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Doctor's Consultation  by Dr. Iain Corness


R2D2 visits Thailand

Remember R2D2?  If you’ve forgotten, remember Luke Skywalker and the Star Wars movies?  Of course you do.  Now while the robot R2D2 is gathering dust in some Hollywood storage space, another type of robot arrived in Thailand a couple of weeks ago, and it was that which jogged my memory.

This new robot is called RoboDoctor, and is involved in one of the latest types of care delivery, and that is called ‘tele-medicine’.  This advance in medicine should not be confused with ‘robotic’ surgery, where the surgeon controls a robotic ‘arm’ which can carry out very fine tasks.  Tele-medicine consists of connecting two doctors (in most cases) to be able to discuss with each other the likely diagnosis and subsequent treatment of a patient.

The following true scenario is a wonderful example of tele-medicine at its most basic and this genuinely happened in Australia.  A doctor in the outback was called to see a patient with a head injury and it became obvious that there was a bleed inside the skull.  If left untreated or unchecked the patient lapses into deeper and deeper unconsciousness and then dies.

The answer to this problem is called ‘trephining’ or making a ‘burr hole.’  By drilling through the skull, the blood can be removed and the pressure is taken off the brain.  This procedure dates back to BC times, and museums all over the world have examples of primitive trephines.  However, the museum cannot tell us how many were successful procedures!  (Operation a success but the patient died!)

There are a couple of spots in the skull where it is safe enough to drill, but exactly where?  A GP out in the scrub would hardly know this.  And now we come to the drama.  The outback doctor had a household electric drill in his home tool kit and rang a specialist in one of the capital cities, who described to him just where to drill - over the phone.  He drilled, the blood was released and immediate problem averted.  Heroic stuff!  And yes, it was successful and both doctor and patient were heroes in my book.

Now back to the RoboDoctor in Thailand, and Pattaya in particular, and further refinement of this tele-medicine concept.  Rather than just audio contact between two doctors, there is visual contact as well.  What is more, the robot can be moved in any direction and directed wirelessly by the treating doctor at the bedside, but this can also be done by the consultant specialist who may be many kilometers away, using Wi-Fi connectivity.  Close up magnification can be done, the visual frames stopped and guidelines drawn on the image on the screen.  For the patient, it is almost as if they are having a consultation with (in this case) a specialist neuro-surgeon at the bedside.

This tele-medicine allows ‘remote’ examinations to be done, which could, for example, be a doctor doing a ‘virtual’ ward round in the middle of the night.  And although I called it “virtual”, it is actually real-time, just as an examination is real-time.

The robot comes equipped with a powerful lens that sees better than a human eye and the high-tech device can hold a patient’s electronic records and tests such as EKG’s, X-Rays and Echocardiograms, and access them immediately.

One surgeon who is using a RoboDoctor is Ivar Mendez, head of neurosurgery and of the medical facility's brain repair center in Canada at the Halifax QEII hospital.  He said patients quickly become comfortable speaking with the robot and forget it's a piece of technology examining them.

“I strongly believe this technology is part of the future of medicine.  It will bring the expert to the patient anywhere in the country.  Robots will not replace physicians,” Mendez said.  “Rather, the robots help provide universal health care ensuring that even individuals in remote communities will have access to specialized care.”

That was the Canadian experience, and that is now being replicated here, with the Bangkok Medical Center, Bangkok Hospital Pattaya and Bangkok Hospital Hua Hin all linked up through RoboDoctors.  The future is here, now!

Life as a novice doctor

Having now been a doctor for over 40 years, I have begun writing another book.  Not another one on life in Thailand (Farang and Farang The Sequel), but snippets of my medical life - highs, lows, funny bits and sad bits.  Here is an extract from one of the early chapters.

After I graduated in the UK, like all new doctors, you have to do a year’s internship in a hospital.  In the UK, this is called your pre-registration year.  In other words, you work under supervision to ensure you kill as few patients as possible.

For the brand new doctor, with a brand new shiny name badge, this is a fairly trying time, and a year in which you find out just how much you don’t know.  For me, I was quite confident that I would be able to diagnose the seventh beta cell adenoma of the pancreas ever found in the world, but I had no idea what to do for tonsillitis in children, of which there are probably seven million cases every month.  The undergraduate education system had many deficiencies.

It is at this time that the tyro doctor has to bow to superior knowledge - not the specialist doctor to whom you are seconded, but to the nursing sisters in charge of the wards you work in.  For me that was ‘Unders’ (Sister Underhill) and ‘Robby’ (Sister Robinson).  It was those two experienced ladies who successfully, I might add, got me through the first six months of my ‘medical’ pre-registration.

My first job every morning was to take blood samples from the patients, after the requests left by the more senior doctors, who did not have to take their own ‘bloods’.  One particular morning I grabbed my list and began collecting.  Everything was going well, until I had to take blood from Mr. Jackson.  He lay there quietly enough, and even though I was sure I had the needle in the vein, the amount of blood issuing was very slight and very slow.  However, I persisted, as I did not want to admit to failure in front of Unders and Robby.  After 15 minutes I had enough blood for a sample and returned the tubes to the Ward Sister’s desk.  “How did you go with Mr. Jackson?” asked Unders.  “Very difficult and very slow, but I managed it,” I said proudly.  “Not bad,” said Unders.  “He’s been dead for two hours.”  After that salutary lesson I always spoke to any patient from whom I was to extract a blood sample.

Every week we had a ‘Grand Rounds’ where the entire medical and nursing team would visit each patient in the medical wards.  Around the bed would be (in order) the Senior Consultant, the Senior Registrar, the Junior Registrar, the Senior House Officer, the Junior House Officer (me), the Nursing Sister, the Charge Nurse and then all the little nurses.  The order was sacrosanct and obviously steeped in medical history, because if I moved myself up the order while walking to the next bed, I would be elbowed out by my superiors, and if I dallied, and moved down the order, then the nursing staff would regroup behind me and push me forwards.

It is rare to forge long-lasting friendships as a junior doctor.  You are only there for six months before you move on to another teaching hospital for the second six months.  However, I did get quite friendly with one of the surgical team, a Pakistani royal, Prince Siraj Ghazali.

When we were registered on call on the same evenings, on those occasions it was my pleasure to dine with the Prince.  Hospital food is almost universally dreadful, at any hospital I have worked in all over the world.  Often I felt that patients got better to escape the food!

Siraj had that Asian charm, which he could turn on at will, and he would charm the hospital cook.  While the rest of the doctors ate mass produced slop, the Prince and his friend would have a special table set up, complete with starched tablecloth and partake of an English cook’s idea of a Pakistani curry.  At least it was better than the standard fare.

Can you ignore rectal bleeding?

Can you ignore rectal bleeding?  Yes you can, but at a huge personal risk.  Not every case of rectal bleeding is from a pile (hemorrhoid) that will settle.  (And in fact, most do not.)

A very good friend of mine had a scare a few weeks back with some rectal bleeding, but fortunately the cause was found with a colonoscopy, the condition was amenable to surgery and he is now over it.  But it could have been the other way round.  Never ignore rectal bleeding.

The rectum is the last portion of the large bowel that ends just before the anus.  Bleeding from this area can herald a sign of a mild or life-threatening importance, which is why all episodes of rectal bleeding must be investigated.

Depending upon how high up in the gastro-intestinal tract is the cause of the bleeding, it may be seen as black, tarry stools, maroon stools; bright red blood on or in the stool, blood on the toilet tissue, or blood staining the water in the toilet bowl bright red.  Treatment can range from relief of symptoms and let Mother Nature do the rest, to antibiotics, blood transfusion, or even surgery.  It all depends on the cause.

There are many potential causes, including Hemorrhoids (piles) which are swollen rectal veins in the anal and rectal area.  They can cause burning, painful discomfort, as well as bleeding.  External hemorrhoids are small swellings that are easy to see and quite painful; however, internal hemorrhoids are usually painless.  A feeling of incomplete emptying may be noted with bowel movements.  Treatment focuses on relieving these symptoms with the use of stool bulking agents and softeners, and if necessary, removal of the bleeding piles.

Rectal fissure is another.  This is a tear in the lining of the rectum caused by the passage of hard stools, which can lead to mild rectal bleeding of bright red blood.  Exposed nerves and vessels result in moderate to severe pain.

Diverticulosis, those little pockets on the bowel wall, can also bleed.  The stools are dark red or maroon.  Pain is usually absent but surgery is required in up to 25 percent of these patients.

Bloody diarrhea is often seen in Bacterial dysentery, which we have all had to a greater or lesser degree.  Responsible organisms include Campylobacter jejuni, Salmonella, Shigella, Escherichia coli, and Clostridium difficile.  A most unsavory bunch!  The treatment depends upon the organism, but generally intravenous fluid replacement and an anti-spasmodic and broad spectrum antibiotic will bring this under control.

Another common cause of rectal bleeding is Inflammatory bowel disease especially in young adults - typically those younger than 50 years of age.  Bleeding occurs in small to moderate amounts of bright red blood in the rectum, usually mixed in with stool and mucus.  Associated symptoms include fever and abdominal cramps.  This condition generally settles with steroids.

Of course, the one that everyone worries about is bowel cancer.  We lump these together under the general heading of Tumors and Polyps.  Polyps bulge out from the lining of the colon.  Bleeding occurs when large polyps develop.  They can be hereditary, and are usually harmless, but some types can be pre-cancerous.

Both benign and malignant tumors are frequently found in the colon and rectum.  Those people older than 50 years are most affected; however, tumors can be found in younger people.  It should also be noted that less than 20 percent of people with tumor or polyps will have rectal bleeding.  However, when bleeding does occur, it is usually slow, chronic, and minimal.  Diagnosis requires careful evaluation with colonoscopy.

Rectal bleeding from a traumatic cause is always a critical concern.  Rectal damage from a gunshot wound or foreign body insertion can result in extensive infection or rapid and fatal blood loss.

And yes, there’s more!  A common source of bleeding is hemorrhage from the stomach or duodenum.  This can occur after someone has swallowed a foreign body that causes injury to the stomach lining or bleeding stomach ulcers.

The list does go on, but these conditions are rare; however, the message is that rectal bleeding must always be investigated.  Never ignore rectal bleeding!

Have you had the spring cough?

Have you had the spring cough yet?  If not, think yourself lucky, just about everyone else has had it.  And it isn’t one of those coughs which goes away in a couple of days, patients are saying it takes at least a couple of weeks.  Or even longer.

There are many reasons for epidemics such as these, and most occur with the change of seasons, hot to cold, cold to wet and so forth, but with the vast majority, the common carrier of the bug is the human race.  This time we can’t blame an innocent mosquito!

Yes, we are the ones who go to work and spread our germs to the office, exploding an aerosol of potentially debilitating diseases into the air, every time we cough.  This is the commonest way of transferring the bugs, by what we call droplet infection.  Every droplet capable of carrying thousands of microbes, each one looking for another human to infect.  You.  Or even me.  In our household, my young son brought it home from school, passing it on to his elder sister and now to me.  Thank you so much, Evan.

The latest bout has been a form of URTI, which is our acronym for Upper Respiratory Tract Infection.  This is inflammation of the bronchus, that part of your breathing tube to the lungs before it splits to become the right and left bronchus.  The medical name is therefore “Bronchitis”.  The clue is in the ending - “itis” which generally means inflammation and / or infection.  Thus you can get Appendicitis (inflammation of the Appendix) and Pharyngitis (inflammation of the pharynx), Laryngitis (inflammation of the larynx) etc., etc.; you get the picture.

Infection and irritation of the breathing tubes is, as we said in the beginning, very common.  The most usual predisposing cause is, however, our old friend cigarette smoking!  If you don’t believe that cigarette smoke is irritating, try letting cigarette smoke waft into your eyes and see how they will sting and water.  Your sinuses and bronchi do just the same!  Once the irritation begins, the mucous lining becomes swollen, and it becomes easier for the germs to take a hold.

With Bronchitis, it generally begins as a slight irritation deep in the back of your throat.  There can be some soreness as well, even on swallowing.  Unchecked this develops into a ‘productive’ cough, with loads of thick, tenacious gunk being coughed up, which we refer to as ‘sputum’.

One of the signs and symptoms your doctor will want to know is, “What color is your sputum?”  This gives us a chance to see if your cough is from an irritation or infection.  If you are bringing up large lumps of yellow or green glue then you have an infection, but if the mucous is clear then you probably do not harbor a nasty bacterium in your throat, but an equally nasty virus.  If however, the sputum is red and bloodstained then you may have burst a little blood vessel in the throat - or of course, this could be an early sign of lung cancer but don’t panic yet!

If the sputum you are coughing up is thick, green and gooey, this is fairly suspicious of a bacterial infection, and sometimes we will attempt to “grow” the bug to identify it.  No, this is not for germ warfare, it is just so that we can feed the bug some different antibiotics to see which ones exterminate the bug best.  This is a much more accurate way of choosing the correct antibiotic, than selecting ones by the pretty color they are on the pharmacist’s shelves.  And I don’t go along with trotting down to local pharmacy and getting “some antibiotics”.  That’s how we end up with antibiotic resistance.

If you have gone over a week and your cough is showing no sign of letting up then it really is time to line up with all the other coughers at the outpatients department.  Just make sure you can describe the color of your sputum!

Remember that if you are a smoker, the chances of the cough lasting longer are much higher, as well as your being more likely to catch the cough from someone else.

Cardiac unit diet - fast weight loss?

I met an old friend at a networking evening this month.  I hardly recognized him - he had lost 45 kg in weight.  “Did you have surgery?” I asked, thinking he might have had the sleeve gastrectomy which is the latest “keyhole” surgical procedure for obesity.  But no, diet was all he had done.

Now I do not know if it was this particular diet I have published here, but I do know that this one works.  It is not strictly a “diet”, it is more correctly a “weight loss” program.

One friend of mine had dropped 15 kilos in two months with this diet that obviously worked!  This is put forward as a seven day diet, and although I am not always in favor of ‘crash’ diets, this one does merit some study.  It is reputedly from Sacred Heart Memorial Hospital and is used in their cardiac care unit for overweight patients to lose weight prior to surgery.

It states the first no-no’s as being bread, alcohol, soft drinks, fried food or oil.  Agree totally, though probably half of you have already decided it’s too hard!

After that there is a concoction called Fat-Burning Soup (FBS) which you make up and keep in the fridge.  You gobble FBS any time you feel hungry and have as much as you want.  You are also advised to drink plenty of water suggesting 6 - 8 glasses a day along with tea, coffee, skim milk, unsweetened juice or cranberry juice.

The physiology of hunger works that when the stomach is empty, messages are sent to the brain to send down food.  Fill the belly with non-fattening food and the hunger pangs will be less, but the weight does not go on.

Here is the recipe for the Fat-Burning Soup:

4 cloves garlic

2 large cans crushed tomatoes (810gms)

2 large cans beef consommé

1 packet vegetable soup

1 bunch spring onions

1 bunch celery

2 cans French beans (or fresh)

2 green capsicum

1 kg carrots

10 cups water

Chop all veggies into small pieces.  Boil rapidly for 10 minutes stirring well and then simmer until veggies are tender.  Add water if necessary to make a thinner soup.

Now the other downside to dieting is food boredom.  A week of FBS, water and cranberry juice will sap the resolve of most overweight people, so what this diet does is allow you to add different items on a daily basis.  Here are the suggestions.

Day 1, any fruit except bananas.  Eat only soup and fruit.

Day 2, all vegetables.  Eat as much as you like of fresh, raw or canned vegetables.  Try to eat green leafy vegetables.  Eat vegetables along with soup.

Day 3, eat all the soup, fruit and veggies you want today.  If you have not cheated you should have lost approx 3 kg.  (If that is so, it is an amazing loss in three days - but keep going anyway!)

Day 4, bananas and skim milk.  Eat at least three large bananas and drink as much skim milk as you like today.  Eat as much soup as you want as well.  Bananas are high in calories and carbohydrates, as is the milk but you will need the potassium and carbohydrates today.

Day 5, beef and tomatoes.  You may have 600 gm of beef or chicken (no skin) and as many as 6 tomatoes.  Eat soup at least once.

Day 6, beef and vegetables.  Eat to your hearts content of beef and veggies.  You can even have 2-3 steaks (grilled) if you like with leafy green vegetables.  No baked potato.  Be sure to eat soup at least once.

Day 7, brown rice, vegetables, fruit juice.  Be sure to eat well and eat as much soup as you can.

By the end of day 7, if you have not cheated, you should have lost 7 kg.  The theory is good, but I caution against losing too much, too soon.

If your weight loss needs are greater than 7 kg, then continue for another week, but I do not recommend much further than two weeks at one time, and do not repeat the program within three months.

And if all else fails - then it’s sleeve gastrectomy!