Herbal remedies for asthma are safe

if everybody's ready i'm gonna go ahead andget started i don't know if everybody's here yet but i'm it is a little after 6 so i guess weshould get moving so i want to thank everybody forcoming to the talk um, i am christina johnston i'm a neurologist that work that works atlakeshore health partners on i've been the in town practicing for thepast year so i've sort of met quite a few patients with ms in my first year ofpractice and

i was asked to do a talk to thecommunity about a common problem that i've seen so far and ms was like thefirst thing that popped into my head i thought um, there would probably be somequestions and things that um, there's been some new medicationsthat have come out over the past few years so i thought it would be a reasonable thing to review just kind of do an overview of what is ms uh what are the symptoms of ms, howdo we diagnose ms and then some of the newer therapiesthat have come out over the past few

years i wanted to kind of touch base on those and then will beplenty of time for questions at the and i didn't get really really specific abouta lot of things cause i knew there was going to be probably a lot a questions so um but we'll have plenty of time forthat at the end okay also i wanna apologize ahead of time ihave a cough drop in my mouth cause i'm getting over bronchitis so i apologize in advance um

okay so i have nothing to disclose i'm independently employed i don't work foranybody else except for lhp so just want to get that out of the way ahead of time so what is ms what happens with ms? um ms is a chronic disease in the that affects thecentral nervous system that means that the brain the spinalcord and also the optic nerves which are the nerves that project to the eye and allow us to see can be involved in thisprocess

um, everyone has an immune system thatnormally fights of diseases such as bacteria and viruses any sort of infection and we think that the reason ms occurs is becausethere's a sort of case of mistaken identity that the immune system mistakes the central nervous system as a foreign object or foreign being and itunfortunately attacks it and creates a problem so statisticallyspeaking everybody likes to talk about statistics a little bit to get a generalidea

of how big of a problem this theis in terms of our country um it affects approximatelythe statistics vary a little bit but around 350 to 500 thousand so um people in just the unitedstates alone worldwide there's over two and a half million individuals and the estimate that in in the unitedstates alone approximately 200 people per week are diagnosed with this diseaseso it is rather common um more so than a lot ofneurologic diseases and its probably affected a lot of

i means i'm sure a lot of people up herein this room are affected but even in the general community most of uscan say that we know someone or or know of someone that has or um a family member who is affected by msor a friend or something it's very very commonly seen. um, it typicallyaffects males less than females i we don't really knowunderstand why that is but the ratio is about two to three females to one male um but that's kinda what wesee typically caucasians are affected morepredominantly

um than african-americans althoughcaucasians african-americans and hispanics are the most commonly affected we don'talways see it as much in asians although it can occur and there's a few other ethnicities thisis not as common um children can be affected by thisdisease although it's very rare in my training i did see i a fewchildren that were affected but mostly it occurs in our younger years it kind of the the sayingis that it affects a person when they're

in the prime of their life theirtwenties or thirties or forties or fifties when they're really you know doing greatthey're living their life they're having children they're getting married and this happened so it tends to occur kind of in the northernareas of the world the united states predominately inthe united states it's even more in the upper portions of thecountry as you get more south it doesn't seem to be as prevalent andthat's the case across the world so

europe japan some of those areas are moreoften effected northern european countriesspecifically tend to have a higher predominance of ms as well we're not really sure what that is theresome theories about that vitamin d or sunlight exposurecould be playing a role in why that occurs more commonly than nearer to theequator because it's very infrequently seen in the countries that are closer to the equator the life span a person with ms is

generally about on the average only afew years shorter than the normal life span of atypical american so you know people who are diagnosed withms still live a full life only they have to sort of um deal with thesymptoms and the chronicity of this disease so we still haven't identified exactlywhat the cause of the disease is but there's a lotta research so i just put this slide in because thisis i found this on-line and it's a picture above many famous faces

who have been affected by ms i think that's teri garr annette funicello who just passedaway she was seventy years old so she lived a long time with ms richardpryor ann romney was in the news with the lastelection kinda brought a lot of attention toward ms and raised a lot of questions about itmeredith vieira's husband i think richard cohen is his name he'sum a famous individual who's been in thenews a lot about you know what

attention toward ms and jackosbourne was diagnosed a few years ago so he's been in a few newspapers and magazines over thepast year so that i've seen so but it is it does affect anybody so so getting into a little bit moredetail about specifically what is it so everyone's brain and spinal cordare you know consist of nerves and thenerves are lined by a protective barrier called the myelinsheath so the analogy that we use is

that it's like an electrical cord with a protective you know insulation around the cord and that's the case withthe nerve so what happens is that the normalnervous system connects the brain to the spinal cord tothe nerves in the extremities which connects with the muscle andallows us to do things like move walk feel a sensation uh, visualize theworld so when the immune system attacksthe the myelin or the covering up the nerveit creates a disruption in the signal

transmission and so the signals can't get from the brainto the leg or to whatever is affected and it creates a problem so it usually happens when inflamation occurs after the attck of the immune system on the myelin so what happens with that is an attack aclinical attack a relapse a flare whatever term you choose to use our or yourneurologist uses to use but that's what it is so it's a suddenonset of neurologic

sometimes meaning weakness numbnessanything like that that comes on and doesn't go away for atleast 24 hours for some people it lasts for you know 3-4 daysfor some people it lasts several weeks and some people never i mean it canpersist longer so typically though that's not the casetypically it's a short term a few days a few weeks and then itgradually starts to improve which is why i sort of people can havesymptoms and then they get better and they ignore it and they don't even knowthat they have symptoms of ms. oftentimes ithappens to a 24-year-old 25-year-old you

know a young person they get better and they don't thinkanything of it until something happens later so that's the classic pattern that we here of relapsing remitting so a relapse followed by a remissionmeaning healing and going on with normalactivity so the symptoms can come on later inlife usually in this in the setting upinfection if we're stressed out if we're tired

and it's the result of the sclerosis left on the brain or the sclerosis just means a scar soafter the brain is attacked or there's a damage tothe nerve there's a scar that forms as it healsbut that scar doesn't have the same capacity that ithad prior to its damage so it can leave residualsymptoms going forward. over the course of one'slifetime you can see a decline in physical activity you can see a declinein cognitive ability so there are some chronic components tothis disease which is what

leads to the disability component you know and and managing thesechronic symptoms is you know that's my job that's what theneurologist sort of managers and and deals withon a routine basis so i put an illustration in here and actuallytried to put into my slide but it didn't work soi'm gonna actually just go to the youtube website it's not my video but i found it onlineand i thought it was a fantastic illustration

of the pathology that justtried to explain multiple sclerosis, ms is a disease thataffects the central nervous system the cns which consists of the brainspinal cord and optic nerves everything we do whether it's taking a step, solving aproblem or simply breathing relies on the proper functioning of thecns to understand how ms may impactthe cns we must explore the disease at thecellular level in the brain millions of nerve cellscalled neurons continually send and

receive signals each signal is a minute but necessarypart of intricate cns orchestrations thatculminate in the actions sensations thoughts andemotions the comprise the human experience normally the path over which a nervesignal travels is protected by a type of insulation calledmyelin sheath this insulation is essential for nervesignals to reach their target in ms the myelin sheath is eroded

and the underlying wire like nerve fiberis also damaged. this leads to a breakdown inthe ability of the nerve cells to transmit signals it is believed that the loss of myelinis the result of mistake in attacks by immune cells immune cells protect the body againstforeign substances such as bacteria and viruses but in ms something goes awry immune cellsinfiltrate the brain and spinal cord seek out the myelin

and attack as ongoing inflammation andtissue damage occurs nerve signals are disrupted this causesunpredictable symptoms that can range from numbness or tingling to blindness andparalysis these losses may be temporary orpermanent that was a really nice illustration ofwhat i tried to explain but obviously i can't do the video as nicely that explained itbut i thought that was a good explanation sort of of what thephysiology of ms is just so that you can

all understand if you weren't aware already so again why does it happen we don't reallyknow there's a lot of theories out there there's been a lot ofinvestigations about what specifically causes it because for for like i said it affects us at ayounger age so there's a theory that it's gotta be viral i mean we're all exposed to varyingviruses throughout our lifetime the one that's most commonly thrownout there is the epstein bar

virus which many of us were exposed toin childhood some of us were affected and got mono from it some of us hadno symptoms of it and they think it could be contributing or have some some role in making the immunesystem go awry and creates this this disorder as i stated earlier vitamin d hasrecently become a sort of big focus of ms and especially in preventingrelapses because we we think that low vitamin d levelslow sunlight exposure kinda that northern latitude

thing that i talked about beforethat that has some implication in in the relapse in and the and the incidence of worsening disease so there's a lot ofresearch going on in that and a lot of physicians now are starting to monitorvitamin d levels and if they're low which most people inmichigan have a low vitamin d level we're starting to replace it and kind ofget those level up a little bit into a more therapeuticrange because we think it'll help genetics is also something thatthey're looking into it can run in families

there's definitely a large number of you know families that do have msthat runs in the family but they haven't identified a specific genetic linkage i mean i have a number of patients in mypractice in my training i saw a lot of people that you know their parent was diagnosedor they had a sibling who had been diagnosed with ms so it it seems like it has some sort ofgenetic linkage but we just haven't really identified it yet

so ms is a broad diagnosis there are four typesof ms. the most common and the most significantly more common is the relapsing-remitting multiple sclerosis that affects about eighty-five percentof people who are affected by ms it's clearly the most common a much much less common is a primaryprogressive multiple sclerosis i'm not going to spend a lot of time onthat one or any of the others because it just it's not as commonly seen butprimary progressive multiple sclerosis

you don't really see the relapses the patients who are affected by that they they get a symptom and they don'trecover from it so there continue anytime that they havea new attack on their system they just continually decline but they don't havelike an outward attack and then recovery so it's a little bit differentand we think it might be a little bit thethe physiology of it is obviously a little different we haven't clearlyidentified that either there are not as many therereally aren't any therapies for that type of ms either and relapsingremitting

multiple sclerosis does have a number of therapies so i wanted to really focus on that type for this talk secondary progressive multiplesclerosis is kinda something that you see later in life in the disease processafter you know you've had it for a numberyears you start to sort of not have as many relapses or not as often and and things just start to quietdown or they seem like they quiet down but what we know about that is that inthat stage the relapses become less

prominent but the disability part seems to become more evident so thescarring on the brain that occurred earlier in life now starts to affect us more seriously and then progressive relapsingmultiple sclerosis is very for a rare but it is a is a conditionwhere there's a progressive componentthat can have relapses but that you know you you have a relapse but you don'tcompletely recover and it's more profound

than in relapsing-remitting so it's a littletricky to diagnose you don't see that one as often either this is sort of a illustration of the the type that i just described this oneat the very top here is called benign multiple sclerosisthat you know it it we don't see thatone a whole whole lot there's a very few people that have multiple sclerosis but they the completely return back tonormal and they just don't really

develop disability over their lifetime it definitely occurs it's just not ascommon and we don't we don't tend to focuson that one as much either those people are usually kinda groupedin with the relapsing-remitting because it is so soimilar there's relapses the disability just doesn't seem to beas profound but you can see with this illustrationwas trying to say is that with with each relapse there's a sort of apeak in disability the the y-axis here's the disabilityfactor this is time

so as our lifetime goes on there's a arelapse and we get better but if you notice youdon't completely return to baseline you may have a teensy bit of aresidual weakness or whatever your disability is and then a few years go by and then youhave another relapse and maybe you still don't return exactly to that baseline atyou are at and as it goes on it's just a little bitgradual progression of the disability component with primary progressive as i said there'sjust really no relapses there's

just a continual steady increase in theamount of disability over time but you just don't seethose peaks in sudden onset of symptoms the secondary progressive form here isvery similar but as i said there's just a much more you know a much less recovery to to the baseline there and it just as youget later in life to even the relapses become less prominentso and then this is the progressiverelapsing

so symptoms i mean everybody wants knowwhat are the symptoms i think so many people in my office who come and say i think i have ms i've been readingon the internet i think i have ms please tell me i don't have ms. i can't tell you how many times i seethat and then there are the people that come in they possibly do have ms so how how do we how does theneurologist know well i mean obviously this is a greatillustration because it shows that it

affects every part of the body essentially oftentimes initial symptoms canconsist of loss of vision in one eye or optic neuritis sudden wake up onemorning can't see out of an eye pain painful vision gradually progressesover a few days and then after a few weeks starts toreturn that's very commonly seen as one of the initial symptoms of ms it can vary though i mean some peoplecan have episodes of double vision or sudden

imbalance but as i said earlier in thetalk but symptoms have to be sorta consistent and last for more than 24hours so when people come to me and say i woke up this morning my leg is numband later in the afternoon it back to normal that's not ms okay certainly sensation can be affected numbness paresthesias meaning tingling burningthat type of thing that can that can definitely be msbut it's not something that you know we wake up with in the morning and it'sbetter by afternoon

that's different weakness oftentimes the initial symptoms orlater symptoms of a relapse or weakness that affects a limb you know my arm is all the sudden clumsier orheavier than it used to be and it's just not getting better and i think something's wrong its it's aprofound neurologic symptom that doesn't get better or doesn't get betterright away okay with the spinal cord involvement you can see things likebowel and bladder dysfunction

urinary incontinence urinary urgency having to go all the time difficultyemptying things of that nature. it can affectour swallowing it can affect our speech it can affect our cognition arefocus our mood are energy level i mean everyone who hasms the most common complaint is fatigue. i'mtired i have no energy i have to take a nap every day becauseit's just it wipes you out so these are the symptoms but it's theway the symptoms present and the duration and

and that that really helps theneurologist to to hone in on this could possibly be an ms symptom. so as i said when someone comes to meand they want to know how do i know if i have ms a neurologist is gonna really you know teasethrough the details of the history the history to aneurologist is the most important thing because i wanna know what is happening right nowbut i also want to know what has happened before

i mean what in your earlier you knowyears have you presented with or have you had and yourignored it because it got better you didn't think anything of it um the timing of it as i said how longdoes it last how when did it go away. has it ever comeback um that's really really critical tomaking a diagnosis the neurologic exam is obviously veryimportant um and can only you know a neurologistis probably the only one who can do it very well

um it's a challenging thing to do umthe imaging of the brain and spinal cord is very important before we had mri ms was much moredifficult to diagnose because we didn't have specific pictures wherewe could see the lesion or the inflamation or the attack um sometimes now less commonly we we still do a spinal tap to make ananalysis of the spinal fluid and see that there's evidence and inflamation but thirty years ago anyone who possiblyhad ms

got a spinal tap nowadays that's notnecessarily the case mri has significantly brought us muchmore advanced and we don't always have to dothat now evoked potentials which are the visual um the visual testing to see ifanyone's had optic neuritis i mean we used to have to do thosethings to really solidify a diagnosis and sometimes we didn't know sometimeswe had to wait now we sometimes may have to wait alittle bit to see if there is another relapse or see if there are new symptomsthat develop

but most of the time or very very often we can figure it out rather quicklybecause i technology has advanced so much but again i do see people sometimes where i say this is a clinically isolated syndrome you have a high likelihood of developingms based on your symptoms based on your imaging but it's not ams yet because they're very strict criteria that a neurologist uses and i'm not going to get into all that cause it's really boringand so this is a typical mri of apatient who's been affected by ms.

so i have two views here um this is asagittal image and this is an axial image of a typical mri so what we're seeing here is these areas here here here here sort of along the middle of thebrain this is the these are the eyes here this is the back of the head the spinal cord starting to develop downhere so we're as a neurologist, we look kinda alongthe center of the brain where ms likes to hang out

it tends to affect the portions near tothe ventricle which is this portion here and these are the ventricles here andhere as well and in both images you see these areas of inflamation these bright spots on the brain and theyreally like to hang out near the ventricles we don't know why but um that's the sort of classic picture of what an ms brain looks likethese areas where the inflammation is located is probably when arelapse occurred so we like to monitor mri's going downthe road after a diagnosis is made

to monitor the progression of thedisease to monitor if the the medication that you're on isworking it really provides a lot of information this is a picture of a spinal cord that has um a lesion on it so kinda just ageneral illustration of what we're looking forwhen a neurologist orders an mri that's why we want to get so what do we do for treatment umthere's no cure but we have significantly advanced intherapies over the last twenty years

um there's at this time still enormousamount of research in ms, um, they as i said in the last three years there'sbeen three new therapies that have come out which i'll talk about in a few minutes um there's a lot of drug trials goingon right now there's clinical trials there's you know in the lab trials going on andwe're moving very much toward toward um you know better therapies and therapies that areworking much much

um stronger at reducing relapses andminimizing disability which is really important so obviously though it's still abalancing act because we have to maintain our immune system and find atherapy that allows our immune system to be suppressed enough so that it's notgoing to continue to attack itself so it is rather challenging and that'swhy it's taken so long to get to where we are now wehave therapies available that work with minimal side effects and um you know that you can be on for a long along period of time

so the treatments that we do haveavailable obviously the acute relapse is when something happens most the the themainstay is steroids it still is it was fifty years ago um when you havean acute relapse if anyone has ever um had a relapsesteroids are kinda the mainstay it ek expedites the healing process it doesn'tcure anything but we want to get you back to your baseline as soon as quickly as possible and get you backon back on your feet. um, the diseasemodifying therapies are the ones that i'm gonna spend most my time talkingabout and the symptomatic therapies um

i'll touch on a little bit but that'sreally individual so you know based on what your symptoms arethere's there's multiple treatment options but it's sort a veryindividualized so in 1993 was the first um disease modifying therapy that cameout it was betaseron it was an enormous breakthrough for mspatients because all the sudden there was something to put to be on to reduce the relapse rate andto reduce the potential of of progressing withdisability

um since since that time so in 20 years we've come up with 8 fda-approveddisease-modifying therapies actually i think there's actually 9 butone of them i didn't include because i don't see people using it much anymorebecause it has a lot of bad side effects so kinda moving away from that one sincewe've gotten some newer ones um ah all of the disease modifying therapiesthat are on the market um have been shown to reduce relapsesmost of them have been shown to at least reduce the progression of disabilityand many of them have

have also been shown to reduce the thenew lesions seen on the mris that we that we periodically check so most of the actually all the therapies are generally safe and well tolerated when i say generally there are a few um significant complications withseveral of the therapies that we very closely monitor and we look out for and and we're very on top of those ah potential risks so we'll talk about that um on avaerage the injectable disease modifying therapies have been shown to reducerelapes by 30 percent

the injectable um have been around the longest um only in the last three years are therepills available now so most people who have had ms this long have been on injectabletherapies of some kind um all have an anti-inflammatoryeffect on the immune system so reducing inflammation bringing theimmune system down to a more manageable level and reducing the relapses um most of thetherapies require some kind of blood monitoring

there are a few that don't require as much butthere are you know a maintenance test that oftentimes have to be done to ensurethat it is it safe to continue beyond so the first category is that i'm gonnatalk about are the interferons interferons are normally present in our immune system and betaseron is the first one thatcame out it's also called extavia it's believed to suppress the movement of t cells which are a typeof immunecell across the blood-brain barrier sothere's a there's a wall between like

the the blood flow and the brains cellsthemselves and so the immune cells have to sort of transpose across that and invade thebrain to cause the attack so this medicationwas aimed at reducing that transposition ofthe t cells across the barrier the barrier into the brain this is aninjectable medication every other day it's been around the longest there'sbeen a lot of people who are on it at first and then since that came out there's afew others that have come out as well in

the same category it's approved for relapsing-remittingmultiple sclerosis it as i said reduces relapse and byabout thirty percent so it's a pretty reasonable numberit does have the unfortunate side effect of them flu-like side effects with the injectables but um for its different for everybody and wehave you know wonderful nurses that we you know use totrain our patients to help sort of minimize those unfortunate side effects

um interferon um beta-1a are the avonex and the rebif this isthe same medication but in a different form in a little bit different dose so avonex is a is a once-weeklyinjection um it reduces relapses as i said byabout thirty percent as well all the interferons are about the same interms of numbers it's been shown to slow disabilityprogression which betaseron did not and also reduce the mri leasions that are seen

mmm so avonex is once a week rebif isthree times per week under the skin both have flu-like side effects unfortunately but as i said for most people it'susually worse in the beginning when you're starting the therapy as you sort of get established on thetherapy the flu-like side effects do tend to dissipate and you sort of learn how to how to manageit you pick a day that sorta works for you that you're able to be a little under the weather and stillkinda go on with your day to day

functioning with both of these medications um bloodmonitoring is required you have to monitor the lever we monitor the the the white count to make sure thatyou still have a good immune system in that the platelets and other things haven'tdropped so we do do periodic blood monitoring with the both of thesemedications the other injectable medication is glatiramer acetate or copaxone copaxone is a different category ofmedication that's not an interferon

its actually a combination of aminoacids that are believed to be found in the themyelin or the on the a it resemble the mylan and itsupposed to suppress the t cells and reduce inflammation um it's approved for relapsing-remitting multiple sclerosis as well it does also have a 30 percentreduction in relapse rate it has not been shown to decreasedisability

um but it is widely prescribed it everyday under the skin it has very minimalside effect it has no flu-like side effects it is tolerated by most people who dothe injections and its kind this is the one i kinda tellpeople it's like being a diabetic you sort of just do your shot every day and you justgo on with your your day so this is one that'sbeen very widely prescribed for women who want to have children it'ssafe during pregnancy this is the only

one that has been shown to be safe for pregnancyfor women that are in their childbearing years andaffected by ms this is one that is often used because you know you don'thave to go off of it you don't have to go back on it for some of these medicationsit takes several months before they reach full effectiveness so that's a nice that's a nice perk tysabri is a once-a-month infusion tysabri is a very wonderful drug when itcame on the market it was like the breakthrough it was i believe 2007 ihave to look that up specifically but

it may have been 2007 when it came onto the market and it was pulled from the market a yearlater because of an infection of the brain that was foundto occur called pml pml is a viral infection that isirreversible and it can result in death it canresult in very significant disability and it is not taken lightlyby any neurologist it is a wonderful drug now in the sensethat it's once a month you go for your fusion yougo home and that's it for the month and you feel great and there's no sideeffect and its a fantastic option

but it has very specific protocol that has to be very closely adhered toonly approved neurologists and approved centers canadminister this medication you have to have very strict criteria with every infusion you have to havea patient who is incredibly willing to adhere to the rules and it it is very closely monitored but it has a reductionrelapses of by about 67 percent so far surpasses all the other ones

it slows disability progression andreduces the mri lesion and it's a great drug but i'll tell youhave seen pml and it's not great it's horrible itkills people its it is worse than ms so that's why we don't we don't pick thisfor every person with ms this is a medication thatis reserved for patients who have failed other therapies and are havingprogression and we need to do something stronger but it's a great drug

yes when it is used yes as is the case with some ofthese other medications that we'll talk about so these are the new oral therapies so anyother a 50 and tech for their of health which is awesome no injectionmany more so don't wanna make you mine in 2010 it's a once-a-day tablet it has areduction in relapse is about fifty percent

but unfortunately this one has um someunfortunate cardiac side effect that we have to really closely monitored there have been some reports of suddencardiac death with this medication so we have to pick patient to have no history of cardiac problems arevery minimal risk risk of cardiac disease on it has it produces a disease progressionit reduces mri region on it up believed to keep the lymphocytes inside the lymph nodes andprevent them from

i'm going to go to the brain so that'show we think it works i'm this one can also affect our visionin 'cause a macular degeneration so that's something that has to be screenwhile on this medication on there's a little bit of bloodmonitoring of the screen for z/os oster or her on that shingles by rest but its job it's a good medicine to it's been outfor three almost three years now and there's a number people on it andthey're doing great sold that was the first one

i last follow by your weather pro why wealways called theraflu my careful in mind is a agent that has beeni around for i'm not not here for thenight um left phone in my which is anotherderivative i love up here for the night or similar has been around for much longer so we dohave some information about this on similar products and it was approved as a once-a-day tab what you is believedto have hit a flamer three properties that reduce the lymphocytes and the

in the central nervous system thespecific seven or a little little sticky to me i don't completelyunderstand that exactly but its i'm it's been around and it'sstarting to be prescribed more commonly on it has a specific similar with theinjectables about 30 percent i'm however the big the big fancystatistic here is that eighty percent left new lesions on mri which is youknow a really important i factor for forpatients this is %uh pregnancy category axoanyone who's in there childbearing age range is probably notgoing to be a good candidate for this

medication because it's very risky i'm category act in the medical worldmean absolutely not cannot get pregnant onthis medication even males who on could potentiallyimpregnate their wives are supposed to be warned about that because that's beenfound from and also to be a problem so we haveto monitor blood pressure and we have to do a tv screen but this is a once-a-daymedication that is an option for people if you're me onyour childbearing years and it's okay to be on something like this

than this is a great option i i mean i'm i'm really excited about the final southi'm and tech for there is the most recent one that just came out a fewmonths ago it's a twice-a-day medication it has alittle bit different i'm back in them mechanism of action apredominately work from the anti-oxidant pathway from which is kinda a new thing i meanwe vote we always hear about anti-oxidant thing as both a drink all these and accident you know throughyou said that thing for

it that there there is a lot of ongoingresearch in this area so there's probably going to be more drugs in thefuture coming out in the area this heather a reduction relaxes by of53 percent on disability is also decreased by 38percent the side effect prior profile is prettygood i mean it it does cost them flashing for people the face feel a little hotfor about an hour so after your does tends to get better after about an hourfrom what i'm told and tends to minimize over the course ofthe first few

first few weeks by the end of the firstmonth and told that much better i'm it can cause an upset stomach somegastrointestinal discomfort but its sounds like a great drug alsovery little fight a fact starting to see i mean i have a couplepeople are there now i haven't heard a lot about feedback fell i've talked with some colleagues whothink it's great i worked in a center that this was a medication on in the research trial i so great great day out on the fun thismedication was available

in europe for psoriasis so it's been onthe market for a long long time and they have a lot of good data thatits safe and effective of l so this is a great option for people so with all these nomads how did theneurologist user how does the patient on you know how do they know if theircandidate for these new medications well that's complicated a little bit armyou know for patients that have been stable on their injectablemedications it's really hard to to take them off abit right away knowing that they're doing so while

for patients who have horrible sideeffects they've been he never have an accident when he nearly there forwhatever the case maybe they had their compactness and the they just have had horribletolerability issue 3 years and now these pills are available i mean that's areasonable option but it's very individualized with eachcase scenario its it differ on thought process into why would weswitch for some people they they do fine airduct herbal medications but they're just getting worse

and they need something different andthese are available and they have a different mechanism action so it's a different way offighting of immune system so that's a reason to pick it for some people they have no symptomsbut there are my eyes are looking worth and something needs to be done so thatdisease progression or disability doesn't occur in 10 years so i mean there are a lot of thoughtsthat go into a neurologist mind when we meet with you every visit to talk totalk about your therapy

i'm it's not an easy choice on it's it's a it's a big it's a bigdecision to switch therapies and there's risk with which in therapyand their side effects were searching therapy so is very individualized anyone knowthem if they know all about the the risks of medication and it'sit's a case by case decision so what if i for one person thenecessary pie for the next person so what if you think you have an ass orwhat if you know somebody who that you are concerned might have my math the tosee somebody about it they need to get

evaluated by a neurologist somebody whois familiar with a mass who can really look into it on becausewhat we know about a mass and what we've seen even before before i was even born and31 years old well i mean this has been a long foraround for a long time and you know my trainers have been doingthis for a long time they saw people when there was nothingto do and every year things got worse but now withtherapy things slow down and and people areliving longer with left disability with

more functionality there no one not me it's now they have amassedbecause they can you know have less and less symptoms as they'relike 10 cause on and if you don't get treatment as soon as possible or as early as you can then the risk forrelapse is increase as and with that is disability so theearlier you're suspecting sometimes the girl you should see somebody inc andfigure it out for people who have been diagnosed withms and have been living with us for years that the whole different you knowit's a different ballgame

arm the symptomatic therapies are as isaid earlier very individualized there's plenty of medications out there to treat the fatigue to treat thespecificity to treat the depression to treat the bladder problems to you know i mean there's there's lotsof things that we have in its obviously with one thing is that work we trysomething out then if you know something doesn't work we stick with it but its its it depends on the same foundit depends on the person but i'm you know that's a conversationyou have with your neurologist

so when when a piece with a mask onthrough my office and i see them and i say howare you doing me not the time to say all my fightersfiring me or are not sleeping or how or and on thetop i mean because thats that the conversation thatyou have with your neurologist is how are you doing mean when when iwalk in there are many say how are you know that's what i'm i'm great but i'm thesafari me i mean that's what the neurologist newsnow that's how we decide how to treat

your symptoms and what to change in what to dodifferently so physical therapy is a great optionoccupational therapy for people who have you know you know different i mean it'sdifferent for everybody but those are great resource to the physical therapist in this town areawesome their top-notch i've sold many greatresponses from people that have gone physical therapy for youknow not just amassed we have a really great

i'm community with wonderful resource sso i find take advantage of that term in patients and i always make that an option on assistive devicessometimes are very helpful for you know foot drop or whatever the casemay be on you know when upper extremities arespastic and it's hard to go grab things are open jars and its its there's things available forthat so you have to talk to neurologist about it so that we can get get to the healthyyou need

living environment something had to bechanged living in a house that doesn't have a ton affairs you know bathroom accommodation thingslike that so that we can minimize complications exercise is always you know i never tellthem not to exercise i mean there's out there different degrees of exercisersdifferent things to do exercise is really important healthydiet good sleep home you know stuff stressmanagement hard stress management is something that andthe doctor can preach to you and any

person can preach to you but it you know i mean every person hasstress and everyone deals with it differently but it is important because when you'remore stressed your symptoms are accentuated and it's really important tosort of keep that under control and if you're struggling with that toask for help support refer great till i'm for porkribs are wonderful in the sense that they can give you someone from listen to yourstruggle

and also you know here what other peoplehave gone through it it's wonderful in some cases they can make you a littlenervous that oh my gosh i am i gonna be in a wheelchair because that's the mostcommon fear everybody and and i will tell you it'snot it's getting better i mean people are doing better forlonger with the advancement a medication so i thinkthe people that are weird wheelchairs thirty years ago if they were to havebeen diagnosed now maybe wouldn't be in a wheelchair asfeeling or maybe not ever its it's two things have changed andthings have advance and we definitely

are making a lot of strides so i put the fight in here actually wehave a handout over here with this information so these are justsome wonderful online resources that of anybody familiar with them but thenational ms society is a fantastic resource for helping with you know disabilitybenefits for insurance for work for all sorts of questions that we facein our day-to-day routine when you're living with a math i'mnamath lifelines them a active sources those are both onlineresources that can answer questions that

can provide i'm you know there's a mentor their i what i think both of themactually i must leave by the time as active force have resources to talk with a mentor ifyou need just somebody to talk to or someone who's been there there therethose resources there on the ms. foundation & spa sharedsolutions is great because they help with you know in questions at work questionsabout injectable therapies how to make

things better if you're struggling from they're they're wonderful ownersays that can provide way more our answers to questions that probably ican hit and fell i use them a lot self and on your side and i went a little bitover arm there's about 10 minutes left i'll have out safer any questions so i hopethat wasn't too boring or 200 perfect i okay thank you i

the the question why is on i hadmentioned some speech sometimes and the question was what would be somespeech something that frontal lobe lesions while i suppose that's a complicatedanswer as as is the case with most neurologyfrontal lobe lesions if they involve them older pathway can affect you know themechanics above the mouth so can make you have a more defarthritic or more about flirty your speech

are making about the throat so couldhave more modest phonic or some kind of like problem i know how to explain that very well butit it can make your your speech down a little thicker because thethe vocal cords and the the the throat doesn't move as nice andeasy as it use to sell i'm that would be the most obvious thingi would think of so the question i was in the videopresentation there was a comment about how the the pathway or about the pathophysiologyof an ass is that detects the mylan

but also that attacks the nerve fiberitself meaning axe on and that is true what we learned about our math with mriis that when the mylan is damaged the accentbeneath it can start to wither away because it isthat we don't know why that happens but probably because it isn't protectedas well and so the signal isn't being train ducted as well and the nervestarts to die of a little bit and we know that because i'm mri we seethese black holes is what they're called buttheir holes

in the brain that occur almost on a bitlike a stroke but it's not a stroke it's completely different ideology but it's a hole where the the nerveitself has basically sort of deteriorated we didn't really know that until mri sothe theory has changed a little bit and that's where we think the diseasedisability long term comes from is when those black hole or the the axeon itself has started to be this integrated oraffected is when the the secondary progressive disease comethen we've only learned that over the

past twenty years but you it without contrast it's actually i'm aon the t1 sequences which i'm i have many sequences that we lookat and when we're looking for active information we always look at the flarefake ones are the key to flare sequence that those were the sequence as shown inthe images during this presentation but they're also the sequence called t1and that does demonstrate the black hole so we don't see it an early amassed wesee then later on that

cell but yes that's a wonderful questionwe didn't know that for a long time i'm the question foreverybody is does the number i've lesions on mricorrelate with the number relapses or the number are the severity ofdisability i got answer is no i'm there are mri's they look horrible like the 1i showedyou i've no idea that beijing was i i just picked that picture because ithought it was a good illustration but mri can be horribly deceiving and look where the like that and havevery few clinical symptoms

okay the opposite case can occur whenthe brain never really look that bad but the location of the lesion can be inthat specific precise location that it put leaves you with a lot a disability so patients who havebrain stem or spinal cord lesions and not a lot inthe outer portions of the brain can have a lot of disability in lifereally bad and their brain doesn't look that bad so it doesn't always correlate but the reason we monitor mri is becausewe wanna see is there any new

regions that have had some sort ofclinical correlation because there is a silent component andmath because every new lease and doesn't always have a symptom so not in my training are not in my career time i'm i get a repeat didn'thear the question on can we use combination therapy toimprove the immune system fight against i mathi'm the reason the answers now we don't dothat i'm and the reason is because for example in

the i text every trial those patients that developed p.m. i'll were alsoanother 30 some of them have been on avonex okay and some of them have been on otherchemotherapy drugs for other conditions and we think that that significantlyincreases the risk of infection and so we're incredibly leary i'veexposing people to too many infections because brain infections are veryserious so we don't take that lightly and most of the studies are are comparedagainst placebo

on there's very few trial to comparehead to head against another product but they do not allow people to be instudies with combination therapy for that reason because i've the risk ofinfection so it ecological box and a lot of peoplehave discussed that but in my training in my career and eveni think in the twenty years that they've beenavailable people are just not doing that i mean i've i've not seen that anywhere cell and in fact sometimes when we takepeople off medication and what's worse is something differentwe give them a little bit of a washout

period meaning some time to get that drive outother system so that that is not a risk exercise for that's great it's mentally therapeutic it obviouslyvery you feel better and we think that keeps you a mandatoryfor longer felt thank you that that's great can you still have amass if you don't have lesions on your brain probably not okay that i am there is a condition called honor mylatest after car which is a very into a

mass it's not an ass but it is usuallyconsist of spinal cord lesions with no liens on the brain and opticnerve so it's nerves on the eyes and spinal cord andnothing in the brain which it's very similar amassed but ifyou have a massive you have something on your bringing now in my opinion is in my opinion is a funbetter than vitamin d i'm i don't know the answer to that ithink it i think it might be i mean look at thepeople that live close to the equator

they don't have this problem see kinda wonder right but we don't havethat ability we'll we have you know how many month of cloudinessand no sunlight and it makes us all depressed and crankybut i mean it it does make you wonder bowlthat's all we have as the vitamin d3 for or a supplement inthis area the country's how often that's a hard question howoften it is is it in the arms versus the legs or probably refers tothe life versus the arms or both i'm i don't know that i've ever

paid attention to that truthfully ithink we notice when it's in the legs more of 10 because it affectstheir walking effects are emulation but the arms arenot taken lightly either i mean writing we are driving everything we do i mean idon't i don't really have an answer to that because i never really paidattention to watch is more prominent for a lot of people in effect 15 thebody so if the arm and a leg on one side for of but is it just one arm or justone lag i don't know which one mark on for andthis is a complicated disease because everybody's different not one singleperson with ms looks like the next

person it's very variable cell it which is thechallenge so that i thought he wants to knowbecause the location of the lesion that mri are so close to the ventricles in thecenter of the brain does that mean that there's somethinghaving to do with what we ingest into our bodies and that it's crossingthe blood-brain barrier somehow and affecting the brain in the centre portions fromsomething we ate

i don't know i i'm never heard back thatphiri inexpensive one for insurance is a lot of times are youknow people use their insurance if the payfor those expensive thing so that's why they hurts so much because insurancecompanies molpe the big box and if you don't haveinsurance or free insurance won't pay the static at the big bucks so i i truthfully i don't have enoughlot of knowledge about where that

cheapest devices are located i knowthere's just you know i i refer people to medical devicestores because every month options but i don't know that that you're rightthey're not they're not cheap it's such a in my practice i'm i don't want anyone i don't want anybodynot be on drug because they don't have insurance there are so many resources most ofthese drug companies will make sure you get the drug and andmost of them have assistance programs so that you can get it for free for ayear or two or you can pay

you have attend our copay or they almostall these drug companies bent over backwards to get you on their their therapies i meet my partnertrained in inner-city chicago in you know he he saw people who had nomoney no place to live and we're getting drugs so these drug companies will make surethat you can get therapy if you have a diagnosis so somebody who told me because they don'thave insurance enactment take their medication

i can i that's not enough for me me hi i really do work very hard to get peopleon therapy because i really strongly believe that you know idon't want to be disabled so i i want i want to make anyopportunity to keep you functional keep you livingas long as possible i think that's changing a lot now ithink one other one other company they know for sureabsolutely will pay for your dog if you can afford it and in fact actually to %uh the companythen oh well yes people with the

injectable the aft since the orals have come available imean i think i've only been here for a year okay so i've assumed a lot of people whohave been in this community and had a diagnosis and you know maybe they're just lookingfor a new neurologist so yeah people that i've had a long termdiagnosis and he did the injectables and couldn't deal with it both people have been offered drug itried to get them back on therapies

i really have because i'm especially forcoming in there are already using a cane or there already have been you know something going on or orthey're having relaxes and they're still me the biggest thing is clinically howare they doing it for not having relapses anymore and the baby there there stable or their may be progressing a little bityou know that's going to be a different situationbecause these medications are pro for relapsing forms

so on paper that is something we have tobe careful about because if you're not having relapses anymore it may not be covered cell these thesetherapies are only study in relapsing-remitting cases are notstudied in primary progressive they're not studying and secondary progressive so that's a little bit of anindividualized case as well but yeah if people have an offer theinjectable i am trying to get them back on yourtherapy is thank you so much to everyone okay

herbal medicine who have severe asthma

there is the mountainbhadragiri, it is iike ayodhya for andhraites, no sage iike vaimikimentioned about it, this piace became famousas south saketapuri, the great devotee bhadra beggedsitaram to appear to him again, he observed severe penance, bhadra requested him to appear intreta yug as rama, to fuifiii his promise lordvishnu took birth on the earth,,, who married the daughter ofmother earth,

accompanied by his divine sheii,and the discus on either side,,, with bow and arrow, aiong with sitaand lakshman he appeared to bhadra, devotee bhadra requested vishnuthat he turn him into a mountain,,, ,,, and vishnu in his reincarnationas rama shouid dweii on its peak, o god vishnu i payobeisance to you who biessed me with yourgracious appearance with your consort janaki (lakshmi)and hoiding the divine bow and arrow, adorned by divine weapons, the sheiiand the discus on either side and the adi seshu asshouider ornament

accompanied by brother lakshman, which is iike ayodhya for andhraites, we are dead tired. how long dowe walk in the jungle? my lord rama told me thathe is here and l should find him. told me in my dream to lighta diya and offer him holy food. he told you so in your dream!l will kill you with this. how can something saidin a dream materialize? my rama won't lie even in dream. search seriously.you will sure find him.

you are too devoted.don't get carried away in it. you treat us with your herbalmedicines wheneverthe need arises. today she says it is ram.tomorrow, something else. don't take her words seriously.let's go back. o lord rama, mother sita,lakshmana, are you hiding in ant hill? rama, your life is full of hardships. you were born, soon wentto forest, lost your wife. lead a tough life.why did you, again, hide here?

why did you get caughtby me, an old woman! l can hardly do anything foryou. who will look afteryou? who will build a temple foryou? ...and take care of you? gopanna, you have come in timeto save the idol from falling. ldols are glowing! so, carry these idols carefully. hey, parrot, stop there.

where are you? flower, when will mygopanna come? parrot, my gopanna hasnot come yet. hey, parrot, cousin, l want that parrot. l cannot leave with yousitting on me. greetings to birthday girl. may l give you a giftwhich both of us can have? what is that?

lt is so cute! bring it tohome in a cage to play. singanna, announce in thevillage that, on the eve of... .. ramanavami celebrations,we will feed the entire village. ls it okay?- okay. o god! feeding an entire villageis not easy. lt costs a lot. recently you had distributedall the grains to them... .. in the name of drought. we will be on the roads soonif you continue such things. you tell him, gopanna.- okay. mother.

mother .. l've a doubt to clear.-what's it? how could l breathe whenyou were pregnant and carrying me? that is what is god's miracle. l see! l heard that frogs liveenclosed in huge boulders. true? - true. what about food forthem?- of course, it is god. when he can performsuch miracles,... ... won't he provide for us ifwe become poor by charity work? l got what you mean. l'll send necessary groceriesas yourfather wants.

send chandrayya.- okay, mother. gopanna, here isthe cage you wanted. lt is nice. o parrot,it is foryou. what is the news from the village?- may l tell you, gurrugaru? why do you call me so?- because you are always snoring. l'll break your head rascals.siddhu, what's the news? your brother-in-law, withgrand ramanavami celebtations is going to turn our village,nelakondapalli like ayodhya. l want you to talk about me,the great learned man.

not about my brother-in-law. about you...may l tell you? you are making mockeryof the village. who said so? l'll stabhim with a cane to... greetings, brother-in-law. greetings... whatever my brother sayssounds like poetry. my brother is likeparamanandayya. l hate that comparison.

l like comparison to kingbhojaraju who is a learned man. comparing to a gluttonwould be appropriate. l'll break your headyou, rascal. get lost. brother-in-law, where ismy niece? niece!you ugly looking fellow! hello, sister-in-law.hasn't our son-in-law, gopanna come? our son is gopi and your daughteris rukmani. he is coming. enough of jokes.my daughter is endowed.. .. with many good qualities.

l'll get her marriedto a revenue officer. will you please... brother, even kids pay noattention to what he talks. you please come and have snacks. go. snacks are okay but don'tplan for wedding reception. gopanna and our kamalalook made for each other. shut up elsel'll stuff it in your mouth. greetings to wouldbe father-in-law. nonsense. anyway, why isthis parrot here?

today is kamala's birthday.l brought it as a gift for her, uncle. the parrot is cute. kamala is playingin the backyard. go and give it.- l'll. -wait. wait. why are you givingthe parrot as gift? because gifting ratwon't be nice. lf you want to challenge me with words,... ... show your knowledge in it.

okay. here is the riddle. what are you, to anewly born baby of... ..yourfather's daughter-in-law'sbrother's, son's, would be wife? what! what!! here l repeat... he cannot answer?- he will answer. gopanna marries kamala. lf he fails?- our kamala marries gopanna. you cannot. - of course l can.-you can what? - riddle.

today l'll explain weddingof rukmani. show it to us, fast.- be patient. he is krishna. she is rukmani devi. she fell in love with him. rukmani asked krishnato come. he came. he was taking away rukmani.sishupal obstructed them. l think my blouse knot got loose.tie it. he shaved off rukmi's headand beard.

before your blouseknot came off. where are my friends?- gone. -when? before l tied the knotof your blouse. get lost. - did you call mehere to send me off? this isn't like a cagebut like a dome. lt represents our love. he is the father l raked my brain butcouldn't solve it. no! should l solve it?

let's see.- okay. who is yourfather'sdaughter-in-law? - my wife. l know. grandfather. that's it, uncle. as per our bet... - get kamalaand gopanna married. no way. my would be son-in-law,revenue officer will arrive anytime. father, stop the cart.-why? hey, girl... wait.are you married? not yet.

lt was a hard slap, father. mother... -we have cometo see an alliance. now you know. get in.we are getting late. - okay. yes. they have come and restingin the guest house. brother-in-law, we decidedwhen kamala was born that.. now l don't think so. shut up. l cannot give my girlin a poorfamily. they spent away everything in thename of charity and devotion. for relationship, friendship or evenfight, equal status is necessary.

l won't marry off my daughterinto a poorfamily. you may leave. cousin... who broke the bow oflord shiva? srirama. what do you mean? my father is gettingme married elsewhere. lf you don't come, change hismind and marry me... which god blessed by birth?- our village god, lord krishna.

so, he will sure seethat we marry. okay? tell them about me. oh, l forgot. he is ourfamily priest, pingali. his word is an orderfor us. he is a master in astrology. what is your name? pronounciation is wrong.let me pinch you hard. say, shasha bisha shastri. l told him to say.let me pinch you hard.

you called me, an ugly fellow!! you glare at me!of course you are ugly not me. anyway, why do youneed my horoscope? l mean, your daughter's.- lt is in that plate. sit down now.pick it up. you are too much. how is my son-in-law,the would be revenue officer? shut up, you fools. don't bother. he makes such noisewhile reading horoscopes.

mother, ask the bride to come fast.l'm eagerto see her. father, kamala is likean orange fruit. her cheeks are round. you may ask questionsher if you have any. first question is... l want to ask few questions.come this way. we have to change withthe changing times. come. the parrot is cute.ask your questions fast. who came to ashokvan for sita?- ravan.

what did he say?- that he wants to marry her. what did sita say? she showed him a strand of grasswhich meant he is worthless. are you teasing me! what did she say? nothing. showed her skill in direction.-what do you mean? tell us what she showed you.-a strand of grass. how do you find their horoscopes?- totally opposite.

l don't know what to answer. should l tell you the fact?- of course, yes. your entire family is goingthrough a bad phase. never mind. l'll perform ritesto do away with it. and get her married to him only. good. let me congratulate you.that is the spirit. lf you too are bravel'll tell you something. lt's okay with us.we are ready forthe wedding. that's the spirit.

lt says that whoever marriesher will undergo imprisonment. lmprisonment!! let's get up. please don't do it. mother, father, let's go. please, don't ruin mydaughter's life. you mean, we ruin ourson's life? wife, let's go. brother-in-law... we are finished.

now my daughter cannever be married. please calm down. uncle, whetheryou agree ornot kamala would be my wife. no, cousin. l don't get intotroubles because of me. foryou, l'm readyeven to go to heaven. nephew..- uncle, what's this! l request you to give herhand in marriage to my son. brother, say yes to engagement.-yes. here came the coachfrom golkonda.

akkanna and madanna have come. aren't they gopanna'smaternal uncles? -yes. greetings, brother-in-law.was the journey comfortable? i dream enough of separation i iove to hear you say so these moments areprecious to us we never experiencedsuch pieasure before, don't take my invitation iightiy

these sweets are iike piiisto intensify our romance these beds are gateway to heaven these bodies are instrumentai,,, ,,,in cuimination of our joy my body knows no tirednessdon't stop me that's enough, wife, what is yourparrot saying? husband, l've a doubt.-what's it? a male parrot is called'ramachiluka'. -yes.

then, what is a femaleparrot called? how about calling it'sitachiluka'? very nice! l want to unitethis parrot with it's mate. you are my brothers, but arelike my fatherto me. his charity work made us poor. we have nothing lefteven to prepare holy food. you are holding high postsin the court of tanisha (king) please help gopanna get a job. we have already tooka decision about it.

we will take gopanna withus and get him a job, okay? okay, uncle. l'm not god buta devotee of god. l'm not a king but a publicservant by god's grace.. you were supposed tointroduce your nephew to me. greetings o badusha (king) your uncles say you arewell liked by public. l want to hear what peoplethere feel about my rule? can l give an honest answer?

or lie to remain in yourgoodwill like your officers do? l commend your guts.tell me the truth. you must be aware that our regionwas hit by drought recently. l know. l presume thatyou know we had sent.. ... enough funds for relief. the king must realize thatyour duty doesn't end there. what!! explain clearly. get me an ice cube.l'll explain. who is there?

assume that this is thefund you had sent. now, pass it on to thenext person. - okay. by the time it reached theneedy people this is what happened tothe money you had sent. excellent! your nephewis great like you two. let's keep watch to preventsuch a thing in future. king, provide him someemployment. how can your ordernot be obeyed? hire him as revenue officerof hasnabad.

transfer him as the headof golkonda jail. come to me o my beauty. you are so beautiful. he is inside.-we are guards. what are you doing here? you send beautiful girlsto our officer. don't we look like men too,to you? - speak up, pandit. no. you don't. what about you?why did l ask you! my dear...- sir... sir...

l told you not to come inwhen l'm doing important work. what's the matter? new revenue officer is coming. what did you say!!new revenue officer! your brother-in-law hassent this himself. what!! you lost your post.-you... lt landed up in golkondaprison. what!!-your girl fell down.

never mind, my dear. l'll writethe golkonda fort in your name. l'll show what l can do. whoever is coming hereis going to die. ... my post as the revenueofficer of hasnabad. o river godavariwhy are you so turbuient? my ieft eye iid isfiuttering means,,,, good days are comingfor our god sitaram o river godavari,,, dancing of peacocks whose feathersadorn lord krishna's crest,,,

the joy of the jumpingsquirreis that heiped lord rama,,, the arrivai of goodtimes for lord rama sacred verses are sonice to hear! better is the new officer. we have not come to praisehim but to stab him. l'll stab him whenl find an opportunity. count your days you siton my chair. let me count the problemspeople here have first. you will be in trouble.l'll kill you.

stop. you should send off theex-officer with due respect. l'll show you what respect is. l'll go to golkonda, make mysister, the queen teach you a lesson. what! - this coach isn't for usbut forthe new officer. don't go behind the horses.they will kick you. lt is my personal experience.-you rogue... pantulu, l don't know whatyou do but you must... ... build a grave for him soon. we brahmins cremate thedead bodies.

keep them inside.- okay. what will we do with sucha huge house? we are only two.lt is all ours. l go in the morningand return by night. wonder what you will doin the meanwhile. l'll wait foryou likemother sita waited for rama. sir, troubles from head ofour village are increasing. okay l'll make enquires abouthim and take action. relax. load them into our vehicles.please, stop. - do it.

how do we survive? you are paying only half ofthe agreed money for 2 years. you die if you cannot pay up. before that we had storm.you know everything. l know. that is why l'mtaking what is available here. l'm taking away your daughteragainst your last year dues. pay up and take her back.put her on the cart. stop. what is this atrocity? sir, you have to saveme from these rogues.

how can you chain them andforce them to work? you gave them loans againstwhich you robbed everything they possessed,robbed the entire village. end of bonded labour. the farmer has the upper hand. the land belongs towhoever cultivates it. villagers who cultivate underthe agreement will own it. l'll prepare legal documentsto that effect. hail the revenue officer.

god knows nothing. what are you talkingto yourself? l feel like carrying you. why?- carrying you meanscarrying my baby. you know gopannais going to have a kid. kid will be born but won'thave father. - how come? l won't tell you but do it.what do you mean? madam, here, forthe celebrationof lighting lamps on 14th day of the month kartik, you areteaching girls to dance.

but things there are badwith master. he is roaming all overthe villages, jungles. here men are cruel likeanimals. you must warn him. no one can stop him fromdoing what he wants. bye, sir. gopanna, you will nevercome back. l love you.l'll fulfill your wishes. serve you pure honey. come. so, you are shurpanaka's sister.

o hoiy, aimighty,,,omnipresent, rama o rama who has seshu, thechief of serpents, as his bed o rama, who is worshipped bythe god brahma and other gods haii lord ramahaii sitarama o rama, who is servedby guha o rama, who has shabarias his great devotee o rama, who iives in theheart of hanuman o rama who is thelord of sita husband!.....

gopanna is not caught yet! mattesaab is angry thatl did nothing to gopanna. gopanna is angry that l couldn'tfind out who wants to kill him. what do l do? you are caught in thecross fire. - shut up. sir... -yes. - gopanna is goingto attend the office from tomorrow. look into this first. kamala, l'm going to office. you are going to office a longtime afterthe accident.

before that a visit to theold lady who saved your life... good that you reminded me.let's go together. come. rama, l've broughtfruits foryou. are you hungry, dear? eat. you old lady, you are feedingdefiled fruits to god! have you gone mad? she is not mad.she is deeply devoted. yes. devotee shabari testedthe fruits fortaste... before she offered to rama.

we called it great devotion.this woman is like that too. sorry. we shouldn'thave said it. don't just sit. he is therevenue officer of this district. grandma, we came to thankyou for saving my life. you are the revenue officer! sir, you are a righteousand a just officer. look at my lord rama. he appeared to me in my dream. asked me to worship him.

l am worried who willserve him after my death. l've to take care of my rama. because, this is the placewhere rama held court when... ... he came to jungles whenhe was exiled from ayodhya. close by is the placewhere sita and rama visited. come with me. l'll show you.- let's go, kamala. grandma, bring them backbefore the night fall. beware of insects too.let's leave. - come with me this is the cottage wheremy rama stayed,

here is the piacerama and sita spent time, this is where mother sitadried her saree this is the garmentrama had worn these are his hoiy foot prints these are the un-erasedmarks of the deer these are the stones wheremother sita appiied ,,turmeric and kumkum, it is here lakshman drew aiine for sita not to cross, here are the marksof abduction of sita by ravana,

this is the hoiy piacewhere rama waiked, distribute to all.- okay. what are you staring at? no? lt took me the wholenight to sign those papers. you haven't signed but wrote'srirama' on all of them. you are supposed to come formeals. why are you sitting here? l'm talking to you. oh! the cunning deer... my lord, look at thegolden deer.

lt is beautiful.- l want it to keep as pet. how can rama not fulfillyour wish? lakshmana, your brother seemsto be in trouble. go, see. mother, it's impossible thatmy valiant brother can have trouble. you refuse to go as yourintentions aren't good. lakshman is a noble man. lf he leaves you alone, youhave to go to lanka. don't do it. don't cross the line. saint, accept the alms.

don't you know the rule that... ... you have to walk up tome to go offer alms? don't look scared. l'm ravanathe great king of lanka. you... ravan.... rama is omnipresent he is our soui he had shown his supreme powerin many incarnations of his the sun, the moon, the starsthe gods are aii part of him aii the worids in theuniverse inciuding the bramha,

,,, the rivers, forests, animais,aii eiements and the hoiy scriptures,,, are aii part of him, rama, be kind to me. gracious god, l've searchedforyou in all the worlds. why did you go away from me? why are you living in jungle?why are you wearing jute clothes? you lived in the forestonce before with sita. lsn't that tough life enough? how did tretayug(eon treta)come in kaliyug(eon kali)?

this is the proof to the sayingthat for devotees sake... ... god changes even the destinywritten by the creator brahma. ln this holy bhadrachala region,a true devotee of rama... is going to build anincomparable temple for rama. yes, hanuman. ln future this isgoing to become a holy place. as a prelude, few remarkableevents are going to take place. l came down to earth to witnessthem personally. lt is a wonder! the real story behind theseoccurrences begins now.

my rama must be gettingwet on the hill. hanuman...-yes. - look there. look at her behaviourin utter devotion. welcome, sir.she has gone completely mad. says rama is gettingwet because... ... there is no temple for him.so she removed her roof. she is sick by beingwet all the night. madam is going tonelakondapalli. arrange for palanquin.- okay.- hurry up.

bhadrayya, you need not comehere to work from tomorrow. l'll give you work in the office.go there. - okay, sir. you clean up the place,lock it up and give the keys inthe office. - okay. kamala, pack up.you are going to native place. l told you l'll stayhere for delivery. lt's a big houseand we have many servants. l'm not going stay here. until l build a templefor lord rama

l plan to stay in thejungle under a tree. lt's a great decision.what's my leaving for... don't say a word more if youhave any respect for me. you are pregnant. cannot face thehardships of stay in the jungle. do as l say. to fuifii his father's wordrama got ready to go to jungie, sita got ready to go with him, rama toid her that she cannotface the hardships of iife in jumgie, sita asked rama how can he go awayfrom her, who is iike his shadow,

l'll stay whereveryou stayno matter how the life is. don't separate me from my god. kamala, l wish that l shouldbe born as your wife if l've ... rebirth and reciprocateyour devotion towards me. grandma, dammakka, god like our revenue officeris going away from here. all of you come here. greetings, sir. why did you come hereforegoing comfortable life!

this is our house untill build a temple for rama. stay here! she is pregnant too.this rain, cold... l heard that you removed your roofbecause rama has no shelter. he took this decision becauseof that. how can you stop him? my life is almost over. don'ttake me seriously. listen to me. l won't leave even if lord rama himselftells me until l build the temple. building the temple isn't easy.lt costs lakhs of gold coins. money will come. - from where?who gives? people will give.

for rama the monkeys havebuilt a bridge across the ocean. similarly people will dothis noble job. they crib even to pay taxes.l don't think they will help. but l believe. l'll bring outthe piety in them. l'll beg from everyone andbuild the temple with that. we are with you, sir.-we too. let's all vow to do it bywearing yellow coloured clothes. hail sriram.- hail sriram. you are our protector

we seek your graciousnessbhadrachaia rama when do we be abie toconcentrate on prayers and chant your hoiy namewith totai devotion? o rama, beioved of sita when do we abie to chantyour hoiy name with devotion praise the lord krishnaof brindavan rama, you are gracious. enough money is collected forthe construction of the temple l pay obeisance to you.

your son is born at theauspicious time. our son is born at thebeginning of the noble deed. you spoke what is in my mind. move aside... so much money! nothing is impossibleif god is kind. out of this total collection,1,00,000 coins are towards taxes. ... build the temple, with theremaining 6,00,000 gold coins. what is this? nothing happened to him.

someone spit on his face.nothing happened to him. how much is it? more than 1,00,000.- o god! more than a 1,00,000! whatever above 1,00,000 is mine. okay. one lakh is.. look at the letter gopanahas sent first. - hold it. gopanna seekskings permission to... you want permission! he gets permission only ifthis letter reaches the king.

gopanna, l'll burn you and yournewly born baby like this. don't cry, dear... aiiah (o god),,, which god is gracious,divine and grants saivation? who is wise, nobie and kind? who is the most beautifuiand beioved of aii who eise but lord rama cherish the name 'rama'whichis a driving force for aii the lord, one of thetrimurthys

who is omnipotent who is omniscient whom the 7 worids worship who is gracious,and omniscient that is srirama cherish chanting the name srirama it wiii iead you throughout the iife you have enchanted us with yoursong in praise of rama. both of you are alike, whenit comes to devotion.

you have proved, with your song,that devotion knows no boundaries. you are...- l'm kabir a devotee of lord rama. l think you are a muslim.how come you are devoted to rama? his grand father's nametoo was kabir. he became devotee of ramabecause of his grandfather. the five elements, the sky,earth, water, fire and the air... ... are above all racesand religions. lord is omnipresent.how can man made obstacles... ... prevent us fromworship him?

l'm blessed by the visit of amagnanimous person like you. please come to my houseand bless it. kamala, please bring waterto washthe feet of this revered man. welcome. this is our house. house! this tree shade is our house.he resolved to stay here until... ... he builds the temple for god. lt's a great resolution. chanting the name of 'tarakarama'.would make all resolutions fruitful.

yes. lord shiva has initiated thissloka(hymn) to his consort parvati. l'll initiate it to you.your wish will surely be fulfilled. l'm blessed noble man, you have blessed me byinitiating with 'tarakamantra'. l'll teach it to all. l'll beginto write 'sriram' a crore times. you have collected huge amount.why didn't you begin construction? l've sent letterto the kingrequesting for his permission. l've not yet received permission. you don't need his permissionbut of lord rama's.

that is done long ago.don't delay a good deed. coming dasami is very auspiciousas perthe sage vashisht. lt is the best day to layfoundation forthe temple. what is best! my foot! because of that rama spent14 years in exile. anyway, how can a muslim fixauspicious day for ourtemple? why are you angry? answer my questionif you have guts. lf your answer is right,l'll shave of my hair and grow beard.

lf you cannot, you have to shaveoff your beard, grow hair like me. l think we are not worthy enoughto talk about sage vashisht. at the auspicious time he fixed, rama's footware were declaredto rule the kingdom. the great sage knew that rama waslord vishnu and he was born to eliminate the evil. auspicious time was chosen forthat purpose. lf you teach me again,l'll pull away your beard. you keep saying l'm a muslim. but we have became relativeswhen lord venkatesha (vishnu)

married bibi nancharamma. (a muslim) relatives! my foot.don't make me angry else... your head will be at his feet ifyou say one more word against him. o saint, foundation fortemplewill be laid at the time you fixed. he is coming. hey ram, my lord... where are you barging in? to see rama and to wash hisholy feet with river godavari waters. don't talk nonsense.l won't approve it.

once the installation of idol is donenon-hindus cannot enterthe temple. god doesn't mind it. that's enough. one push andyou will roll down the mountain. stop it. let that great man get in.- then we have to go out. -yes. what is in your stomach? what is in your brain? lt is full of...- shut up. lt is empty. never mind if you are not allowedto go in. the lord came to you. hail lord rama.

great devotees, l herebymake arrangements for... ... all to come here irrespectiveof their caste or religion. as a beginning to that,l orderthe celebration... ... of lord rama and sita's weddingto be conducted in open air. ls this how the dolls marriagecelebrated? l missed your weddingceremony in treteyug. l have also realized that the greatdevotee ramadasu is our gopanna. l could read your mind, hanuman. ln future gopanna will be know assri ramadasu (servant/devotee of rama)

gopanna, your son fellin the ditch and died. my son fell into theditch and fell asleep. you used to work day andnight to build the temple. the construction is completeand my son fell asleep. o son of raghu dynasty,beioved of sita piease be kind to me eise,,, ,,,iife wouid be difficuit for me ,,, kiii the demons andto rescue sita o virtuous rama,,,

,,,i seek your kindness hanuman, save the boy's life.-as you order o lord. mother...- son... lt proves that lord ramais here. lt is all a drama by him tomake this place a holy place... where devotees come to pray totheir god and be blessed. king, our mattebhai came totell you something. tell me, what it is. you appointed gopanna but hisdeeds will empty our coffers.

what is he doing? he is instigating people sayingthat farmers are land owners. he told them to occupyforest lands too. he is issuing legaldocuments of ownership. ln the name of compulsory tax hecollected 6,00,000 coins... ...and built rama templewithout your permission. he has already built it. how did it strike you to chantrama's name while playing? you too keep chanting lord'sname while doing chores.

like father, like son. you installed rama in the temple.he installed you in his heart. he appeared in my dream and namedyou 'ramadasu'(servant of rama). hail sri ramadasu. kamala, rama has blessed me tobe his servant. l'm blessed. why are you here?- for spending government money forthe construction of templethe king ordered foryour arrest. come with us. you will take him only overdead bodies.

stop. you obey me as l'm yourofficer. king is my officer. l've to obey him. kamala, what's this? where am l going?l built the temple for rama. forthat l'm going tokrishna's birth place (jail) take care of my lord rama. conductpujas and prayers at the temple. what wrong has he committedto deserve this? everyone has to go throughwhat is written in theirfate. why did you misuse governmentmoney without my permission? lt is not misused butput to proper use.

didn't you think my permissionwas necessary? l've written to you for itbut there was no reply. any proof for it?- this pantulu. sir, l cannot keep quietnor open my mouth. you have to talk. l advised him to seek yourpermission but he turned it down. he announced that he is the kingand went ahead with the construction. now he says something else. what do you say now?

lf you believe this crook's words,you may punish me. l take it. how dare you say so! l'm telling the truth. everything here will be ruined butmy ram temple will stand forever. the power, luxuries and possessionsare short lived, but not the temple but it will be written in history thatthis temple is built during yourtimes. look at your nephew! stop arguing with elders andaccept your mistake. excuse me. with elders permissionl want to mention elders mistakes.

elders mistakes!!what mistakes? why was taramati palaceand bhagmati palace built? what was the purpose to build a bridgebetween golkonda and bhagyanagar? the romances of your ancestors. you built graves foryour deadrelatives around golkonda. why? what way are they usefulto people? why is peoples money spenton these with whose permission? we never questioned you before. l'm compelled to open my mouthnow because l'm challenged..

when you can build palacesas a token to affairs and... ... can build graves inmemory of dead relatives,... ... what is wrong in buildinga temple for our rama? our lord rama was anobedient son. he was a one woman man. he was an example for brotherhood. he was a just ruler.an emperor. not just in bhadrachalam butevery village in lndia will have his temple. please understand.stop listening to lies.

come to bhadrachalam.visit the temple and be blessed. keep alive the harmony betweenthe hindus and the muslims. shut up. stop the nonsense. how dare you question meinstead of accepting your mistake? lmprison this arrogant man. torture him severely. mother, l heard that father isimprisoned and being tortured. i don't forget yourname even in my dream why don't you answer to our pieas?

you have saved even thesquirreis before i beiieved in your kindnesstowards your devotees throw chilli powder. you are known for your kindness, piease be kind to usbhadrachaia rama what is the opinion ofthese prisoners, of me? one female inmate said...-what?-you will hit me if l tell you. l won't hit you. tell me.that you... -what? you smell like a dead rat.

but your heart is like a perfume. a male inmate...- speak up. your singing ... - my singing...- sounds like howling of a fox. and you kept quiet! we hit him hard for calling youa fox when you are like an ox. you rogues... what are you doing?-what did you say? you hit us butdon't abuse me in urdu. okay, l won't.press my arms.

pancakes - say it right.- shut up. l made these as you orderedwith more of salt than flour. afteryou eat these you will go... they are not for me butfor ramdasu. he should cry after eatingthese pancakes and we should laugh. you will.- let us go. some noise is coming from inside. after eating these hewill become quiet. drop it down. o rama, your name isso sweet to chant,

it is sweeter than fruitsbanana and dates sweeter than the sweet rice,and fresh butter stop it. stop it l say. has he become docile now?agreed to say sorry to me? why don't you talk?what is he saying? should we sing and show you?- sing. god, your name is very sweet. shut up. what is happening? l don't know what you do buthe must say sorry to me.

okay o king.l'll make him say sorry. l'll break your bones. are you mattesaab?- no, why? you looked like him. are you matte?-no. - then who is he? hey, who are you? - how can you beso rude to new inmates? forget it and tell us what crimehave you committed to come here. l brought her out andwiped her dry. l'll kill you. how can yoube punished for saying a life? you... -what will you doif you find mattesab?

l'll thrash him like we washclothes. - then? - dry him. here is the knife andhe is mattesab. do it. mattesab is a nice man.his 3rd wife is a nice lady too. me too. gopanna you knew thatwhoever marries kamala is destined to go to prison. yet you dared to marry her.you don't deserve this. he dared many hardshipsto build rama temple. piease taik at ieast now, who eise can save meother than you?

it costed me 10,000 goid coins, i got a brooch made for lakshmanwhich costed another 10,000 or your father-in-iaw king janaka whose grandfather's propertydo you think it is, to,,, ,,, enjoy this grandeur? her husband is in jail and she isenjoying 3 meals a day and sleep! they claim they are devotees. she crosses river godavarito offer prayers daily. who knows what she does?

you add to others suffering? l'll peel off your skinif l get angry. she only screamed at you.but you know what l do. get inside. you look better behind barsthan in the government office. shut up.- oh, ex-revenue officer's wife! l beg of you to let memeet my husband once. to see the mam who made the mistakeof building tbe temple? go see husband... you may leave now.

this is unfair. you knowhim well. get him released. we have 2 kings. one is tanisha,who rules the kingdom. we are worthless in front of them. l cannot take it anymore. l'll go to the king andqueen to beg foryour life. mother sita,teii him to save me, o gem of a woman,teii him to save me, daughter of king janak,teii him to save me, lord of bhadragiri, who ispraised by goddess parvati,,,

,,, when wakes up from sieep,piease teii him to save me o mother sita,,, sita, there were no tears when youwere asked to enterthe fire in lanka. nor, when you were sent off to thejungle when you were pregnant. then why are there tearsin your eyes now? everyone says you protectthose who seek protection. then why are you takingso long to save ramadasu. o allah you are gracious. who are you? - my name is ramoji.- l'm lakshmoji.

how did you come in? you uttered allah (god)here we are. what!! who are you? we are servants of ramadasuwhom you have imprisoned. a man who swallowed governmentmoney has servants too! great! he has not swallowed it buthas built a temple with it. lakshmoji, l told youto control anger. he is...- enough. tell me why are you here? we came to release him.

there are 6,00,000 coins.count them and issue us a receipt. wife... look there!- o god! hundreds of guards are on duty.closed doors are intact. l wonder how theyentered and gone out! l cannot say it'sa dream because here are the bags ofmoney they gave. these are not just gold coinsbut are rama madas (ancient medals) 100 times more valuablethan our coins. yes. these were the currencyused during sri rama's rule.

god, l don't knowwhetherto believe it or not!! hey, ram, my god... one cannot understandthe acts of sriram easily. they came dazzling inthe midnight. who do you think that ramoji andlakshmoji who gave you the gold? they, in fact, are ramaand lakshman of lla dynasty. they appeared to us!!we are so fortunate!! ln deed, you are.but sinners are some others. ltching...scratch mescratch me...

what is happening? they defamed a great devoteebecause of arrogance and authority. now, they are paying for it. pray to ram and youwill be alright. hail sri ram ltching is gone. my burning feeling is gone too. our ramdasu is going to bereleased soon. yes. but...- but... what?

actual story is going tobegin from here. but we won't be here to witness it. we have to go to the placewhere we are supposed to be. ramadasji, we have committeda mistake by troubling a great devotee like you. our eyes are opened by theappearance of rama. please forgive us and acceptthese gifts, lands and.. ... the post of revenue officer. let us carry you personally,in this palanquin to bhadrachalam.

let us recompenseforthe sins we committed. you are not sinners. you areblessed ones as you could see rama. l'm the sinner.that's why l couldn't see him. l don't want your services,gifts and lands. l'm sorry. he is begging you to accept them.don't refuse, dear. the god appeared to him and provedthey both are of equal status. l'm only his devotee.aworthless man. we are there foryou.please obey us. stay in our house at leasttill the wounds heal. come.

you can see only myphysical injuries. my heart is broken for notbeing able to see rama. how will it heal? they heal only with my death. mother sita chose to bury herselfwhen separated from rama. that will be my fate toolf l cannot see rama. l must know today itself whetherrama blesses me with his appearance. is beiieving in you,buiiding your tempie,,,, or writing your name a crore times,are my crimes?

why are you not kind to me?why have you not appeared to me? kamala, look at shabari. she first tastes fruitsthen offers them to rama. have i asked you foryour kingdom in my name? but you won't come,why don't you be kind to me? kamala, he blessed all thesquirrels just for dropping sand. but l built a temple.why is he neglecting me? o son of raghuvansh,who eiiminated the demons, piease be kind husband, what are you doing!

rama is not coming to meno matter how much l beg. so, l'll go to him instead. now l understood where he is. yes, look there. during rama's coronation,sita gave hanuman a pearls necklace. he bit in to them to see if ramais in them. he threw it away when hedidn't find rama in them. sita got angry. asked him toprove if rama is in his heart. hanuman tore open his heartand showed her rama in it.

lsn't it?-yes. what does it mean?lt means lord rama resides... that means...my lord is .. in my heart! yes. he himself named you ramdas. where else can he be otherthanin his devotees hearts? husband... no... let me go... let me cut openmy heart to see if he is there. leave me.- husband .. have you come along withthe mother of universe to see me!!

he has come here on the day you decidedto build the temple to witness it. really, o my lord... yes, l'm yours.you built a temple for me. provided daily prayers for us. even hanuman praised you foryour unmatched devotion. look there. for eternity, countless numberof devotees, sages had yearned for and done penance... ... to attain salvation and toget to heaven.

l'll send you both there alive. what is salvation, o lord? everlasting joy. what is there?- nothing but pure joy. you mean, worship you, pray andsinging your praises... .. reading your holy story etc.can be done there. no, no such things exist there. there is no needfor all that there. one gets there for doingall that here, on earth.

what sort of a world is that!!happiness means, chanting your name. happiness means,singing in praise of you,... happiness is serving you. and writing your namemillions of times. without all these, how can thatbe a happy world? forgive me. l don't want it. let our souls remainin bhadrachalam. let us witness the devoteeswho come to see you. we preferthis than salvation.

you are the first people in the histroy ofdevotees who turned down salvation. you are great. l will make this place aplace for salvation (moksha) as a proof of that, here,l'll be known as moksharama and... vaikuntarama' sincel dwell in your soul (aatma) l'll also be called aatmarama. may this bhadrachalabecome a great holy place. may all those who visitthis place attain salvation. hail sriram.

drugs were potent respiratory infections

if you loved the lastone, and i know you did, you'll really love this one too. i don't hold back anything. i'm always talkingabout receptors. i'm always talking aboutmechanisms of action. again, to explain why,to help you remember why, some of these things. vasopressors and inotropes,these are some things that you have access to.

i want give you why is onedrug preferred over another. not because somebodytold you so, but to tell you,physiologically speaking, why. granted, it's probably goingto match your protocol. so what. and now you know why. and if you ever had todeviate from protocol, granted you'd getwhipped and yelled at, maybe you would atleast hypothesize

why you would need to deviate. or maybe i need to call for medcontrol and ask for something. objective-- compared andcontrast some of these things. obviously, volume status inyour critically ill patients. kind of talk aboutwhat physiologically is going on when someoneis actually in shock. there's a coupledifferent shocks. they're hypotensive. that's what you know.

why are they hypotensive? there's different reasons tobe hypotensive and in shock. list some of these bloodpressure or cardiac output things. talk about lactic acid andsome of the other things that we would be lookingfor in the hospital. and i'm giving it toyou and you're like, but we don't do any of this. i know.

what happens if you pick apatient up and transfer him to another hospital? then you may have someof this at your disposal. i'm not saying you'redoing anything with it, but it's there. i want you to knowwhy is it there. what else can youpossibly be doing, right? just taking an intense personfrom one place to another, right?

if i'm wrong, i canjust shut up now. and don't tell me i'm wrongbecause you want me to shut up. i'm wiley. also describe the catecholaminevasopressors and inotopres. what makes themsomewhat different. and what are someclinical endpoints you need to look forwhen these are running. pretty much what that isall saying, what is shock? i'm shocked.

no i'm not. because if i wasshocked it would be a life-threateningcondition that occurs when the body is notgetting enough blood flow. so, there's manythings that can cause not getting enough blood flow. can lead to, obviouslyif left unchecked can lead to yourorgans not doing well. because they're notgetting enough blood flow.

as blood is going to beshunted, and blood is always shunted to your brain. you can live without kidneys,your body knows this. your brain, not so much. so everything always tendsto shunt to the brain. brain, heart, but you know, youdon't do well without liver, all these other things. shock requiresimmediate medical help. types of shock.

hypovolemic. that's a big word. what does that mean? yeah. low volume-- hypovolemic. low volume. they either lost blood,paid for college by plasma, i don't know. they lost blood.

cardiogenic shock. it generates from the heart. the heart is the problem. so you're not gettingenough blood flow because the pump's broken. if your sump pump is broken,your basement is flooded. kind of same thing with this. we'll talk about it. distributive shockand obstructive shock.

obstructive shock couldbe a massive clot. or, if we have a massiveclot in our lung area, we like to call it a pe. you don't tend to livelong with a massive pe. so these things areobviously of major-- so what will affectblood pressure? this is not rocket science. i am not telling you anythingthat is not painfully obvious. if your pump is notworking, as we talked about,

your sump pump is notworking, you've got a backup. your blood flow is not goingif your heart is not working. you've get an mi, somearrhythmia, acute heart failure, some valvular disease. heart's not working well. hypovolemia. hemorrhage. intractable diarrhea. you always forget about that.

you think there's no waythey'd poop themselves-- you can lose a lotof volume in stool. funny, it's funny, wealways talked about poop from when we were little. we'll still laugh alittle bit about it. not so funny when you poopout four liters or more. you can lose a lot ofwater, and a lot of salt. heat stroke, same thing. lay out in the sun, do alot of work in the sun,

technically couldbe going into shock. we kind of forgetabout those things. like yes, ok, we know aboutthem, we pick these people up. it can be verydangerous as well. decreased cardiacoutput and vasodilation. this happens in sepsis, orsometimes is drugs induced. anaphylactic shockis the same thing. and neurotrauma. if you actually wind up shockingor damaging your spinal cord,

you will becomehypotensive enough because the nervessupplying the vessels stop and those vessels open up,and they become hypotensive. and for a shortperiod of time, you need to give them apressor to get those back. they'll bounce back eventually. but if you don'trecognize it, the person can actually die on you. now you go from a neck injuryyou can go into a shock,

because the vasculaturewill open up. because they're notgetting that neurotone. everything that leadssomeone to death is always a vicious cycle. to get this viciouscycle, whatever it is, you're not supplyingenough blood. so you have inadequateblood flow to the organs, your tissues become hypoxic. we're a dual-fuel system, soif you don't get enough oxygen,

what's it going to do? you're going to switchto anaerobic metabolism. anaerobic metabolismmakes lactic acid. in a short period of time, whenyou're running really hard, that's ok. you can stop and you startbreathing and it's good. but when you can't, and youkeep building up lactic acid, it becomes a problem. then you get ametabolic acidosis,

which causes cardiacdepression, which then causes inadequate bloodflow to the tissue. which then causes more,and more, and more, and you can spiralyourself right out. so you've got tobreak this somehow, in any of these places,stop that cycle. so how can we break this cycle? where is the system broken? try to figure out, hey,they are low blood pressure.

where's the system broken? where can i intervene? trying to figure out whereis it initiating from is of great help. it's very hard to do,especially in the field. but it's something thatwe're all trying to do. do i need a vasopressor? maybe. maybe not.

what happens if iadd a vasopressor and it's really the heart? am i helping the heart out? i'm adding stress to the heart. oh, well, the heartwas actually sick. we'll talk aboutthat in a little bit. how much of avasopressor is too much? when i start making theheart sick and sicker. let's say the heartwasn't the sick part,

but i can make the heartsick with my vasopressors. sorry, this is moreof a joke, if anybody knows the movie, sure thing. unfortunately it's fromthe '80s, and i'm old. anyway. who made liquid soap and why? we're going talkabout monitoring. and we'll go quicklythrough the monitoring. this is a lecture i give tomany people, so i apologize.

some of this monitoring stuffmay not always apply to you. but it will apply ifyou pick patients up from one icu to another. so we'll talk about andanswer five of the six. i don't know who madeliquid soap and why. they probably madea lot of money. hemodynamic and oxygentransfer monitoring. blood pressure isthe gold standard. mean arterial pressure iswhat we're really looking for,

is more of a mean than systolic. you want to knowwhat that average is. that's what your mean gives you. what is the heart rate? if i can figureout cardiac output. to get cardiac output, ineed an invasive line placed. i can't get cardiac outputin the emergency department either. so i'm in the same boat you are.

i can't get that. i can just kind of go by myother signs and symptoms. well, i don't think theirheart's working too good. you look at how they'reoxygenating, stuff like that. cardiac index is actuallyyour cardiac output. and i'll talk about all these. over body service area, strokevolume is how much squeeze, how much volume is being ejectedwhen their heart is beating. central venous pressure.

that is how much pressureis in your venous system. when we look atyour blood pressure, that's how much pressureis in your arteries. as your blood goes from yourarteries to the capillaries, the capillaries arelarge, very spacious. you lose a lot of pressure. when we talk aboutlike 120 over 80 is what we look forin a blood pressure. on the venous side,we're looking like 10.

that's how muchpressure you lose as it goes intoyour venous side. and 10 is actuallya great number. you're topped off. you're looking good. you've got enoughvolume onboard. you can also look atsystemic vascular resistance. if i take your bloodpressure right now, let's say it's a gardenhose, and you're doing fine.

and the spigot is turned on andi'm able to knock that knob off so i can't turn it up anymore. you've got great pressurewith the garden hose. i'm able to takeoff the garden hose and now i put on the fire hose. it was a great stream before. how is that streaming out now? and that's whatyour svr gives you. systemic vascular resistance.

you didn't lose any volume. the vasculature just went ughh. this is what you see in sepsis. the heart's fine,the pump's working. the volume didn't go anywhere. i just put on some fire hoses. pulmonary, thisa wedge pressure. a very, very specialcatheter gets this one. we almost neversee this anymore.

but it is of great value. pulmonary artery pressurewould get on an echo. when you're looking atoxygen purposes, when you look at someone'spulse ox, you're looking at theirarterial oxygenation saturation, your sao2. that's what you'relooking at in a pulse ox. you like to see that 100%. somewhere in the 90sis fine by me too.

but you're looking at 80s-- ifthey have copd it may be ok. i'm not necessarily happy. you get a mixed venous, thatbecomes a lot more complicated. some of these otheroxygenation stuff. you can actually get to apoint where you can find out how much oxygen you aredelivering to the end cells. which actually gets to thatwhole vicious cycle thing, when we're talkingabout we didn't deliver enough oxygen, which causes itto switch to a different fuel

system. lab values. cbc tells you how muchblood somebody has. electrolytes can kindof point to how well the heart's working. metabolic panel, bloodgas, lactate level as well. your mean arterial pressureis very good for us to know. and your mean arterial pressuretechnically can be calculated. i know machines give it toyou, but it can be calculated.

your heart is activelybeating a third of the time. so you take your systolicblood pressure times one third. and guess what? it's not beating2/3 of the time. voodoo math there dude. i know it's hard. but if it's a third of the timeit's beating, 2/3 of the time it's not. so you get a diastolicpressure, when it's not beating,

times 2/3's. that will give you yourmean arterial pressure. that's how you calculate it. why is the meanarterial pressure more so when you'reevaluating this? it's because the arterialpressure is an endpoint. you want to get that averagepressure up high enough that you're delivering enoughoxygen to all the end cells. so if you're looking atit systolically speaking,

let's say you've got 120 over 2. my mean pressure stinks. not really deliveringenough oxygen. and if you're in bypass surgery,they'll put you on a pump. let's say they put you on pump,your pressure is 50 over 50. it's a constant pump. it's not like a heart beating. so it's really focusingon what we're looking for. we need restorationof adequate perfusion,

is really whatyou're looking for . coronaries, also your brain. map's less than 50, you'renot getting enough delivery. svr is your systemvascular resistance. you're going to seethis more in sepsis. don't worry aboutcalculating for central cvp. we talked about it already. skip that. what will affect your cvp?

blood volume. what else? also if you're in some sortof right heart failure. will this make sense to you? if my pump is broken, will isee the backup before the pump or after the pump? before the pump. so if my right heart is failingme, say i had my rca occluded and i blew out theright side of my heart

and my right heartis failing me now, where will i see the backup? in the body, the vasculature. so this should make some sense,if my central venous pressure, which normally is low, isstarting to get pretty high, there's a chance that yourright heart is failing. eventually right heart failurewill lead to all heart failure. the left side as well. heart rate we know.

cardiac output issimply calculated if you know stroke volume. you know how muchvolume is being ejected, you take that timesyour heart rate. that gives you cardiac output. that is an ok determinanton how your heart is doing, but it's not the best. the best determinantis cardiac index. why?

cardiac index is basedon body surface area. [inaudible] exactly. it's geared towardshow much mileage that heart has to beat against. you take a very, very smallperson with that same output, it doesn't have to travelover all that mileage. you take someone verytall, very large, that's a lot ofvasculature mileage

you need to pump against. same thing as with hoses. if i link as manyhoses as i can, will that pressure beas good as if i only had a really short hose? no. the really short hose is reallyfiring out from the source. so intuitively itshould make some sense. so when i'm looking at-- grantedthese numbers you can't get

in the field, i can't getin the emergency department. but if i've gotsomeone in an icu the probably havethis hooked up. they probably have animmediate monitor, a catheter, that's giving themcardiac index. it's giving themcardiac output as well. but what you really wantto look at it not output. you want to look at index. we don't get these anymore.

wedge pressure is veryimportant as well. it tells you howmuch backup you get. and what it is doing,i will tell you. you get it from aswan-ganz catheter, not that you need to know that. swan-ganz catheter,what they would do is they would put thecatheter in the right atria, put it in the rightventricle, blow up a balloon and have it float intothe pulmonary artery.

pretty dangerous. yes it is. that's why we don't doit too much anymore. because if you blow outany of those things, you're probablyhurting your heart as in permanently hurtingyour heart and not living. but what that willtell you is how much pressure is in your lungs. if the left side, which isthe biggest side of my heart,

is failing me, where'smy backup going to be? in the lungs. i'm going to have a lot oflung backup or pressure. this swan-ganz catheter wouldtell me that kind of pressure. it will also tell you how muchvolume the person has on board. your cvp is lessinvasive, and it will tell you thevolume as well. but we used to use the swan-ganzcatheter with this wedge pressure to find out how goodthe left heart was working

and see how much volumesomebody had on board. oxygen delivery. we will blow past this. lactic acid wealready talked about. if you've got someonewho is hypotensive, and it could be shock,what would you look for? well, primary labs youdon't necessary worry about. what do you worry aboutfor a patient history? what do you want to know?

what meds they're on? have they been eating? have they been pooping a lot? has the poop been diarrhea? has it been blood? these are things thathelp you and help us when the he gets there. you guys tell us thisstuff all the time when you're dropping people off.

he pooped a lot ofblood, because i have to hose out the rig ican tell you that right now. you're telling us this. so he could be hypovolemic. could be septic. they're feverish, they're hot. you've got to know ifsomeone has got somewhat of an infection. they were in the hospitaland had some kind of surgery.

and now that side isoozing with some pus. it doesn't takerocket science to go, there could be an infectionthere causing the hypotension. so some of these thingsare just painfully obvious as a possible source. things to think about. cardiogenic is harder to see,unless they have a known chf. cardiogenic shock and chf arefairly similar, fairly close. cardiogenic shock tends tobe, you weren't expecting it.

somehow the heart took ashot, took an unexpected turn. chf tends to gradually come on. they didn't take enough lasix. they're already ontreatments more than likely. obstructive causes. trauma, that's obvious. gi bleed tends to be obvious. intractable diarrheatends to be obvious. delivery or miscarriage,all these things

are going to be obvious. you will know these uponpicking the person up. get them some fluids on board. cardiogenic causes. mi, that's obvious. like boy, i did an ekgand it's tombstones. if the pharmacist can recognizeit's an mi, you guys can too. trust me. an arrhythmia, youcan recognize that.

acute heart failure,taught to recognize. if it's an unknownheart failure, it is tough to recognize. so then you're looking atsome of those other things and weeding out. well, they're notbleeding to death. it's a guy. he didn't have a miscarriage. you go through allthe other things.

valvular disease. you listen to theheart and it seems like one is really loudor regurging really well. if you can hear itwithout the stethoscope, that's probably the problem. if you hear the swish,swish of the heart without the stethoscope,that's a six out of six murmur if you'relooking at the grading. that's where itdoesn't take much.

that means their valveis pretty much shot. sepsis. bacterial, fungal, or viraltends to be the cause. things you need to look for. very quick facts--and again an aside. brought you through all thatterrible stuff that you rarely look at to get you to some ofthe stuff that you do look at. your best vasopressorin the world within normal limits-- fluids.

if blood pressure is low,the best thing you can do is give them some fluids. as long as they don't have chf. even if you give someone500, even with chf, that ain't gonna domuch of anything. they'd have to be sobrittle of a chf person that you-- to put theminto full failure, they'd be living in thehospital on iv drugs. trust mt.

so you're not going tohurt anybody with 500. maybe not even a liter. whatever your protocols are. your best pressor in thewhole world is always fluids. always. catecholamine receptoris less responsive when the patient is acidotic. that's a physiological fact. so let's say you have tostart somebody on a pressor

and you know they're acidotic. it may not work real well. let's say someone is coding. let's say you come upon somebodywho has already been coding and somebody is doing cpr. and you give them some epi. and it doesn'tnecessarily work right. they're probably acidotic. even though somebody is doingcpr, and it's great cpr,

it's not as good as theheart is ever going to be. they're gradually gettingmore and more acidotic. you give somebodya milligram of epi, the body will respond atless than a milligram. i can't tell you howmuch less, but it's less than what itwould normally be. so maybe the next epi may work. i'm just letting you knowsome of these things. if something goesdown in front of you.

like they were fineand all of a sudden they go down in front ofyou, that epi may work. because they're notmaybe as acidotic. so some of thesephysiological facts may help you toknow maybe i need to work this a little longer. maybe i need to keepdoing the things i'm doing to get tothat same endpoint. may need ludicrous amounts ofcatecholamine vasopressors.

when i'm talking to some of mypharmacy students and i'm like, ok, let's say i want to startsomebody on an epi drip. they'll want tostart them at two. normally i would like two. but if they'rereally acidotic, no. i don't want to startthem at two mics a minute. i want to start them atfour, eight, something. or titrate it quickly,knowing that their body is not going to see the same amount.

so it helps you to know,i need to move faster with these drips, then slower. because the personis probably acidotic. so some of these arejust tricks of the trade. just things to knowphysiologically. once you know that, you canget somebody better, faster. what you have learnedabout heart failure really will apply in thiscardiogenic shock stuff. it just applies.

what i ask myself when i'vegot somebody who's hypotensive, my first questionis, is the heart ok? is it a pump issue? that's always my first question. because the otherstuff is obvious. you're seeing blood fall out ofsomebody, yeah that's obvious. i know it's hypovolemic shock. i don't even have toask is it a pump issue? because that's something that'sgoing to kill them right away.

is it an arrhythmia, isit somewhat like that? is the heart ok? heart seems like it's ok. all right. then i'm looking hey,is the piping ok? is my vasculature ok? and is it a supply issue? supply issue is always the lastfor me because it's obvious. they've had a miscarriage,they've had something.

it's so obvious, it seems. not always. the gi bleed that bled outwell before you got there and he cleaned himself up. he bled out so much that hedoesn't have much more to give. we start giving himfluids, all of a sudden he starts going again. oh! that's why he's hypotensive.

i thought it was something else. it wasn't obvious. have i seen that? yes. it wasn't obvious until youget the fluids back in him. let's talk about some ofthese drugs that you can use. yay. dobutamine. you don't have access toit immediately on a rig,

i'm assuming. but you can pick somebodyup who's on dobutamine. dobutamine affectscatecholamine receptors, so obviously it isaffected by acidosis. all it does is helpthe heart squeeze. dobutamine justaffects the beta. going through all this. all it will do is have theheart beat faster and stronger. that's all it does.

that's great. right? downside is canproduce hypotension. whoops. you know i don'twant hypotension. right. so you normally are notgoing to dobutamine itself. rare case would chf. what happens is you'vegot stretch receptors

on the aortic arch. once they feel that pressurethat activates them, they relax their vasculature. if you've got chf, they'realready stretched out. you can give a chfpatient dobutamine. they won't respond like that. they're already stretched out. you see chf patients gettingdobutamine boluses, maybe even at home.

it can happen. dopamine. dopamine's effectis three stage. it depends on your rate. going back to dobutamine. you can still usedobutamine as long as you take into accounttheir hypotension. so if you put onanother vasopressor that's going to blockthat hypotension.

put on norepi, put on dopamine. when do you wantincreased contractility? when do you want theheart to beat better. when in those shocks doyou want it to beat better? which granted, you mightnot necessarily 100% know. but we may finallyfigure it out. i've actually done this. i don't have thesemonitors to find out if they're in cardiogenic shock.

but i"m watching their pulseox get better when i give them a slight bolus of epi. hey, the pulse ox will getbetter, then it falls off. the pulse ox will getbetter, then it falls off. because i'm helping theheart beat a little better, then it falls off. i'm like, i thinkit's cardiogenic. should give some dobutamine. doesn't work all the time,but when you can see it.

dopamine has an effectthat's based on your rate. do you guys haveaccess to dopamine? you know the variousrates that it's at will give you different effects. so at low dose weused to call it renal. we don't do this anymore. it in theory would helpthe kidneys be supplied. it doesn't. in practice it doesn't work.

so anybody that says they'redoing renal dose dopamine, they're wrong. intermediate rates, 2 to10, it stimulates the beta. which just means heart. so you get increasedcontractility, cardiac output, your heart's beating better. and you also get betterperfusion all around in your heart. so between 2 and10, you're really

looking at kickingthe heart better. you don't reallyget that hypotension like you do with the dobutamine. that's why dopamine isa little bit better when you're looking atjust cardiogenic. you can go anywherebetween 2 and 10 and get that almostsame response you get from dobutamine. almost the same response.

not fully. at high rates, nowyou're clamping. any time you see alpha, thatis vasculature clamp down, or causinghypertension, or trying to increase someone'sblood pressure. so you get lessof that beta, you get more vasculature squeeze. so you get less heart kick,more vascular squeeze. let's say i don't havecardiogenic shock,

let's say i've justgot septic shock. so the vasculature is big. instead of garden hose,i've got the fire hose. higher dose dopamine. don't start at two. don't start at ten. if you know it'snot cardiogenic. if it's sepsis, start at ten. very high rates,then you're really

actually decreasingrenal blood flow. that's all you're doing. epinephrine. we all know epi, epi boluses. anybody know how we came up witha milligram for code purposes? how we cam up with a milligram? anybody? it's the dose that theywould use to restart a heart, on average, when they didopen heart surgeries back

in '60s, '70s, whenever it was. so kind of like a dose onaverage that would help kick start a heartthat they had stopped. so that's how we cameup with a milligram. is it really sciencethat it's a milligram? it might even be weight-based. who knows. we haven't reallyfound their science. because it's tough to do adrug study on people dying.

it's tough to getthe volunteers, know where the volunteers are. and you definitely can'tget college students to sign up fornear-death experiences. they find that bad. any time you see alpha,think of vasculature squeeze. any time you see beta,think of heart squeeze. this squeezes both. alpha, so you getvasculature squeeze,

and you get the heart to kick. epi is great for gettingthe heart to kick good, and also to get thevasculature to squeeze. downside is, if you'vegot a sick heart, yay, i got that to squeeze better. wait, i'm workingagainst this resistance. you can actually makea sick heart sicker. because yes, you gotit to beat harder against a lot more pressure.

it's like taking yourwater pump that's not quite good in yourcar and flooring it. it always works better. your pump is probablypumping faster. until it dies, becauseit's probably going to. because it wasalready weak to start. you mechanics outthere, i'm trying to give you a visualization. so epi is good when you lookat getting the heart to work.

but think about theeffects afterwards. you will make asick heart sicker. so as long as they don'thave a cardiogenic issue, epi is not poor. cardiogenic issue, you'regoing to make it worse. you'll notice it. they look better, thenthey tail off quick. start thinking maybethe heart is sick. maybe i need mydopamine at 2 to 10.

norepi is epi-like. its alpha and beta givesyou that vascular squeeze. uses that beta, but alittle less tachycardia. so a little lesssqueeze on the heart. but same thing you getwith epi, you pretty much get with norepi. you don't have thataccess to you in the rig, but you'retransporting patients. sepsis protocols, norepiis the drug of choice.

phenylephrine is another drugyou don't have on the rig, but you may be transporting. all it does is affectthe alpha essentially. it doesn't do anythingat all to the heart. so you just getvasculature squeeze. you can increasesomeone's blood pressure. it doesn't do anythingto the heart at all. if they don't havea sick heart, fine. they've got a sick heart, youmade it sicker really fast.

because it doesn't doanything for the heart at all. you just stressed the heart out. follow? everyone's with me? boring as heck, right? staying awake? wish i had my amphetaminesto spread now. vasopressin. you have vasopressinavailable for you, right?

vasopressin does not affect thecatecholamine receptor at all when it's working. so is it affectedby acidosis at all? the answer is no, ifyou wish to look ahead. remember i said yourcatecholamine receptor is less responsive when you're acidotic. your vasopressin is not. so say you come acrosssomebody who has been down, someone's doing cpr.

you don't know howlong they've been down. v-fib, v-tach, whatever. you shock them, certainly. they're still in it. your assumption, because youdon't know how long they've been down, could bethat they're acidotic. your protocol saysreach for epi. maybe reach for vasopressin. because it will work thesame potency no matter what.

downside is, ifit's a sick heart, you've caused a lot ofvasculature resistance, a lot of stress on that heart. and you haven't helpedthe heart at all. that's the give and take. works no matter what. acidotic, nonacidotic,doesn't matter. but if there was aheart issue-- you don't know if there'sa heart issue.

obviously you thinkit's a heart issue because the heart'snot working well. but you don't haveto worry about, hey, they're not gettingthe full thing. so trying to give you some hintswhen you're out in the field doing what you're doing. there's all that alpha, betastuff that i talked about. you kind of link the drugsto where they are affecting. that's for your ownbenefit when you go home.

a loose diagram ofwhat the drug's alpha was affecting the beta inthat visual graphics look. so you're going to link itup to where is it working. because you're going toclamp down on any of these. you're clampingdown on something. you're even clamping downon gut and stuff like that. until you clamp downso hard, so long-- we have some patients in theicu, we start to worry about, are we starving thegut of blood supply

because we've beenclamping down so long. it can cause moredamage with this stuff. yes, their body is alive. but eventually we're going tokill off something possibly if we overstretch stuff. cardiogenic shock treatment. we need to increase theircardiac output, aka index. possibly increase ordecrease there resistance. if they've got asick heart, i've

got to worry about howmuch resistance they have. goal is, i want thecardiac index about 2.2. granted you don't havethat index marker. i don't have thatindex marker, either. but you can see that they'redelivering oxygen better. you can just see that. and a cvp of 10 and awedge pressure of 15. same thing like chf. cardiogenic shock is like chf.

luckily there was somebodyback in the-- well i don't know when this was. forrester's hemodynamicclassification, kind of did with chf. they don't necessarily teachchf much like this anymore. but if you know what theircardiac index is and you know what theirwedge pressure is, and you take thispoint right here and you put it onwhere they are.

and you want them lessthan 15 and above 2.2, follow the arrows. a cave man can do this. it's not rocket science. it's look at a graph. some people don'tlook at the graph and they wind upguessing and spit-balling and stuff like this. there's science outthere, and why not use it?

so if you've got somebodywho is not beating well. it's almost like heart failure. heart failurewould be over here. fluid loaded and heartnot working well. get their heart to work better. you can use dopamine,whatever, to get the heart working better. and you give them diuretics. you get them over here.

what about in the field? you've got someonewho has bad chf? where do you start? you start nitro? nitro moves you this way too. where you want to be. that's why you start nitro. you're decreasing thatresistance on that heart and having the heartwork a little bit better.

supplying blood to the kidneysso they can actually pee. that's why you're doing nitro. i can show you a graphwhy you're doing nitro. do the nitro to havethe heart beat better. before you do, if anybodyhas a diuretic that they're able to give, do not give thediuretic until the nitro's been on for like 10minutes or so, please. have the heart beat betterand supply the kidneys before you actuallygive a diuretic.

or else the diuretic is notactually getting to the kidneys like you want it to. have the kidney supply be betterbefore you give the diuretic. there are some units outthere that have diuretics. start the nitro, let thatrun for a little bit, then do a diuretic. ideally. there are ways that wecan actually dose stuff once we know someof these numbers.

that's why i'm tellingyou some of these things. any questions oncardiogenic shock stuff? realize if you stress theheart with the resistance, you're going to makethe heart sicker. but you need them also tohave a good blood pressure. i don't have a goodanswer for you. you give them a lot offluids, that's not necessarily your friend either. start with dopamine.

start with some otherstuff like that. dobutamine soundsgood, but you've got to cover for thatreflex hypotension. septic shock. there's other guidelinesout there as well. don't have to eventhink about this stuff. make sure theyhave enough volume. i'm really over-explaining this. i'm making it where a doctorwill punch me in the face

that it's too simplified. but it is mostly true. if i take a dirty, disgustingnail and scratch your hand, it gets inflamed right? what? and your white blood cellsneed to come out and fight it, so it gets inflamed to limit,to try to enclose that exposure, and to get thewhite cells there. now let's say i put dirtyand disgusting stuff

in your vessels. what does that do? same thing. they expand out. that's really what's goingon with septic shock. heart's fine, the volume's fine. vasculature justgot really huge. ok. well how can you fix that?

best fix in the whole world--fluids, fluids, fluids, fluids, and fluids. until their cvp-- granted youdon't have that monitored. i don't necessarilyhave that monitored until the doc puts it in. until their cvpis about like 10. is somewhere between 8 and 10. but it's going to be a while. it would be a coupleliters in before they

may come close to that. unless of coursethey've got chf. you've got somebodywho's history is like, they hadan infection, they have hypotension, you can geta couple liters in probably, to get their fluid up. because the gardenhose that was good, now they've got the fire hose. the reason why?

the bacteria is in there. your body is doingwhat it should do. it just happens to be, oh yes,we also need blood pressure. oh darn. that vicious cyclething we need to. break make sense, what'sgoing on with septic shock? cvp less than eight, yougive a lot of fluids. we look for meanarterial pressure of 65. anything less than 50, you'renot supplying enough blood.

65 is really your best bet. if their heart rateis greater than 100, which most of the time itis, if you've got somebody with low blood pressureand their heart rate is not greater than 100,they might have a drug onboard causingthat, like a beta blocker. more than likely it is. so you would add norepi. norepi is your drugof choice for sepsis.

so if you're picking upsomebody who is septic and they're not on norepi, andthey're somewhat tachycardic, i'd be suspicious whythey're still on norepi. not that you need toask for something else. hopefully you're justtransporting from one place to another. we realize that person isnot on probably the best pressor they should be on. there might be a reasonthey're on that one.

but i'm just letting youknow it's not ideal for you. if the heart rateis less than 100, it could be because betablocker, something else, or just because. you could give them dopamine. and you're really looking forthe mean arterial pressure, like i said. when you get toa point where you get their blood pressurestabilized, and they're still--

you get a mixed venous,this gets very complicated. i'm telling you too much. now we're really to the pointwhere we're fine tuning. where the person isgoing to live, but boy, we could make themso much better. you can possibly add just alittle bit of the dobutamine to have the heart beat betterto actually get a better supply. it's like a recipe. you follow the recipe,the person's better.

sometimes people don'tfollow the recipe and then you have topick them up and maybe take them somewhere else. or whatever. just trying to let youknow what is normally the case that should occur. if you pick up somebodywho's in septic shock, there are things you shouldbe seeing unless there's some other comorbidity,some other reason why.

what do i want you totake away from this? you can give epi. you can give dopamine,all those things. realize the difference onthe dosing of the dopamine will cause different effects. a little more cardiac andthen a lot more vasculature. you can stress out the heart. clamping on the vasculatureis not helping the heart. epi does help theheart, but only

for a short period of time. you can actually overpower that. back in the day, sometimespeople would do high dose epi. the reason why itfell out of favor, and it really wasn'tin favor to begin with, is yes you can getsomebody back because you overpower that acidosis. you could see thereason why they wanted to use high dose epi.

the person's been acidotic. i want to give them moreepi to equal a milligram. they don't know howmuch more to give them, but they give them more. but it causes somuch resistance, you're going to causesomeone's heart to fail. so that's why youreally shouldn't do it. as long as youunderstand [inaudible] of why some people do it.

any other questions at all? that's stuff you already knew? trying to explain the why. granted yes, your med persontold you, because i said so. and maybe explained it. i'm trying to reallygive you the science why. so if you have togo off reservation, or are asked tocall, maybe you have an idea what you can ask for.

that's it. i don't have anything else. i've bored you enough.