or have taken those types of meds within 48 to 72 hours" (depending on which one they are taking). Otherwise, I encourage them to be generous to others who have chest pain but have perhaps forgotten their nitro. I also take the time to refute that old wives' tale that "if you take it and your head hurts, it's not your heart." Nothing could be further from the truth. I explain to them that nitro isn't a very "smart" drug because it engorges all arteries and when you engorge a brain artery it causes a migraine-type pain in a small percentage of patients, so I advise them to keep Tylenol handy.
To take the mystery and some anxiety out of nitro use that is fairly common with first-time users, I form an "O" sign with my left hand, then I place my other fingers inside it to simulate a partial blockage in a heart artery. I then explain that when nitro reaches the vessel, it expands it, leaving room between the "blockage and the vessel wall" that allows blood to get to their aching heart muscle. That visual (though oversimplified) goes a long way in reassuring patients with coronary artery disease of the wisdom and logic of actually opening the pill bottle.
I also encourage patients regarding other uses for nitro: to occasionally lower persistently elevated blood pressure (if they are asymptomatic) and to buy time until "morning or Monday" if they are reluctant to strike out to the ER. I also warn them to literally cover their mouths if they have taken an erectile-dysfunction med and then find it necessary to call EMS because a good EMS team will burst through the door with their nitro-guns blazing for a chest-pain run. I assure them that other preps such as calcium-channel blockers and opiates can be used to quiet their chest pain instead.
According the website GoodRx, a bottle of 25 nitro tablets costs anywhere from $8.79 to $10.31, with a "cash cost" of $11. An ER visit costs thousands. Our lack of prescribing those tiny white pills or the spray that comes in a ruby red bottle can cost lives. One may argue that the lack of nitro prescribing isn't a life-threatening issue. I counter that many times in the cath lab, I've relieved ST elevation from spasm or during an episode of ischemia with a simple sublingual dose. I challenge anyone to show me a randomized placebo-controlled trial that demonstrates that nitro isn't beneficial. When someone finally does a study that looks at how many patients with angina or coronary artery disease arrive at the ER door for treatment of chest pain with no nitro prescription, in this Affordable Care Act–driven medical economy, I bet we would write or e-prescribe the heck out of it. Meanwhile, why don't we take it upon ourselves as the good practitioners we are to start prescribing more of it today?
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