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Update by Natrakorn Paewsoongnern
 
 
 

Doctor's Consultation  by Dr. Iain Corness

 

Is EBM good for you?

The practice of Medicine is a fascinating story that has unfolded over thousands of years. “Healers” have been part of most societies, and in ancient China, for example, you paid the doctor to remain well, not for treatment of your ailment. Now there’s an incentive bonus for you!

Then there are different kinds of “medicine” given such names as “conventional”, “alternative” and “complementary”.

These different ways at looking at the same subject (making you well) can be quite confusing, and for me much hangs on the term EBM, which stands for Evidence Based Medicine.

Mind you, it has also always been the case where people like to throw stones at conventional clinical medicine. Claims of over-servicing, over-prescribing and downright fraudulent practices are thrown about, citing someone whose uncle/friend/mother (delete that which is inappropriate) suffered at the hands of “bad” doctors who misdiagnosed the illness and the patient died.

Now, there are certainly some “bad” doctors out there, just as there are “bad” lawyers, “bad” real estate agents, “bad” mechanics and just about any profession you would like to think of. But they’re not all “bad”.

And me? I am a conventionally trained British/Australian style medical practitioner who has spent a lifetime practicing EBM. Practices that have been proven to work. Call it “good” medicine, if you like.

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 knowledge under the supervision of accredited specialists. An arduous road, but one that is 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.

Those ‘powers that be’ also try to 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 if you are prescribed a ‘statin’ drug it will lower your cholesterol levels. They have been tested.

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 conventional medicine afloat.

I am often asked my opinion on “alternative” medicine, and 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 actually cure cancer, epilepsy, halitosis or lock-jaw by inserting dandelions 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 dandelions in the first place. Ignore the claims that “Big Pharma” is suppressing cancer treatments. If someone has the answer, they will be multi-millionaires overnight.

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.


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Falling off the bed

Ever turned over in bed and the room began to spin? And you were sober? It could have been Benign Paroxysmal Positional Vertigo (BPPV).

This 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 don’t know!

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 can 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.


The will you make in the living not in the after-life?

I’m sorry, but I have it on good authority that you can’t take it with you. And that’s the reason why I’m not going. But to cover all eventualities, I have made out a will. And so should you. That’s your dying will – but you need to make another, and that’s called your “Living Will”.

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However, there is confusion in the minds of many people, as to what a “Living Will” actually is and what it covers. First off, it is not euthanasia. I repeat, it is not euthanasia. Borrowing from the Mayo Clinic in the US, it states on their website “This written, legal document spells out the types of medical treatments and life-sustaining measures you do and don’t want, such as mechanical breathing (respiration and ventilation), tube feeding or resuscitation.” The important words to note are “life sustaining” and “resuscitation”. Neither of these concepts imply medically assisted suicide.

Once again from the Mayo Clinic, “Injury, illness and death aren’t easy subjects to talk about, but by planning ahead you can ensure that you receive the type of medical care you want, to take the burden off your family of trying to guess at what you’d want done.”

Remember that we are talking about terminal situations here. Not situations from which it would be reasonably expected that you will recover and still have a good quality of life. A fractured hip when you are 90 is a serious situation, but provided you are healthy otherwise, then it would be expected that you would recover. You might need a stick for a while, but you would still be able to have a beer with your mates or whatever your pursuits were before the incident. In other words, the expectancy of a reasonable quality of life is there.

However, if you are in the terminal phase of metastatic cancer, which has progressed despite treatment, the future quality of life is not there. Artificially prolonging life under that situation is then covered by the Living Will.

As an example, note the following:

The Living Will is made while of sound mind. It is not something you scribble out while lying in God’s waiting room. An example of a Living Will. “Being of sound mind and understanding all the implications, I ask that this document be brought to the attention of any medical facility in whose care I happen to be, and to any person who may become responsible for my affairs.

“This is my ‘Living Will’ stating my wishes in that my life should not be artificially prolonged, if this sacrifices my Quality of Life.

“If, for any reason, I am diagnosed as being in a terminal condition, I wish that my treatment be designed to keep me comfortable and to relieve pain, and allow me to die as naturally as possible, with as much dignity as can be maintained under the circumstances.

“As well as the situation in which I have been diagnosed as being in a terminal condition, these instructions will apply to situations of permanently unconscious states and irreversible brain damage.

“In the case of a life-threatening condition, in which I am unconscious or otherwise unable to express my wishes, I hereby advise that I do not want to be kept alive on a life support system, and I do not want resuscitation, nor do I authorize, or give my consent to procedures being carried out which would compromise any Quality of Life that I might expect in the future.

“I ask that you are sensitive to and respectful of my wishes; and use the most appropriate measures that are consistent with my choices and encompass alleviation of pain and other physical symptoms; without attempting to prolong life.”

Now those are only examples. The Bangkok Hospital Pattaya has a pro forma Living Will, which was also repeated in the Pattaya City Expats website, I believe.

The take home message is that a Living Will is not euthanasia, and that you must lodge it, before you need it! The responsibility is yours, as nobody else can say any procedure was what you wanted (or didn’t want), if in the terminal stage of your life.


Lies, damned lies and then there is statistics

Will you live forever? I’m sorry to disappoint you, but statistically you have a 100 percent chance of dying. Yes, forget about “health” medications, statistics will prove it. Did you know, for example, that everyone dies within six months of their birthdays? They do, either before or after (do the math). Did you know that 95 percent of all the people who died in Pattaya last year wore shoes? The statistics would then have you believe that shoes were the greatest killer of mankind (not sure where that puts flip-flops).

A couple of years ago, the Cancer Council of Australia produced a sober warning message (at this time of year anyway), “Quit drinking to cut cancer risk.” The Cancer Council went on further to proclaim, “New evidence reveals the extent of alcohol’s contribution to cancer.”

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Now, having been photographed with the odd glass of wine in my hand on more than one occasion, I was immediately interested. Should I go on the wagon tomorrow? (“Today” was being a bit soon, I thought.)

I continued reading, “Cancer Council Australia has revised dramatically upwards its estimate of alcohol’s contribution to new cancer cases and issued its strongest warning yet that people worried by any link should avoid drinking altogether.”

It appeared that the cancers involved were bowel and breast and the figures indicated that these were nearly two-thirds of all alcohol-related cancers, overtaking those of the mouth, throat and esophagus.

More chilling news was that the Convener of the Public Health Association of Australia’s alcohol expert group, said he would write to the Australia and New Zealand Food Regulation Ministerial Council, to request it mandate health warnings on bottles. (It may be of interest to you that in Thailand there is an anti-alcohol group as well as the anti-smoking lobby).

Now there are many individuals predicting the end of the world, as well as Scandinavian teenagers, so how great a threat was this really? The group media release went on, “New evidence implicating alcohol in the development of bowel and breast cancer meant drinking probably caused about 5.6 percent of cancers in Australia. This was nearly double the 3.1 percent figure it nominated in its last assessment, in 2008.”

Using their own figures we are looking at 94.4 percent were not caused by alcohol.

So now we are getting to the nitty-gritty of all this. If we accept that they have managed to “prove” (beyond reasonable doubt) that alcohol does indeed “cause” 5.6 percent of cancers, what does this mean? Since breast and bowel cancers are only two thirds of the alcohol-related cancers (their mathematics, not mine), this means that together they make up 3.7 percent of the cancers in Australia. Let’s split the figure and make it 1.85 percent each. I remain somewhat underwhelmed, I am afraid. These figures can be read to suggest that 98.15 percent of breast cancers are not related to alcohol ingestion, and similarly the figures for bowel cancer.

Now don’t get me wrong here. I am not advocating we all get smashed every night, and indeed I do not think we should drink alcohol every day. However there are greater risks from alcohol intake than breast or bowel cancer. Liver damage for starters.

So if you are a person who likes a drink or three and would like to check your liver function we do have a GI and Liver Center that would be happy to check for you. Telephone 1719 for an appointment.


HEADLINES [click on headline to view story]

Is EBM good for you?

Falling off the bed

The will you make in the living not in the after-life?

Lies, damned lies and then there is statistics