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Doctor's Consultation  by Dr. Iain Corness


Back pains recently?

Back pain is one of the most common reasons for a visit to the doctor.  I am sure you have had back pain yourself at some time or other.  Would it surprise you if I said that ‘vanity’ was one of the prime reasons we get back pain?  The reason you get a bad back is because our Neanderthal forefathers decided we looked better walking on our hind legs, instead of all four.  Just like a horse, the bones of our spines lock together nicely when we are on all fours, and weight can be carried easily on our backs.  However, when we stand up and try and lift, it all goes pear-shaped from there.  The spine was not designed to carry loads, or pick up loads, in the vertical position.

But unfortunately, lift and carry is a prime example of what we call on people to do, from mothers lifting babies to laborers lifting bags of rice.  The presenting situation is one we meet only too often.  The patient is doing something and suddenly everything locks up and they are immobilized, frozen to the spot.

Back pain is one of the commonest orthopedic problems, and the often used terms such as lumbago, sciatica and slipped discs are spoken about frequently.

Let’s look at the “slipped disc” problem.  First thing - discs do not “slip”.  They do not shoot out of the spaces between the vertebrae (the tower of cotton reels that makes up your spine) and produce pain that way.  The disc actually stays exactly where it is, but the center of the disc (called the nucleus) pops out through the edge of the disc and hits the nerve root.  When this happens you have a very painful condition, as anyone who has had a disc prolapse (our fancy name for the “popping out” bit) will tell you.  Think of the pain when the dentist starts drilling close to the tiny nerve in your tooth.  Well, the sciatic nerve is a large nerve!  When the nucleus of the disc hits the sciatic nerve, this produces the condition known as Sciatica - an acute searing pain which can run from the buttocks, down the legs, even all the way through to the toes.

Unfortunately, just to make diagnosis a little difficult you can get sciatica from other reasons as well as prolapsing discs.  It may just be soft tissue swelling from strain of the ligaments between the discs, or it could even be a form of arthritis.  Another complicating fact is that a strain may only produce enough tissue swelling in around 12 hours after the heavy lifting, so you go to bed OK and wake the next morning incapacitated.  And then you have to convince the employer that you did it on his time.

To accurately work out just what is happening requires bringing in those specialist doctors who can carry out extremely intricate forms of Medical Imaging called CT Scans, Spiral CT’s or MRI that will sort out whether it is a disc prolapse, arthritis or another soft tissue problem.  The equipment to do these procedures costs millions of baht, and the expertise to use them takes years of practice and experience.  This is one reason why some of these investigations can be expensive.

After the definitive diagnosis of your back condition has been made, then appropriate treatment can be instituted.  The forms of treatment can be just simply rest and some analgesics (pain killers), physiotherapy, operative intervention or anti-inflammatories and traction.

Now perhaps you can see why it is important to find the real cause for your aching back.  The treatment for some causes can be the wrong form of therapy for some of the other causes.

So what do you do when you get a painful back?  Rest and paracetamol is a safe start.  If it settles quickly, then just be a little careful with lifting and twisting for a couple of weeks and get on with your life as normal.  If, however, you are still in trouble after a couple of days rest, then it is time to see your doctor and get that definitive diagnosis.  It is the orthopedic Spine Clinic chaps you need to see.

Dengue Fever - it’s here again!

The female Aedes aegypti mosquito, which carries the Dengue virus, is here again.  With a vengeance.  Dengue fever is at epidemic proportions locally and the change in the weather is partly to blame (not to be confused with “climate change”, by the way).

Since the beginning of this year, dengue fever is reported to have resulted in nine deaths in Thailand from 7,000 people who went down with the disease.  The Disease Control Department says the rainy season which exists between May and June each year is usually a breeding period for the dengue virus. Now there will be those who say that nine deaths out of 7,000 isn’t enough to worry about - unless you are potentially the 10th one!

So, despite my previous pleas (and those of the Public Health Department), Dengue Fever and its potentially fatal variant, Dengue Hemorrhagic Fever (DHF) is still with us.  The latest figures have now prompted me to repeat my advice on this subject.  If you remember reading about it before, I apologize, but the subject matter is very important.  This is an important ailment that can be avoided.

However, first you should understand a little more about Dengue.  It was first described in 1780 by a Benjamin Rush in Philadelphia (so it didn’t start here) when the name Break Bone Fever was applied, with the symptoms of pain in the bones and rise in temperature.  The name “Dengue” came in 1828 during an epidemic in Cuba.  The new name was a Spanish attempt at a Swahili phrase “ki denga pepo” which describes a sudden cramping seizure caused by an evil spirit!  Let me assure you that the local brand of Dengue Fever owes nothing to spirits, evil, bottled or otherwise.

Like Malaria, the virus is carried by mosquitoes, this time by one called Aedes aegypti.  The virus itself is related to Japanese encephalitis, Murray Valley encephalitis and Yellow fever, and there are four “serotypes” or subgroups of it.

The mosquito lays its eggs in water containers, preferring the clean water found in water tanks and pots, in the saucers under pot plants and even under the pet’s food dish.  Inside discarded car tyres is another favorite spot.  These mosquitoes are not of the adventurous type and feed during the day and spend their time within 200 meters of their hatchery.  Consequently, the eradication of any local breeding areas becomes very important towards maintaining your own health, as you can see.  Keep your home free from lying water for a radius of 200 meters and you’re looking good!

Simple Dengue (if you can call it that) has an incubation period of around four to seven days and then the full blown symptoms of high fever and headache begin.  The headache is usually behind the eyes and is made worse by eye movement.  From there the pains progress to the limbs with acute muscle pains, which gave it the old name “Break Bone Fever”.  Interestingly, some patients complain of a metallic taste in the mouth.  (Please don’t ask - I have no idea why!)

On the other hand, Dengue Hemorrhagic Fever (DHF) can certainly be fatal!  It appears that Serotype 2 may be the culprit here, but does not usually produce DHF unless you have been previously bitten by types 1, 3 or 4.  In addition to the symptoms of Classical Dengue the skin begins to bruise very easily as the blood hemorrhages into the skin.  Children are generally more susceptible to this than adults.  This also becomes much more of an emergency and is best treated in the Intensive Care Unit (ICU) of your favorite hospital.

With our ability to treat the viral ailments being very limited, the defense against the Dengue virus lies in the preventive measures.  The other precautions are to wear long trousers and long sleeved shirts, especially at sun up and sun down, when the mosquito is at its most ravenous.  The other factor to remember is “D” for Dengue and “D” for DEET.  DEET is the magic ingredient in mosquito repellents, so when you go to buy some, check the label - if it has DEET, then get it.  And then remember to use it!

Is the medicine “natural” doctor?

I have touched on this before, but it needs to be looked at again.  More and more, we are being asked about the medication we prescribe.  Will it mix with something “natural” growing on trees?  And mentioning trees, I am also not a tree hugger.  I am sure trees, like us, have their bad hair days too, but they’ll have to get their hugs somewhere else I am afraid.  I once knew a tree hugger who stopped the man with a bulldozer tearing down a tree at the rear of her house.  12 months later the tree fell over on top of it, demolishing the kitchen and half the dining area.  Trees have obviously no sense of moral gratitude.

I am, however, a conventionally trained British/Australian style medical practitioner who has spent a lifetime practicing EBM, otherwise known as Evidence Based Medicine.  Practices that have been proven to work.

My training included six years at an Australian university that had a good name, and still does, despite undergraduates like me.  I am also proud of my final exams taken in the Royal Colleges of Physicians and Surgeons in London.  I have the honor to have my name listed in the ‘great book’ with luminaries such as Hunter, Jenner and Lister.  I am also indebted to my tutors during the 12 months of ‘pre-registration’, where you apply your limited knowledge under the supervision of senior specialists.  A safeguard for you, the general public.

The ‘powers that be’ are also ensuring that we keep up to date with a process called Continuous Medical Education (CME).  That medical education continues through to today, with CME lectures being attended by my hospital’s doctors, and myself.  Fortunately for me, the slides are in English, even though sometimes the lecture is not.

Those ‘powers that be’ also ensure that we prescribe drugs that are efficacious, that have been tested, and the evidence points to this.  It is not anecdotal evidence, but true scientific evidence shown by research in many countries, with hundreds of thousands of patients.  It is following that type of evidence, that I can recommend with all good faith, that 100 mg of aspirin a day is good medicine.  I also know that prescribing a ‘statin’ drug will lower your cholesterol levels.  They have been tested.  And these days, very rigorously indeed.

I am also the first to admit that we have sometimes managed to get it wrong.  The Thalidomide story still has living examples of this.  However, the medical world-wide network is cohesive enough to ensure that this drug was withdrawn.  It is the checks and balances system that has kept western medicine afloat.  This is not to be equated with the checks and balances system that have been incorrectly applied in the banking industry that sees the institutions on the brink of sinking!

I am often asked my opinion on “alternative” medicine, and all its diverse areas of ‘specialization’.  As a non-tree hugger I try to avoid direct confrontation over this.  If devotees have found that they can diagnose tumors by looking at patient’s auras through their third eye in the middle of their foreheads, then I am genuinely pleased, in fact delighted, provided that they have subjected the method to scientific scrutiny.

If various groups can cure cancer, epilepsy, halitosis or lock-jaw by inserting Himalayan grasses into a fundamental orifice, then again I am delighted.  This is a medical break-through, but as such, must be subjected to medical scrutiny.  If the method stands true scientific examination (not to be confused with anecdotal ‘evidence’) then it will be adopted by everyone, complete with thanks to those clever people who picked the Himalayan grasses in the first place.  After all, penicillin was tripped over, not designed.  But it has had a very rigorous scientific scrutiny since.

As far as the majority of ‘folk’ remedies is concerned, I work on the principle that if you ‘think’ it is doing you good, then it probably is.  But don’t ask me to endorse something that has not been scientifically tested.

When the ‘alternative’ group spends more time proving their methods, instead of complaining about non-acceptance, EBM practitioners will give them more credence.