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Doctor's Consultation  by Dr. Iain Corness


Is there a funny side?

Medicine and the practice of it is a very serious business. Every time a doctor gives an opinion, the medico concerned has to be ready to back it up with some serious facts. Some parts of medicine can be downright depressing, they are so serious.

Take for example, that group of doctors who become Forensic Pathologists. These people do not even get the chance to have a joke with their patients. No, their consultations are done in the cold sterile environment of the autopsy room. As a result of all this seriousness at work, most doctors seem to develop a wicked sense of humor and I was sent some examples of this, taken from court proceedings. These made me chuckle, especially as there appears to be a life-long antipathy between doctors and lawyers, although I must admit I did meet a great lawyer in Australia, I just can’t remember his name...
Anyway, here’s a few from the records:

Q. Doctor, how many autopsies have you performed on dead people?
A. All my autopsies are performed on dead people.
And the second one,
Q. Do you recall the time you examined the body?
A. The autopsy started around 8.30 p.m.
Q. And Mr. Dennington was dead at the time?
A. No, he was sitting on the table wondering why I was doing an autopsy.
And the last one,
Q. Doctor, before you performed the autopsy, did you check for a pulse?
A. No.
Q. Did you check for blood pressure.
A. No.
Q. Did you check for breathing?
A. No.
Q. So, then it is possible that the patient was alive when you began the autopsy?
A. No.
Q. How can you be so sure, Doctor?
A. Because his brain was sitting on my desk in a jar.
Q. But could the patient have still been alive nevertheless?
A. Yes, it is possible that he could have been alive and practising law somewhere.

Humor is actually a very important part of life and in fact you’re dead without it. But jokes aside, laughter really is the best medicine. People who know how to laugh, at themselves as well as at others, do have a better outcome than those who do not. Even with such death sentences as some forms of cancer, you will do much better with a happy, positive, laughing approach to life.

One person who really knew this was a chap in Australia who, once he found he had a terminal illness, held his own wake before he died. In this way he felt he could say goodbye to all his friends, rather than have them drinking over his cold corpse after the funeral. Bizarre perhaps, but I can understand his macabre sense of humor!

No, learn to laugh, read humorous books, watch funny videos, hang around with people who tell great jokes and suddenly you will find that life just seems that little bit better. And you’ll live longer too! Now, have you ever heard the one about the doctor and the actress?

Here’s some more:
In Hospital Waiting Room: Smoking Helps You Lose Weight ...

One Lung At A Time!
The Demon drink:
When I Read About The Evils Of Drinking...
I Gave Up Reading
And another:
My Grandfather Is Eighty
And Still Doesn't Need Glasses....
He Drinks Straight Out Of The Bottle.
And for the UFO fans out there:
The Surest Sign
That Intelligent Life Exists Elsewhere In The Universe Is The Fact
That It Has Never Tried To Contact Us.

Abdominal Aortic Aneurysm or AAA

AAA stands for Abdominal Aortic Aneurysm, and as I have often pointed out, we doctors love acronyms. I am sure that the education bodies decreed years ago that the medical course should contain three years of acronyms, as well as another three years of clinical practice.

So what is an abdominal aortic aneurysm (AAA)? First off, what is the aorta? The aorta is the main artery of the body, directly connected to the heart and taking the vast majority of the blood from that important central pump to the abdominal organs and the legs. This artery is around 2 cm in diameter.

However, a situation can occur, whereby the artery begins to bulge and can grow to four or five times the normal diameter. It is this swelling that is called an ‘aneurysm’. Being of the Abdominal Aorta, then explains the AAA description. An aorta is considered ‘aneurysmal’ when it grows more than 50 percent over its normal size. By the way, aneurysms may occur in any blood vessel in the body, but the most common place is in the abdomen below the renal arteries (the blood vessels that provide the blood to your kidneys). Interestingly, aneurysms are four times more common in men than women and occur most often after 55-60 years of age. Elderly males have yet another aspect to monitor, as well as their prostates!

The danger of the AAA comes from the fact that this can burst, like an over-inflated balloon, and the patient experiences a catastrophic internal hemorrhage. This is generally fatal. Aneurysm rupture affects approximately 15,000 people per year making it the 13th leading cause of death in the US. The incidence of aortic aneurysm increases every decade as the population ages. Fortunately, early detection and diagnosis is increasingly possible as more sophisticated medical screening methods become available.

So why does this aneurysm occur? Aneurysms are caused by a weakening or damage in the wall of a blood vessel. There are many conditions known to contribute to the weakening of the artery wall including atherosclerosis (hardening of the arteries), cigarette smoking, high blood pressure and inflammation or infection.

Atherosclerosis (hardening of the arteries) is the most common cause of abdominal aortic aneurysms. This occurs when substances such as cholesterol, minerals, and blood cells build up in the walls of the artery, and thus damaging it. The muscular wall of the aorta weakens and with the pressure inside the artery, it begins to bulge. High blood pressure may speed up the weakening, but it is not the cause. Aneurysms also tend to run in families, so there is the thought that genetics may play a role in who gets an aneurysm. (When in doubt, blame your parents - for everything!)

There is a strong link between cigarette smoking and the occurrence of aneurysms. Smokers die four times more often from ruptured aneurysms than nonsmokers. Aneurysms in smokers also expand and weaken faster than those in nonsmokers, making this the one hundred and twenty thousandth good reason to give up cigarettes.

Unfortunately, until an AAA bursts, there are generally no symptoms to let you know you have one of these ‘time bombs’ sitting in your belly. The discovery is then usually during an annual physical, where it can be palpated by the doctor, but by far more accurate is an ultrasound, which can give exact dimensions, and thus progressive indication of how rapidly the swelling is growing.

The answer to this is an operation to replace the swollen, weakened artery, with a suitable piece of highly expensive ‘garden hose’ of correct length and diameter. This is a major operation, but once you have had an AAA detected, there is no other way around the problem. There is also some work being done on encasing the aorta to contain the swelling, but this is not the usual method of ‘defusing’ an AAA.

You should be lining up for a routine health check every 12 months, after you reach 40 years of age. When was your last one?

However, if they do find one, you join the ranks of the famous, as Einstein had one, but unfortunately died when it ruptured.

Deafening our children

Have you ever wondered just why Thai ladies cannot talk quietly together? Women’s conversational Thai is a language shouted at full volume, with everyone talking at the same time. For the western male this is something of a (noisy) mystery. However, I have unearthed the secret, and it isn’t a pretty tale, I will tell you now.

What prompted this week’s column was my accidentally stumbling into the 2011 Aerobics championship for schools being held in one of our shopping malls. Whilst it was good to see so many of the schools having an aerobics group present, showing all kinds of physical skills, this was done to music emanating from a bank of huge boom boxes, with MCs shouting into their microphones, to be amplified to the same levels.

When I was practicing as an Occupational Health Physician, we would monitor the noise levels in factories, which by the very nature of the type of work being done, were quite noisy. The upper limit was 90 dB for eight hours. The local shopping mall was nowhere near 90 dB, but I would suggest it was at 120 dB at least.
Now groups such as OSHA (Occupational Safety and Health Administration) in the USA have been able to produce world standards for noise exposure. 90 dB for eight hours, 105 dB for one hour and 15 minutes or less for 115 dB. Anything over that and irreversible changes occur in your ability to hear. That’s for adults - children are more sensitive to noise.

The children in the shopping mall were there for around two hours. About 10 minutes on stage and an hour limbering up and probably another hour watching the other schools. That is far greater than the 15 minutes at 115 dB, and let me assure you, it was much louder than that. It was at the threshold of pain.

To give you some examples of noise levels:
Normal home or office background is around 40-60 dB.
Normal speaking voice is 65-70 dB.
Orchestral climax at 105 dB.
Live Rock music: 120 dB+.
Pain Threshold: 120-130 dB.

The ear is made up of three different parts, including the outer ear which is the part you can see. Its shape helps to collect sound waves. A tube, called the external ear canal, leads inward to the eardrum.

The middle ear is separated from the outer ear by the eardrum. The middle ear contains three tiny bones called the malleus (hammer bone), the incus (anvil bone) and the stapes (stirrup bone). These bones amplify the movement of the eardrum produced by sound waves making the drum move in and out. The Eustachian tube connects the middle ear to the back of the throat and helps to equalize air pressure.

The inner ear is where the sound waves are picked up by a tiny spiral-shaped organ called the cochlear. Hairs on the cochlear sense the vibrations and pass the message as electrical impulses to the brain via the cochlear nerve. The whole system is very sensitive.

There is no doubt that the young ears would be damaged by the noise exposure they suffered last week. If they were very lucky, it would only be a temporary form of deafness (called a temporary threshold shift), but enough repeated exposures will result in permanent degrees of deafness.

Now think of any outdoor party or concert you have been to in this country and cringe at the memory of the loudness of the music. One hour at 105 dB is the safe limit. That limit would have been exceeded both in time and in volume (dB’s).
It is improper for me to be too sweeping with statements, but if your Thai wife has been to enough stage shows, concerts and outdoor karaoke, she will have permanent hearing damage by this stage. So will her friends. And so they have to shout louder. And you go to the pub for a bit of piece and quiet!

This also goes a long way towards explaining why the local populace does not hear phones ringing, and why the girl in the next office has her mobile phone ring tone set on maximum. And I know she has an incoming call before she does!

BPPV - common but often misunderstood

Benign Paroxysmal Positional Vertigo (BPPV) is a very distressing condition, and much more common than you imagine. If you have it, after you move in a particular way, you feel that the room spins around you and you cannot stop it. It is like being so drunk that when you lie down on the bed the spinning rotation is so bad you grip the edges of the bed to stop falling off. That is what BPPV is like - but without the hangover the next morning!

The symptoms of BPPV include the dizziness (vertigo), lightheadedness, imbalance, and nausea. Activities that bring on symptoms will vary, but are almost always produced by a rapid change of position of the head. Getting out of bed or turning over in bed are common ‘problem’ motions. Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, BPPV is sometimes called ‘top shelf vertigo.’ Women with BPPV may find that having a shampoo can bring on the symptoms. It also tends to be recurrent. So until you read further, don’t look up or get your hair washed!

To understand BPPV, you have to understand the workings of your inner ear. You have three semi-circular canals aligned in different directions, which act like spirit levels (the builders type, not the three fingers on the glass barman type) which have cells with fine hairs bathed with fluid as your head moves in different directions. The movement of the fine hairs sends electrical impulses to the brain to tell it (and you) which way is “up”.

However, with BPPV, the natural movement inside the semi-circular canals is disrupted, so the fine hairs send the wrong signals to the brain, and being unable to work out which way is really “up” the sufferer falls over, totally unable to save themselves from hitting the floor. Debilitating and embarrassing! Ask anyone who has had BPPV.

The commonest cause of interruption to the normal ebb and flow in the semi-circular canals is produced by something we have called “ear rocks”. These are made up of crystals of calcium carbonate, and we medicos call these ear rocks “otoconia”. Imagine these rocks to be like sugar crystals in the bottom of your coffee cup. These now swish around every time you move your cup, and likewise your “ear rocks” swish around every time you move your head.

However, it is not all that simple (it never is, is it?) as the commonest cause of BPPV in people under 50 is head injury. In older people, the most common cause is degeneration in the semi-circular canals of the inner ear. BPPV becomes much more common with advancing age, but in 50 percent of all cases, BPPV is called ‘idiopathic’, which is a fancy word we use when we have no real idea as to the cause!

Viruses can be accused too, such as those causing vestibular neuritis, minor strokes such as those involving anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease are significant but unusual causes. Occasionally BPPV follows surgery, where the cause is felt to be from a prolonged period of lying on the back with the chin raised (for the anaesthetic tubes to slip down your throat), or ear trauma when the surgery is to the inner ear. The simple situation is that we can make the diagnosis, but it van be harder for us to exactly pinpoint the cause. To make it even harder, an intermittent pattern is common. Your BPPV may be present for a few weeks, then stop, but then come back again.

Is there any treatment? Yes there is, if ear rocks are the cause. Treatment usually consists of a series of maneuvers you are put through which are designed to move the ‘ear rocks’ around till they no longer cause problems. These are demonstrated by the Ear, Nose and Throat (ENT) specialists and usually result in around a 90 percent cure rate. The most common is called the Epley maneuver or the particle repositioning or canalith repositioning procedure, but have your ENT specialist show you how to do this.

Cancer research - why it is so difficult?

I addressed the Pattaya City Expats Club a couple of weeks ago on the subject of ‘Living Wills’ (and I hope you have registered yours), but in the very lively Q&A session afterwards some statements came up which I feel obliged to answer in the public arena.

A “cancer research” item was spoken about, which was cited as the biggest and most comprehensive and most expensive study ever conducted.

It was implied that the results of the study were suppressed by the beef industry and the dairy industry, because the findings implicated meat and dairy products in the causes of cancer. (The conspiracy theory is alive and well.)

Please consider just ‘how’ the meat and dairy industries can continue to suppress these research results? Buckets of money? But with cancer research being done all over the world, by legitimate scientists, they must be very large buckets, and there must be an army of researchers ready to be on the take. I’m sorry, but I do not believe that the world’s researchers are all corrupt. In fact, at the end of all research papers are statements by the researchers to show whether or not they have any connection with any groups or manufacturers named in the research.

This highlights one of the weaknesses of the internet - “facts” are not subject to scrutiny. You can post anything you like, and there is no vetting of your posting. For example, the email notification that ‘Aspartame’ can cause Multiple Sclerosis and a whole swag of other conditions. The writer’s sister stopped her diet soft drinks and made a miraculous recovery. This tripe has been going round the world for 10 years. You would imagine that if it were so easy to suppress scientific information, the cola manufacturers would have had Frank (the Enforcer) round to his home already.

No, science progresses slowly and with a measured tread. Pointing the finger at potential carcinogens requires much careful study, far beyond a case study of one.

There are many reasons for this, including the fact that your reaction to ‘carcinogens’ (cancer producing substances) is not necessarily the same as the reaction of the person sitting next to you. Individual differences do exist, and may even be reflections of inherited (genetic) influences. This, in part, goes to explain why your Uncle Jimmy smoked 80 cigarettes a day for 60 years and was shot by a jealous husband when he was 103, while the man next door died at 45 with lung cancer after smoking only 20 cigarettes a day for the previous 20 years!

So what is a carcinogen? Cancer is caused by abnormalities in a cell’s DNA (its genetic blueprint). Abnormalities may be inherited from parents, or they may be caused by outside exposures to the body such as chemicals, radiation, or even infectious agents including viruses. Some carcinogens do not act on DNA directly, but cause cancer in other ways, such as causing cells to divide at a faster rate. Substances that can cause changes that can lead to cancer then are called carcinogens.

The difficulties in studying them come from the fact that carcinogens do not cause cancer in every case, every time. Substances classified as carcinogens may have different levels of cancer-causing potential. Some may cause cancer only after prolonged, high levels of exposure (remember the words of Paracelsus: “Dosage alone determines poisoning”). And for any particular person, the risk of developing cancer will depend on many factors, including the length and intensity of exposure and the person’s genetic makeup.

The International Agency for Research on Cancer (IARC), has evaluated the cancer-causing potential of about 900 likely candidates in the last 30 years, placing them into one of the following groups:

Group 1: Carcinogenic to humans
Group 2A: Probably carcinogenic to humans
Group 2B: Possibly carcinogenic to humans
Group 3: Unclassifiable as to carcinogenicity in humans
Group 4: Probably not carcinogenic to humans

There are around 90 carcinogens in Group 1, with most being referred to by long chemical names such as 1-(2-Chloroethyl)-3-(4-methylcyclohexyl)-1-nitrosourea (Methyl-CCNU), however, there are others like solar radiation, alcoholic beverages, analgesic mixtures containing phenacetin, salted fish (Chinese-style) and tobacco smoke.

Now then, has anyone heard from Uncle Jimmy recently?