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Doctor's Consultation  by Dr. Iain Corness


Update October 31, 2015

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 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 - 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.

Update October 24, 2015

Insurance again

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 hospital?
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!

Update October 17, 2015

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 difficult.

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 TV.

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 book”).

Update October 10, 2015

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 OK.” Correct?

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 illegal drugs.

“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 problem.

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 return.

However, it needs the men to admit that they might, just might, have a problem!

Update October 3, 2015

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 personal feelings.

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 the profession.

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 term.”

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.

HEADLINES [click on headline to view story]

Acute Sciatica isn’t very “cute”

Insurance again

Remember Al Whatsisname!

Big boys don’t cry

The medical dangers of being ‘simpatico’