by Dr. Iain Corness
Acute Sciatica isn’t very “cute”
I was reminded of just how painful
sciatica can be when a friend of mine found himself unable to move with
searing pain down the left leg. Fit and active middle-aged chap, a little
overweight but no warning signs. Just bang! Acute pain!
The medical name is “Sciatica”.
Why does this condition happen? Would it surprise you if I said that
‘vanity’ was one of the prime reasons we get back pain? The reason 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 what we call on people to do, from
mothers lifting babies to laborers lifting bags of pledged 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
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 -
the acute searing pain which can run from the buttocks, down the legs, even
all the way through to the toes.
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.
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. “Self diagnosis” is dangerous!
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 chaps you need to see.
One of my friends contacted me this
week with a query about insurance. Not as to whether he should have
insurance, but he was shopping around, not just looking for good deals,
but whether the insuring company was sound, and was it accepted by the
You see, being an international hospital we get patients from all over
the world, so much so that we have an insurance department to handle all
the international claims. And not all insurance companies are equal!
Some are more equal than others!
In addition, if you haven’t upgraded your cover recently, then you may
be in for a nasty surprise. Unfortunately, everything, be that petrol,
bread, or baby’s milk has gone up in price in the past 12 months. If you
haven’t upgraded there could be a shortfall, which you have to find (or
fund), not your insurance company. Remember that medical bills are all
yours – the insurance company just helps you pay them.
Of course, the next question is do you have medical insurance? If not,
perhaps it is time to chat to a reputable insurance agent! Yes, reliable
insurance agents and reliable insurance companies do exist, but you need
help through the minefield.
There are those who buy directly from the insurance company, claiming
they save money direct purchase, but then who is going to bat for you if
there is a disagreement? You may feel you are being hard done by if the
insurance company refuses a claim, but you are just a little policy
holder up against a giant corporation.
You also need help when it comes to filling out the application forms,
in my opinion. And you also need to be 100 percent truthful. Yes,
insurance companies will check on your records, sometimes requesting
extracts from your clinical notes going back 10 years. If it is found
that you have been sparing with the truth over pre-existing conditions,
expect a shock at settling up time at the cashier’s desk.
Remember too, that just because you have an insurance card does not
automatically signify that ‘everything’ is covered. This is why private
hospitals will ask you for a deposit on admission. If the insurance
company later verifies that you are indeed covered for that ailment or
condition, then you’ll get it back, but you have to prove that you are
covered, not the other way round!
And remember to get to know your insurance agent, it just makes for an
easier time when things are difficult.
You should also be prepared for some delays in confirming that the
insurance company will cover you. That is called a guarantee of payment,
known in the trade as a GOP. Without it you are liable for 100 percent
of the fees. If requested medical details are coming from your GP in the
UK for example, there can be even more delays, never mind the time
differential between Thailand and the UK.
Everyone seems to be knowledgeable on travel insurance, but remember
travel insurance is to cover the period of travel. Imagine you are in KL
and on the day you are leaving you are hit by a taxi. Head injury and a
broken leg. You are taken to ICU and then graduate to a ward after three
days. Your travel insurance expired three days ago. Where do you stand?
(With a broken leg, not very easily at all!)
It appears that most, but not all, travel insurance companies will
continue to pay for your hospital treatment – but for a limited time
only. “Get well soon” as the sympathy card says!
Mind you, do you really need medical insurance? The simple answer is
“yes”, particularly as an ex-pat. In your home country there is usually
a “safety net” government scheme, or even a comprehensive one like the
Australian Medicare. You are covered for your medical care with the
premiums taken out on your behalf by the taxation office.
However, that is not the case here! You are in the situation where you
are having to look after (and fund everything yourself), by yourself.
Government hospitals are not set up for you, a foreigner. They are there
for the Thai population. Don’t forget it!
Remember Al Whatsisname!
I have stopped worrying about
Alzheimer’s Disease. What between Google and my eleven year old daughter, I
can find anything. In the mornings when I leave home, there is Little Miss,
index finger outstretched, showing me just where I parked the car last night
and that I have forgotten my work book. And Google, the patron saint of
writers, is always there to remind me of the names I had forgotten. Now all
I have to do is get my brain hot-wired into a wireless network and I can
meet the world head on.
However, we’re not quite there yet, so we (you and me) we have to retain as
much cerebral function as we can. And it turns out that it is not all that
We have known for some time that if you don’t use your muscles, they waste
away. By not using your hands for physical work, the skin on your hands gets
thin. However, we also know that if you use your muscles again, the muscle
tissue builds up and becomes strong once more. If you use your hands again,
the skin builds up and becomes thicker. The message is simply that all is
not lost! Recovery is possible.
However, we were always told that the one organ of the body that could not
reverse the wasting process was the Central Nervous System. Once it started
to fail, that was it. Dementia was just around the corner. Do not pass go,
do not collect 200!
However, that view has recently been challenged and the results are
comforting, to say the least. Experiments have been carried out that showed
that by inducing stress in an animal resulted in chemicals being released.
This on its own was nothing new, but what was new was the fact that some of
these chemicals produced a difference in the brain’s anatomy! The idea that
the brain could not change was incorrect! It could be ‘short-circuited’
resulting in a new wiring pathways.
What was even more exciting was that if the animal was restored to its own
‘safe’ and non-threatening environment, then the brain reverted to its
pre-stressed anatomy! It was possible to ‘re-wire’ the brain.
In turn this has led to much research into the effects of stress and its
reversal, and then on to Alzheimer’s Disease (if I have remembered to spell
it correctly)! And if it were possible for its reversal too!
Returning to the research, we have shown that stress can physically damage
nerve cells used in storing memory. We have also found that mindless
watching of the goggle-box also produces a decline in brain function. In
fact the numbers are more worrying than that. It has now been found that
people with no stimulating leisure activities, and who are couch potatoes
instead, are nearly four times more likely to develop dementia compared to
those people who have leisure stimuli and do not waste hours in front of the
Taking that a step further, and turning the scientific data around to be
useful, it has been found that in being the converse to the couch potato,
intellectually stimulating leisure activities had a ‘protective’ effect for
the brain and its capabilities. What is more, they have also found that if
you are doing a job you enjoy, then this was again protective, but a dull
job with no stimulus or challenge was another way to head downhill.
This does not mean that we all have to take up chess tomorrow, because in
place of intellectually stimulating hobbies, it has been found that physical
exercise itself stops memory loss and stimulates growth of nerve cells.
Another protective factor appears to be marriage! Those who have never
married have twice as high an incidence of dementia than those who are
married. So there you are, rather than say that your wife is driving you
insane, it appears that she is driving you towards sanity instead. (I have
friends who would dispute that!)
So the secret towards staving off dementia and Al whatsisname’s disease is
to have a job you enjoy, get some exercise, watch a very limited amount of
TV and settle down with a good cook (sorry, that should have read “a good
Big boys don’t cry
The subject of this week’s article
follows a couple of tragic incidents recently.
Now, I’m not sure, but I think there was once a pop song with the line
“Big boys don’t cry” in it somewhere, but that is not important. What is
important is that if you came from a western society, you were probably
raised with that dictum. You probably even picked up your crying toddler
son after a tumble and said, “There, there. Big boys don’t cry. You’re
We are all guilty of promoting this stereotype. The big strong man who
protects the weak and vulnerable woman. Countless movies all follow this
theme from “Gone with the Wind” through to “Mission Impossible III”, so
it must be true. Unfortunately for all those big strong super-protective
men out there, the stereotype is not necessarily true and rigid
following of it can be quite contrary to good mental health.
“Men are far more reluctant to talk about their emotional
vulnerabilities than women,” says Dr Nicole Highet, a psychologist.
“This stigma may be due to the perception that emotional problems and
depression are women’s problems.”
“Men tend to be action-oriented, so they mistrust feelings and tend to
regard emotions as a sign of weakness,” says Dr Michael Dudley, a
psychiatrist and chairman of Suicide Prevention Australia. “For men,
mental illness is seen as a moral failing, so they bury pain and don’t
talk to people about it. But depression is an illness, not a weakness.”
Depression is an illness that can strike at any time, even to those
normally associated with dogged masculine determination. Famous amongst
these was Sir Winston Churchill, who guided the UK through the
tribulations of WWII, and who called his depression “the black dog”.
What has to be understood is that just “feeling down” on its own is not
a symptom of mental illness. We all feel down from time to time,
generally when something has happened to precipitate it, even the death
of a family pet. “We all feel sad from time to time, but depression is
an ongoing sadness that lasts for two weeks or more, with a complete
loss of pleasure in things that were once enjoyed. Some men live with
their condition for months, or even years, and become acclimatized to
their low mood or negativity,” says Dr Highet. “But depression isn’t
merely a passing blue mood or something that someone can ‘snap out of’
without help. Depression dramatically alters an individual’s body, mood
and thoughts,” she says.
Since men have been raised not to have public displays of depression,
many adopt strategies to cover the problem, with the common ways being
to become workaholics, risk taking to produce ‘highs’, alcohol and
“Men often try to manage their own symptoms,” says Dr Highet. “While
this may provide temporary relief, it only compounds the illness as they
are not addressing the underlying condition. There is also some debate
as to whether the (drug) abuse masks the symptoms or actually causes the
depression. Whichever way, getting help is essential.”
The incidence in the community is frightening. In Australia, which has a
well developed reporting system, it is believed that clinical depression
is Australia’s fastest growing illness. The National Survey of Mental
Health and Wellbeing found that one in four women and one in six men
suffered from depression. In 20 years it is predicted that depression
will be second only to heart disease as Australia’s biggest health
The enormity of the problem has remained hidden, but consider this:
Depressed men are four times as likely as depressed women to commit
suicide. Of the over 2,000 suicides in Australia each year, 80 percent
are male. There are more men committing suicide each year than dying on
the roads, and almost 50 percent of suicides are males aged 25 to 44.
While the causes of depression are multiple, and men try to mask their
problem, the sad part is that depression can be treated. Modern
pharmaceutical medication is not ‘mind altering’ but restores the
chemical balance in the brain to allow ‘normal’ thought processes to
However, it needs the men to admit that they might, just might, have a
The medical dangers of being ‘simpatico’
When I was still in my first intern
year, I scored a posting to Gibraltar, that rocky finger that hangs off
Spain in the Mediterranean. The rock was to be my abode for the next six
months, while I carried out my surgical term, and it was there that I was
exposed to the Spanish adjective ‘simpatico’.
Whilst similar to ‘sympathetic’ in English, it has a much deeper meaning in
Spanish and refers not only to how others see you, but also your own
Now while being considered as ‘simpatico’ would look to be an admirable
characteristic for a young doctor, it was something of a two-edged sword, as
I was to find out later.
The price is a reduction in the doctor’s personal quality time. As you
become more and more involved with the patients, whose needs encompass 24
hours, the young doctor ends up as a slave to not just the patients, but to
However, being an intern is a stressful time for young doctors. Quite
frankly, after graduation and a nice new shiny name badge, you do not know
enough about common conditions, but are expected to have encyclopedic
knowledge by the patients. In my own case, I was quite sure I could diagnose
an adenoma of the pancreas, but I had no idea what to do with a child with
earache. Like many professions you pick it up as you go – but not too many
professions have the ‘life or death’ tag attached.
In case you think that the pressures are not really that bad, after all, the
popular image of the young intern is one of permanently trying to get into
every nurse’s knickers in between bouts of beer swilling at the closest pub
to the hospital, this has to be based on fact, surely. Let me assure you
that the “Carry On” movie series was no reflection of the real medical
world. Being on call for 108 hours a week does not leave much time for
after-hours gynecological studies with Nurse Smith from ICU.
Stress? I can remember one of my consultants telling me that a 24 year old
female patient was going to die because her heart muscle had given out. I
could not believe that this was the case. Surely we could do something?
Unfortunately, all those years ago we could not. Heart transplants were yet
to come. Pacemakers likewise. The consultant knew when to ‘turn himself
off’. Junior Houseman Corness did not. I kept going back to her bed in the
ICU, willing her to live. She was only 24 for Pete’s sake. She died.
The result of such stress on doctors has been studied quite comprehensively,
and the respected New England Journal of Medicine published the results of
the research carried out by the Johns Hopkins University School of Medicine.
The Hopkins team assessed the specialty choices, marriage histories,
psychological characteristics, and other career and personal factors of
1,118 physicians who graduated from the Johns Hopkins University School of
Medicine from 1948 through 1964.
After decades of following 1,118 physicians who graduated from the Hopkins
School of Medicine between 1948 and 1964, researchers found a 51 percent
divorce rate for psychiatrists and 33 percent for surgeons, rates higher
than those for internists (24 percent), pediatricians and pathologists (each
22 percent). The study revealed a 32 percent overall physician divorce rate.
Results also strongly suggest that the high divorce risk in some specialties
may result from the inherent demands of the job as well as the emotional
experiences of physicians who enter those fields. Right! You’re telling me
nothing I don’t know (from bitter experience, I might add)!
The recommendation was, “Marital counseling during residency training
appears to be a good idea for family and career satisfaction in the long
My eldest son, Dr. Jonathan Corness, has the ‘simpatico’ gene and for that
reason I tried to talk him out of Medicine as his future. But when he
decided that being a Radiologist might be a better specialty than
Pediatrics, I applauded his decision. For people like Jonathan, one step
back from the frontline is a good career move. Unfortunately, I stayed at
the frontline too long.