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Fight or Flight

By Dr. Jim Ferguson
Recent remarks in the media and by our leaders regarding the Zimmerman trial caused me to reflect on a paper that recently appeared in the prestigious New England Journal of Medicine (NEJM).  I first heard of the fight or flight response in health class which we all had to take in junior high school.  I later learned in a college physiology course that our bodies are designed to shift into another gear when confronted by perceived danger.

Just as your car shifts into a more powerful gear for passing, your body releases the fight or flight hormone, adrenaline, that augments your faculties.  Most of us have experienced fear, and some people who have anxiety disorders experience the sensation of fear even without an identifiable source.  Have you ever had a near collision on the highway or awakened from a nightmare?  If so, you can imagine the persistent anxiety/fear that some people feel for inexplicable reasons.

The trite saying goes, “Cold feet, warm heart; smelly feet, no sweetheart.”  Adrenaline released in a stressful situation causes an increase in heart rate and constriction of the superficial blood vessels in the skin to shunt more blood to deeper areas and limit blood loss in the event of injury.  Adrenaline also makes us feel a bit clammy in stressful situations and produces a lot of deodorant sales in western society where body odor is not as acceptable as in other cultures!

An adrenal gland sits atop each of our two kidneys.  These glands produce sex hormones and others aiding salt (sodium) and potassium balance.  The adrenal glands also produce crisis hormones like adrenaline and hydrocortisone; the latter was the focus of the NEJM article.  Hydrocortisone is not only for stress, it also helps maintains blood vessel integrity and vascular volume.  Some of you are old enough to remember President John F. Kennedy.  It turns out that President Kennedy’s tanned look was in part due to Addison’s disease, a condition with deficiency of hydrocortisone.  He almost died with the stress of anesthesia and back surgery because his problem was not known to his doctors beforehand.

Patients in a medical crisis sometimes develop a condition known as SIRS or systemic inflammatory response syndrome.  This condition can be caused by infection or possibly from the dysregulation of normal defense mechanisms to nonspecific inflammation.  The normal response to danger or illness is a stimulation of the adrenal gland and the pituitary or Master Gland.  This results in the release of adrenaline and hydrocortisone to mitigate and balance the cytokines (proteins) of inflammation.  If not successful, edema, shock and organ failure may result.

For more than fifty years the anti-inflammatory effects of hydrocortisone have been know and utilized by doctors.  When the first hydrocortisone agents were available and used on patients with severe rheumatoid arthritis, these drugs were called miracle agents because patients literally threw down their crutches and began to walk.  However, it didn’t take long to observe massive swelling and diabetic side effects of “steroid” therapy.  Additionally, osteoporosis and immune system dysfunction with infection frequently occur.  Now days, we use various hydrocortisone derivatives like prednisone and dexamethasone, but in the smallest doses and for the shortest periods possible.

Long ago when I was in training there was an axiom that no one in shock should be denied a trial of hydrocortisone in the hopes of stabilizing an otherwise desperate situation.  However, numerous scientific studies have led to conflicting results of this desperate therapy.  The NEJM study by Boonen and others was fascinating for a mechanistic internist like me.  Without delving into the intricacies of the science, the conclusion is that there is massive stimulation of the adrenals in severe illness and alteration in circulating hydrocortisone from metabolic changes during illness.  The missing explanation for the clinical picture may be dysfunction of the blood vessels within the adrenal glands caused by the circulating inflammatory proteins (cytokines).  SIRS and shock with adrenal gland dysfunction may result in death from organ failure.

Science operates from the position of reductionism.  In other words, to understand a complicated system you take it apart to see how each piece functions.  We don’t have this option in medicine and have to study systems in an indirect way as Boonen and his colleagues did.  There was a famous Star Trek episode where the experts wanted to take the “robot” character, Data, apart to understand how he functioned.  This would have led to Data’s death.  A trial was held to determine whether Data was an independent being with rights and privileges, or whether he was property to be disassembled for the “greater good.”  Fortunately, justice prevailed and Data won his freedom and his life.

Our country is in trouble and divided like no time since the Civil War.  I wrote an essay for the News Sentinel a few years ago called The Barely Civil War, and it has only gotten worse.  I don’t know how it will end, but many have compared the path of our country to that of Rome.  The Romans sacrificed their freedom and republic for prosperity and false security with the tyranny of the Caesars.

The rancor and strife in our body politic are stimulating our nervous systems and hormones.  I’ve concluded I have no place to flee.  As a consequence I must stay and fight, though I’m not sure how healthy this is.

 

 

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