Tag: Roger MacKenzie

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Anatomy Lesson: Mandy’s Malady

Welcome all anatomy students! It has been a while since I posted a lesson because, frankly, I have been dealing with my own malady – a shattered left ankle! Six months out and beginning to feel and function better. 🥳

Outlander fans recall that in episode Episode 702, “The Happiest Place on Earth,” Brianna gives birth to her second child, Amanda Hope Claire MacKenzie-Fraser. Dr. Claire is there to reassure Brianna and ease the process. The wee one is adored by all and affectionately nicknamed, Mandy.  Fraser’s Ridge is the happiest place on earth and all is well! 🥰

Young Mandy is quickly introduced to the Ridge’s denizens as Granda’ Jamie takes her on a wee stroll to meet a new foal at the stable. Do you see it, Mandy? It is a cutie-beauty like you! 😍 

Mandy’s doting Granny takes her on a guided tour of Claire’s fav room – the surgery! Mayhap she will follow in Granny’s footsteps? 👩🏻‍⚕️

Claire coos to Mandy, admiring the beautiful, wee lass. Then…. she sees Mandy’s fingernails. A closer look and a startled Claire exclaims: “Bloody hell!”  (Couldn’t have said it better myself)  

Ever observant Claire spies a bluish tinge at the base of Mandy’s wee fingernails (below, red arrows)!

Fun Fact: This is not hyperbole.  Fingernails and toenails give clues to at least a dozen possible medical conditions that require evaluation and followup. And, Mandy is no exception.

A quote from Diana’s 6th big book, “A Breath of Snow and Ashes,” documents the moment Claire observes Mandy’s nail beds: ”

“The minute nails were faintly tinged with blue.” 

Bree senses Claire’s concern and asks what is wrong.  She kens that look on her mother’s face. After Claire explains, Bree reports her own maternal observations: Mandy does not nurse well nor is she gaining weight like Jem. What is wrong? 😯

Claire determines that the wee lass has a heart defect requiring more advanced care than Claire is able to provide in the 1700s. She is clear that Mandy’s Malady is life-threatening and she likely will not survive for long without corrective cardiac surgery. Brianna and Roger decide to return with their children to the 20th century to obtain the necessary care to save Mandy’s life.

Arrangements are made for the MacKenzie family to travel through time at the standing stones on Ocracoke Island. Everyone agrees this is the best course of action, but this time and place is no longer the “happiest place on earth!” Will they ever see Fraser’s Ridge and one another again? 🤷🏻‍♀️

Time to start our lesson….What leads Claire to her startling diagnosis? The following are symptoms and clues that Doctor Claire considered:

    • Lethargy and weakness
    • Fast or labored breathing
    • Tachycardia (a heart rate exceeding the normal resting rate)
    • Cyanosis (blue-ish skin color due to a lack of oxygen), primarily seen in lower extremities
    • Dyspnea (shortness of breath)
    • Poor feeding
    • Failure to thrive
    • Distinctive murmur

Another pithy quote from “A Breath of Snow and Ashes:” 

I moved my stethoscope over the tiny chest, ear pressed to it, listening intently. It was my best stethoscope, a model from the nineteenth century called a Pinard—a bell with a flattened disc at one end, to which I pressed my ear. I had one carved of wood; this one was made of pewter; Brianna had sand-cast it for me.

The following image is a wooden Pinard stethoscope, currently for sale on the Internet for about $180 (there are much less expensive versions)! 💰

Claire placed her ear against the cup shaped disc at the top; the bottom of the tube was placed on Mandy’s chest. The stethoscope amplifies the sounds of blood rushing through the heart and striking its valves.  

What did Claire listen for? she was listening for a distinctive murmur: a soft, continuous shushing sound, particularly audible near the base of the neck. It is usually the first diagnostic sign of a problem with a fetal heart vessel.  

Although Mandy exhibits only some of the above symptoms, Claire diagnoses Mandy’s condition as a Patent Ductus Arteriosus (PDA).  

But, before we can understand PDA, let’s look at normal heart anatomy.

Heart Anatomy: To better understand Mandy’s Malady, let’s consider the normal anatomy of the heart and its great vessels. Now, I kid you not, the heart is a very complex organ, both anatomically (structure) and physiologically (function). We will only cover the basics. Understand that there are many more anatomical details that are beyond the scope of this lesson. But, we fearless folk press onward!

Chambers: The human heart has four chambers (next image). Right atrium and left atrium are thin-walled filling chambers. Right ventricle and left ventricle are thick-walled pumping chambers . The walls are composed of cardiac muscle, a specialized tissue found in the heart. (psst….don’t forget, the patient’s left is your right, and vice versa) 🤓 

Vessels: The heart has eight (!!!) vessels carrying blood to and from its chambers. These are (next image):

    • Superior vena cava – delivers blood from upper body into right atrium
    • Inferior vena cava – delivers blood from lower body into right atrium
    • Pulmonary artery – deliver blood from right ventricle to lungs
    • Four pulmonary veins – deliver blood from lungs to left atrium
    • Aorta – delivers blood from left ventricle to body 

Blood Flow: Next, let’s review the pattern of blood flow through the heart. As you read the details, check with the image below to verify the flow.

    • Deoxygenated blood (low oxygen – O2; high carbon dioxide -CO2) from  superior vena cava and inferior vena cava pours into right atrium and then into right ventricle.
    • Right ventricle contracts and ejects blood into the pulmonary artery which branches to supply left and right lungs. 
    • Blood releases carbon dioxide (CO2) in the lungs which is exhaled and picks up O2 from inhaled air.
    • Oxygenated blood (O2-rich) is carried to left atrium via four pulmonary veins. 
    • Blood pours into the left ventricle which contracts and ejects O2-rich blood into the aorta.
    • Branches of aorta carry blood to all other regions of the body (except lungs).  

OK, students, hang in there! With normal anatomy under our belt, let’s look at the fetal circulation. 

Fetal Circulation: Blood circulation in the fetus is different because the placenta provides the functions of lungs, gastrointestinal tract, and kidneys. Thus, a normal blood supply to these maturing organs is not required.

Ductus Arteriosus: The fetal heart has a vascular bridge between pulmonary artery and aorta that shunts blood exiting the right ventricle into the aorta and bypasses the lungs. This vascular bridge is the muscular ductus arteriosus (aqua arrow – below image). Again, because lungs do not process gasses during intrauterine life, most blood is shunted away from them. 

The ductus arteriorsus is patent (open) throughout fetal life and normally closes within 24 hours after birth as blood flow to the lungs is established. Within 2-3 weeks, it turns into a fibrous band, the ligamentum arteriosum. 

All of this is highly regulated by various chemical and physiological substances including oxygen levels. 

Patent Ductus Arteriosus: If the ductus arteriosus does not close soon after birth but remains patent (open), it is diagnosed as PDA, a congenital heart lesion. PDAs are most common in premature babies but can also occur with full term infants. 

Nowdays, if a ductus arteriosus does not spontaneously close after 8 weeks post-birth, it usually is treated with medications, plugged, or surgically closed. Small PDAs may not be a cause for concern and are often not treated.

Adding a bit of perspective – PDA is not new. It was known as early as 129 A.D. to Galen, a Greek anatomist and physician, although he didn’t understand its significance. It wasn’t until 1938, almost two millennia later, that Dr. Robert E. Gross of Harvard Medical School and Children’s Hospital in Boston, Massachusetts, perform the first successful ligation (closure) of a PDA. This was also the first congenital heart lesion to be successful corrected, surgically.

Now, let’s return to Mandy’s Malady. This was her problem. Mandy’s ductus arteriosus did not close after birth and she exhibited some of the concerning symptoms outlined above.  Blood from her aorta flooded her lungs subjecting fragile lung tissues to excessive blood pressure (hypertension). Allowed to go unchecked, the fragile lungs will be permanently damaged and she  eventually will experience right-sided heart failure.

Diana explains all of this with her usual magical writing skills in this excerpt from “A Breath of Snow and Ashes:” 

The ductus arteriosus is a small blood vessel that in the fetus joins the aorta to the pulmonary artery. Babies have lungs, of course, but prior to birth don’t use them; all their oxygen comes from the placenta, via the umbilical cord. Ergo, no need for blood to be circulated to the lungs, save to nourish the developing tissue—and so the ductus arteriosus bypasses the pulmonary circulation. 

At birth, though, the baby takes its first breath, and oxygen sensors in this small vessel cause it to contract—and close permanently. With the ductus arteriosus closed, blood heads out from the heart to the lungs, picks up oxygen, and comes back to be pumped out to the rest of the body. A neat and elegant system—save that it doesn’t always work properly.

The ductus arteriosus doesn’t always close. If it doesn’t, blood still does go to the lungs, of course—but the bypass is still there. Too much blood goes to the lungs, in some cases, and floods them. The lungs swell, become congested, and with diverted blood flow to the body, there are problems with oxygenation—which can become acute.

Lastly, this is a brief video about PDA which you might find useful. It is easy to understand and accurate: https://youtu.be/7DKaCqubuSg. 🤓

Fast forward! It is clear that the MacKenzies arrived safely in the 20th Century and Mandy received the medical intervention needed for her PDA repair. When we meet her next at Lallybroch, she is a healthy, happy, and feisty wee lass, played by Rosa Morris. 🤗

As William Shakespeare once wrote, “All’s Well That Ends Well!”

(Well, it would end better if they were all together, but we shall see) 🤞🏻

The deeply grateful,

Outlander Anatomist

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Photo creds: Sony/Starz; www.commons.wikimedia.org; www.heart.org; www.kidshealth.com; www.medicalsuppliesgh.com; www.medlineplus.gov; www.outlander.fandom.com; www.theoutlandermuse.com; www.twitter.com (now X)

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Mini Anatomy Lesson: Abdominal Aortic Aneurysm (AAA)

 

Anatomy Def: An abdominal aortic aneurysm (AAA) is a bulge or swelling of the aorta that occurs in the belly.

Outlander Def: Mrs. Wilson’s untimely #death-resurrection-death wherein “kindly” fisher folk put Claire firmly on her witchy broom!!! 🧹😱

Hello, anatomy students! To date, I have not written a full lesson about the cardiovascular (CV) system. So, the following quick anatomy lesson of the aorta will be useful in understanding AAA. 🤓

And, we’re off!!! 🏇

Aorta: The aorta is the largest blood vessel of the body! 👏🏻👏🏻👏🏻

What Does it Do? The aorta is an artery, so it is tasked with carrying oxygen-rich (oxygenated) blood from the heart to general regions of the body. The direction of blood flow is indicated by the small black arrows in the next image.

Also, by convention, arteries are colored red to indicate these vessels carry oxygenated blood away from the heart and veins are blue to show vessels carrying oxygen-poor (deoxygenated) blood toward the heart. (pssst…there are two exceptions to this pattern, but I won’t confuse you by including those. 😜)

Along the entire course of the aorta, various arteries branch off to supply blood to the head and neck, upper limbs, chest and its organs, abdomen and its organs, and lower limbs. These branches are not labeled in the image below.

Divisions: Inside the chest is the thoracic aorta – the part within the belly is the abdominal aorta. The names switch where the aorta traverses the thoracic diaphragm (purple arrow).

The part of the thoracic aorta that rises is the ascending thoracic aorta, the curved part is the aortic arch, and the part that descends is the descending thoracic aorta.

Pathway:  The aorta starts at the left ventricle (chamber) of the heart, rises toward the neck, makes a 180º, descends through the chest, and enters the belly (abdomen) where it terminates at the 4th lumbar (L4) vertebra by dividing into left and right common iliac arteries (turquoise arrows). Whew! 😅

How can a practitioner locate L4 when looking at the belly?

Here’s how: the umbilicus (navel) can be used as a fairly reliable surface landmark for termination of the aorta because it lies slightly above L4. Thus, a finger’s width below the navel will locate L4. If a person is heavy or pregnant, this can distort the position of the navel. 

L4 is important because the practitioner must palpate above that level to detect a AAA.

Like other larger arteries, a pulse in the abdominal aorta can be felt (palpated). Sometimes the belly can be seen to rise and fall with the pulse especially after a meal, during pregnancy, or while lying down. This can be perfectly normal.

However, sometimes a pulse in the abdominal aorta can be a warning sign!🚫 

Aneurysm: If the aortic wall becomes damaged, it can developed a distinct bulge or balloon; this is an aneurysm. (Pssst…🤫 Aneurysms also can develop in smaller arteries and in veins.)

If an AAA is present, a practitioner may be able to detect the enlargement by palpating the abdominal wall. The care giver must press firmly enough to feel the abdominal aorta because it lies very deep, near the vertebral column. 

If a patient has a very taut abdominal wall (next photo) or the waist girth exceeds 100 cm, it is more challenging for the practitioner to accurately feel and identify any aneurysm that may be present. A tight wall or a fairly thick layer of belly fat inhibits the deep pressure required for the exam. Lastly, clothes worn by the patient may also impede effective palpation! 😮

Although the following informative video is designed to train students on how to palpate the abdominal aorta, it is easily understood by a lay person. This will give you an idea of how a pulse is felt and how an aneurysm is detected.

The big problem with AAA is it can enlarge to the point of rupture, allowing blood to seep into the wall of the aorta (dissecting aneurysm) or bleed into the abdominal cavity causing dangerous blood loss or even death. 

Rarely, an AAA can become so large, it is clearly visible in the abdominal wall (next image)! The left panel shows an huge bulge at the left side of a person’s abdominal wall. The right panel shows a cross-sectional CT scan of the same mass, identified as a huge blood clot (thrombus) in an AAA. 

OK. I hear the bell tolling…… Time to head back to the wee kirk on the Ridge! 

Germain’s “I spy with my little eye,” alerts Granny Fraser that something is amiss with Mrs. Wilson. 👀  

“LOOK!“     

“Stay back!”

Claire rushes to the other granny’s side and palpates her abdomen. Can she feel a possible aneurysm? Very likely, because Mrs. Wilson is fairly trim and her stays appear to be of the type that end near the waist, so Claire should be able to palpate – no problemo. 

Claire slips her fingers between the folds of the skirt and takes a wee feel. Yep! Just as Claire suspected…..the auld lady has an abdominal aortic aneurysm – it has ruptured and she is bleeding internally.

If Mrs. Wilson had been sans clothes, Claire might have witnessed something like this:

She hasn’t got long, Reverend Roger. Just minutes and she stands before her Maker! 

Wait! Wait! What? How could Claire ken the aneurysm had ruptured?

Well, here are some clues that Doc Fraser likely observed..…. 🤓

Signs and symptoms that an AAA has ruptured:

    • Sudden, intense and persistent abdominal or back pain – a tearing sensation
    • Low blood pressure
    • Loss of consciousness
    • Pasty, cold, and clammy skin 

Although Claire does not know if Mrs. Wilson experienced the back pain (no time to take a proper history), all the other symptoms are recognizable. Claire recognizes that given the lady’s advanced age, fainting is likely due to low blood pressure as a result of internal blood loss. Blood loss plus age suggest aneurysm as a likely cause. These coupled with palpation of the enlarged AAA leads Claire to tell Roger that Mrs. Wilson’s death is imminent! (She’s a lot closer to God than you, Roger Mac –  Bree will be grateful for that 🙏🏻)

Mrs. Wilson revives long enough to forgive her SIL – “You’ve been a good lad.” He did provide her with a hame these past 20 years. ♥️

… And she survives long enough to accept the sin-eater’s gift of devouring her sins. 😮

Lastly, you might be interested in what causes aneurysms and any risk factors. 

Common Causes:

    • Hardening of the Arteries (Atherosclerosis): Fat and other substances build up in the wall of the aorta (or other blood vessels) and weaken it.
    • High blood pressure: Prolonged, elevated blood pressure can damage and weaken the aortic walls.
    • Blood Vessel Diseases: Diseases such as Marfan Syndrome damage vascular walls. 
    • Infection: Although rare, a bacterial or fungal infection can cause AAA.
    • Trauma: Abdominal injury (e.g. serious car accident) may cause an AAA due to a tear in the aorta.

Risk factors: And, like many other diseases, there are risk factors for AAA. Most of these we cannot control but there is one clear exception! 🚬🚭

    • Tobacco use: Yep. Smoking is the strongest risk factor for AAA! Why? Because smoking weakens the aortic walls, increasing the risk of aortic aneurysm and the likelihood one might rupture.  The longer and more one smokes or chews tobacco, the greater the chances of developing an aortic aneurysm. (Doctors recommend a one-time abdominal ultrasound to screen for an AAA in men ages 65 to 75 who are current or former cigarette smokers.)
    • Age: AAA occurs most often in people ages 65 and older.
    • Being male: Men are 3-4x more likely to develop AAA as women.
    • Being white: People who are caucasian are at higher risk of AAA.
    • Family history: Having a family history of AAA increases the risk.
    • Other aneurysms: Having an aneurysm in another large blood vessel, such as the artery behind the knee or thoracic aorta can increase the risk of an AAA.

Read about Mrs. Wilson’s walk through the valley of the shadow of death in A Breath of Snow and Ashes, Diana’s longest big book (1,152 pages)! 

“No, Grannie! Look!” 

I followed his outthrust finger, and for a moment, thought he was pointing at his father. But he wasn’t. 

Old Mrs. Wilson had opened her eyes.

There was an instant’s silence, as everyone’s eyes fastened at once on Mrs. Wilson. Then there was a collective gasp, and an instinctive stepping back, with shrieks of dismay and cries of pain as toes were trodden on and people squashed against the unyielding rough logs of the walls.

“Give her a bit of air, please,” I said, raising my voice. The stunned silence was giving way to a rising murmur of excitement, but this quelled as I fumbled to untie the bandage. The room waited in quivering expectation as the corpse worked stiff jaws. 

“Where am I?” she said in a quavering voice. Her gaze passed disbelievingly round the room, settling at last on her daughter’s face.

I, meanwhile, had been doing my best to check the old lady’s vital signs, which were not all that vital, but nonetheless fairly good for someone who had been dead a moment before. Respiration very shallow, labored, a color like week-old oatmeal, cold, clammy skin despite the heat in the room, and I couldn’t find a pulse at all—though plainly she must have one. Mustn’t she?

I put my own hand on her abdomen, and felt it instantly. A pulse, where no pulse should be. It was irregular, stumbling, and bumping—but most assuredly there.

See Hiram Crombie’s MIL and her final moments before leaving her mortal coil in Outlander, Episode 602, Allegiance. A verra poignant scene, indeed!

Gobs of grannies in this episode! 😉

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www.familydoctor.org, www.feghalicardiology.com, www.nejm.org, www.oxfordmedicaleducation.com

 

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Mini Anatomy Lesson: IP Joint

 

Outlander Def:  Wait!  What???  Roger Mac has a joint? But, but….he is a Presbyterian minister (almost)!

No worries. NOT that kind of joint! 😉

Anatomy Def:  IP joints are between bones of each digit.

Let’s take a wee keek at hand anatomy to ken Roger’s bones and joints. The next figure shows bones of the (left) hand.

Collectively, the digits have 14 bones. Every finger  contains three tiny bones, each known as a phalange. The proximal (near) phalange is green, the middle plalange is blue, and the distal (far) phalange is pink.

But, alas, Mr. Thumb only enjoys two phalanges: proximal (green) and distal (pink). 

To identify the digits, anatomists number them from one to five: 

    • Thumb =  digit #1
    • Index =  digit #2 
    • Middle = digit #3
    • Ring = digit #4
    • Little = digit #5

But, wait for it….drum roll…. 🥁 Anatomists number fingers, from one to four:

    • Index = finger #1
    • Middle = finger #2
    • Ring = finger #3
    • Little = finger #4

Horror of all horrors…. This means that finger #1 is also digit#2!  😱

You  possible can see how this numbering system could get physicians into trouble. Adding fuel to the fire, anatomists in some countries regard the thumb as a finger and thus describe five digits and five fingers. Bottom line, US hand surgeons often prefer using terms (not numbers): thumb, and index, middle, ring, and little fingers to avoid confusion and mistakes! 🙄

Moving on!

In anatomy, a joint is the site where two or more bones meet and allow for movement –  the greater the number of joints, the greater possible movements. Thus, the many joints between phalanges of our five digits permit greater flexibility allowing digits to flex (bend) or extend (straighten).  Thumb also can oppose (touch) each finger, individually, and little finger also can oppose the thumb. These movements are possible because forearm and hand contain numerous muscles that move the bones.

Joints between phalanges are named interphalangeal meaning “between phalanges.” Because each finger has two interphalangeal joints, these are further defined (see next figure of right hand –  ignore metacarpophalangeal joints):

    • PIP (proximal interphalangeal) joint occurs between each proximal and middle phalange.
    • DIP (distal interphalangeal) joint occurs between each middle and distal phalange.

Puir wee thumb only has one joint between proximal and distal phalanges, so it has just a single IP (interphalangeal) joint. But, no tears for Mr. Thumb – he is verra special!

Whew! 😅 Took a bit to explain that!

Now, back to Roger’s anatomy! 😜 (I thought you would be up for that!)

Ergo, manly Roger is flexing the IP joint of his right thumb! 👏🏻👏🏻👏🏻  And, since in most people, the left hand is our shield hand while the right is our sword hand, it is just possible that Mr. Minister is contemplating a stramash! 

Try This: Flex (bend) one of your thumbs. Note it has one joint between its phalanges, the IP joint. Now flex any finger. Note it has two joints, the PIP joint nearest the palm and the DIP joint nearest the fingernail. Well done, student!

The hand and its fingers are elegantly engineered and staggeringly complex. If you wish to read more about them, I have written two long anatomy lessons of the hand.

Learn about  IP, DIP, and PIP joints in Anatomy Lesson #22, “Jamie’s Hand, Symbol of Sacrifice  and Anatomy Lesson #23, “Harming Hands, Helping Hands, Healing Hands.” 

Read about finger and thumb joints in Diana’s first book, Outlander. The following excerpt is from Jamie and Claire’s lovely outing in the countryside, shortly after the wedding : 

“Above one dark speckled pool, Jamie showed me how to tickle trout.

…  “All it is,” he said, “is to pick a good spot, and then wait.” He dipped one hand below the surface, smoothly, no splashing, and let it lie on the sandy bottom, just outside the line of shadow made by the rocky overhang. The long fingers curled delicately toward the palm, distorted by the water so that they seemed to wave gently to and fro in unison, like the leaves of a water plant, though I saw from the still muscling of his forearm that he was not moving his hand at all.

…  “There he is.” Jamie’s voice was low, hardly more than a breath; he had told me that trout have sensitive ears.

…  One finger bent slowly, so slowly it was hard to see the movement. I could tell it moved only by its changing position, relative to the other fingers. Another finger, slowly bent. And after a long, long moment, another. I scarcely dared breathe, and my heart beat against the cold rock with a rhythm faster than the breathing of the fish. Sluggishly the fingers bent back, lying open, one by one, and the slow hypnotic wave began again, one finger, one finger, one finger more, the movement a smooth ripple like the edge of a fish’s fin.”

See Roger’s IP joint in Starz season six outlander promo photo!

The deeply grateful,

Outlander Anatomist

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Photo Credits: Starz, www. geekymedics.com, www.quizlet.com