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Update May 2018

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Update by Natrakorn Paewsoongnern

Doctor's Consultation  by Dr. Iain Corness


May 26, 2018 - June 1, 2018

The waiting list

Long before personal computers, smart-phones and other digital devices were given to us, there was the Dictaphone.  This was really just a fancy name for a tape recorder, but its purpose in Medicine was to expedite the letters to the GP’s who had sent in patients to the hospital.

The hospital authorities realized that to leave the Junior House Officers (of which I was one), who were already overworked, to type their own letters would produce another ‘choke point’.  The advent of the Dictaphone would speed up the whole process and everyone would be happy.  Well, that was the objective.  The reality was, as is often the case, not as smooth as imagined by the authorities.

The first problem was that there were nowhere near enough Dictaphones.  The second was that there were nowhere near enough secretaries, so the hospital was still receiving calls from angry GP’s who were seeing patients in their rooms they had sent to the hospital, who had been admitted, treated, discharged and the GP had not been informed of the diagnosis, treatment given, and when follow up was to take place.  As you can imagine, continuity of care is important.

The following is a true record of a Dictaphone medical report.  The Doctor was a Colin Wilmshurst and the GP I have called Dr. Brown and the patient I have called Mr. Smith.  I was in the next cubicle which allowed me to eavesdrop.

The next important item is ‘bunions’.  These are bony outgrowths on the inner side of the joint for the big toe.  They can grow quite large and are unsightly and make it very difficult to wear shoes.  In fact, many people with bunions will cut their shoe over the bunion so that they can actually wear the shoe.

But back to my story, which by the way is totally true.  It was 1967 and Colin began with the usual address, “Dear Dr, Brown, Thank you for sending in your patient Mr. Smith, and I agree totally with your diagnosis.  He has indeed bilateral bunions (bunions on both feet.)  This being the case, it will be necessary to admit him for an operation by one of the orthopedic surgeons.

Unfortunately there is quite a waiting list for non-urgent procedures, but I confidently expect we will admit him for surgery in the early 1970’s.  In the meantime I have advised him to wear thick socks!”

That was the situation with waiting lists in those days, and although things in the UK are not quite as bad these days, there are still long waiting lists for non-urgent cases.

A couple of years back, when my dear old Mum was still alive, she was admitted with an irregular pulse to a hospital in Scotland.  She ended up being there for three weeks, not that she needed all that time in hospital, most of the time was waiting for the doctor, waiting for the EKG machine to be free, waiting for the specialist, waiting for the report to be signed by the consultant, waiting for the social worker to look at Mum’s house.  I can honestly say if Mum had been here in my hospital in Pattaya, she would have been examined, a diagnosis made and treatment instituted within two days.  Yes, I realize we have a private hospital here and Mum was in an NHS hospital in the UK, but if the UK could use the same model as ourselves, there wouldn’t be so many waiting for a vacant hospital bed.

May 19, 2018 - May 25, 2018

Growing old – the end game

Many seniors will tell you just how dreadful old age really is.  However, even if you don’t like getting older, with all the attendant aches and pains, it still beats the alternative!

There are also people like my father who was only afraid of one thing – growing old.  So he didn’t.  He died aged 56 of a massive heart attack, and missed the enjoyment of watching children and grandchildren grow up, and holiday travel, because for pensioners, every day is a holiday.

Fact Number 1: we are all getting older.  Not wiser nor necessarily richer, just older.  Just keep your seat reserved in God’s waiting room and you’ll be right.

OK, so we are all living longer, what can we do to get our arthritic hands on the elixir of youth?  If you believe the popular press, the answer to aging is multivitamins.  Peddling mega-vitamins is a megabuck industry, credited with improving your health, your love life and fixing everything from falling hair to falling stock markets.

The question is, should you take daily doses of antioxidants such as beta carotene, vitamin A and C or selenium to protect yourself against cancer, heart disease or tinea?  There is some scientific suggestion that people who have a high level of antioxidants in their diet may have a lower risk of heart disease and certain cancers.  That is why the nutritionists say we should eat at least five portions of fruit and vegetables a day.  However, other studies also seem to suggest that taking those same antioxidants in pill form may not have the same effect and may even be harmful.  Who do you believe?

Cancer Research UK says, “These products don’t seem to give the same benefits as vitamins that naturally occur in our food.”

The British Heart Foundation agrees, “Research does not support the claim that taking extra antioxidants in the form of supplements will benefit the heart.”

Catherine Collins, chief dietitian at St George’s Hospital in London says, “The whole idea that you must meet some vitamin and mineral target every day of your life is a marketing myth.  You can eat lots of fruit and veg one day and not much the next but over a week you will still get the right amount of nutrients.  There is very little scientific evidence that there is any benefit whatsoever in taking a daily multivitamin – even in old people.  You cannot exist on a poor diet then shore yourself up with a multivitamin.  The idea that taking high quantities of vitamins will give you a health boost – like putting premium petrol in your car – is complete nonsense.”

Dr Toni Steer, nutritionist with the British Medical Research Council’s Human Nutrition Research in Cambridge, states supplements cannot compete with real food because when we eat fruits and vegetables the vitamins and nutrients interact with other chemicals to produce positive effects on the body.  “If these same vitamins are pulled out and isolated in pill form, there is no guarantee at all that they will have the same effect.”  This is the old in vivo and in vitro argument.

Another nail in the multivitamin pill coffin came from the US journal of the National Cancer Institute which found that men with prostate cancer who took more than seven multivitamins a week were 30 percent more likely to get an advanced and fatal form of the disease.

The American Medical Association found that people who took antioxidant vitamin tablets (particularly vitamins A and E, and beta-carotene) were more likely to die earlier than those who did not.  Oops!  That isn’t something you will read on the back of the multivitamin bottle.

Let’s look at the old Vitamin C to ward off the common cold, as proposed many years ago by Linus Pauling.  Common claim: one gram doses will ward off or even cure the common cold.  Reality check: the human body can absorb only 500 milligrams of vitamin C and will excrete the excess.  Vitamin C reduces the average length of a common cold from five days to four and a half – if you are lucky.

The answer in staying young is to stay active, keep the mind exercised and do things you enjoy.  Just do it!

May 12, 2018 - May 18, 2018

Feeling a little ‘liverish’ today?

Have you ever stopped to consider that the most important organs you have are all singletons, while with the less important ones you have a back-up duplicate? You have two lungs and you can get by on one, kidneys ditto, eyes ditto, hands ditto. But you only have one brain, one heart, one bladder, one uterus (ladies), one Willy (men) and one liver.

Yes, one liver, one of the more important organs you possess. Without it you will die, whereas you can get by without a kidney, or a lung or an eye, for example. Yes, I’d rate my liver above my kidney any day.

So what does this liver do? Think of your liver as a filtering and de-toxifying device. Chemicals are taken up by the liver, to be broken down into non-toxic chemicals, all to protect your total system. Clever organ your liver.

The most well-known liver toxin is our old friend Ethanol, more usually referred to as grog or booze. That alcohol affects the liver is well known, with the end result being called Cirrhosis, a kind of fibrous hardening of the liver which then becomes unable to carry out its job correctly. Toxins build up. You feel unwell and it’s all downhill from there.

But the list does not end there either. Some proprietary or prescription drugs can produce an inflammation of the liver tissues too. Or worse, produce a breakdown of the liver tissue itself. Amongst these is the headache medication paracetamol (the ubiquitous headache tablets, for example), but before you throw them out of your bathroom cabinet, it requires some heavy and very frequent dosage of paracetamol to do this. Remember Paracelsus: “Dosage alone determines poisoning.”

Other prescription items that may produce liver problems include Methyldopa, several penicillins, Simvastatin (the cholesterol lowering drug), Diclofenac (a non-steroidal anti-inflammatory) and Ketoconazole (anti-fungal).

So we all know that prescription drugs (even though you can get most of them over the counter in Thailand) can be dangerous, that’s why they have a PI (patient information) leaflet inside the box, but what about “Health” food preparations? The purveyors of these all cite the fact that the ingredients are “natural” so everyone assumes that this means “safe”. Not quite so fast, I’m afraid. Lead, for example, is a naturally occurring compound, and not much good for young kidneys. However, since we are talking about liver problems, hands up all those of you who have heard of Echinacea? Supposedly fixes everything from falling hair to fallen arches - but is it “safe”? Well, Echinacea, along with Kombucha Tea are two of the commonest compounds showing a well-documented history of being toxic to the liver. So if you’re sipping Kombucha tea because you’ve drunk too much alcohol, I would suggest that you stop right now!

Others for sale in the Health Food shops with known toxic effects on the liver include Evening primrose oil, Valerian, Chaparral, Japanese Daisaiko-to (for dyspepsia), Chinese Jin-bu-huan and several forms of herbal teas such as those from Heliotroprium, Senecio crotalaria and Symphytum. Makes you think that the ‘Health’ shops that sell them may be incorrectly named, doesn’t it!

But while the column this week seems to be spreading doom, gloom and disaster, it’s not quite that bad. There are tests we can do to see if the liver is in trouble. Liver enzymes can be measured in the blood and a Fibroscan will show if the liver is getting fibrous, on its way to Cirrhosis.

The other good news is the fact that the liver is a very powerful organ and is capable of regenerating itself quite quickly, so in most cases of toxicity following ingestion of chemical compounds, by stopping taking them, the liver recovers and the patient feels well again.

So remember that if you are taking anything regularly and you feel unwell, it may be the liver - but tell your doctor everything you have been taking! And no thanks, I’ll give the herbal tea a miss today.

May 5, 2018 - May 11, 2018

True tales from the examination couch

I have been a doctor for more years than the length of time some of the readers here have propped up a long wooden bar with a nubile hovering near their wallets. Yes, I’ve seen quite a few changes in the art of medicine in my time, and it is an art keeping patients happy while the treatment seems to be so slow in some cases.

Remember the five inch floppy? Not the computer one, but the one we didn’t talk about 30 years ago, so secret that we didn’t even refer to it by name, but used the acronym ED. That stood for (I can say it in these enlightened days) Erectile Dysfunction. Roughly explained as the inability of the penis (another word not often spoken in polite company, which I usually refer to as Willy the Wonder Wand), to get erect to carry out its number one function in a man’s life.

ED caused marriages to fold as men with the affliction looked for a lady with the key to making the member remember its function. And then along came Alprostadil, and this was long before the blue diamonds.

As a GP working on the frontline of medicine you were brought up to speed on the latest developments by the detailers, and a rather breathless chappie came to see me to tell me about Alprostadil, the wonder drug that could put the lead back in any man’s pencil.

One would imagine that the cheers would be heard everywhere at the bar with its attendant nubile, but there was one drawback. Alprostadil only worked by injection. And that injection was directly into the penis. Definitely cringe material.

As a medical student we were supposed to be able to get blood samples from our classmate’s thumbs. That of course was someone else’s thumb, but which of my fellow undergraduates would I trust with mine? Simple answer – none of them, so I spent 30 fruitless minutes chasing my thumb around the room. And that was for a thumb prick. Imagine the problems with a different prick.

What the treating GP had to do was get over the innate reluctance of patients exposing one’s member, and then teach the patient how to inject the Alprostadil. To make this even more of a hit and miss, the dosage was not accurately known and we were told that the first injection should be done in the surgery and then send the patient off having guessed the dose, probably somewhere in the middle of the dosage range. In addition, the patient was to telephone the GP in the morning to report back so we could get some idea of dose and result.

My first patient in need was an Aussie welder, blue Jacky Howe singlet and all. These are the salt of the earth characters, with the blue singlet very much an Australian icon, originally worn by shearers and now adopted by the blue collar workers. “Can’t do me homework Doc,” he said, getting straight to the point as Aussies do. After examination and history taking, he was certainly suffering from ED. So following explanation and an embarrassed demonstration by both doctor and patient, he hared off to see if he would get a pass for his homework that evening, and with the promise to ring me in the morning.

First call was my welder, “How did you go?” said I. The reply was straight to the point, “Best root I’ve had in years!” (Forgive the Aussie vernacular, but that’s how Australian welders talk.)

Delighted I congratulated him, but he went on a little further. “I think we should cut the dose down a little, Doc.”


“They could have picked me up by the legs this morning and ploughed the front yard with me!”

I admit I was unable to stifle my laughter, but my patient didn’t worry. “When’s me next injection, Doc?”

With the advent of Viagra (Sildenafil, AKA the blue diamonds) the need for Alprostadil waned, but is still used today for those ED sufferers for whom Sildenafil is not getting them a pass on their homework.

April 28, 2018 - May 4, 2018

Check-ups. Worthwhile? Or a waste of time?

Check-ups are inherently involved in that important feature called the Quality of Life. Longevity alone, with no Quality, just isn’t worth having. Being stuck in a wheelchair as a double amputee for the last 20 years of your life because you did not know you had diabetes is not the Quality I would want.

Check-ups are designed to find deviations from normal health patterns at an early stage. Early enough to reverse the trend, before damage has occurred. This includes high Blood Pressure (BP), a significant factor in poor future health if unchecked now. Unfortunately, elevated BP generally gives no warning symptoms.

Now blood sugar. It requires sky-high sugar levels before you begin to feel that something might be wrong. By then the sugar levels have affected vision, the vascular system and many other systems, all of which can decrease your future Quality of Life.

Cardiac conditions are very easily found during a routine check-up. Blood tests and an ECG (EKG) can show just how well the heart is functioning. The inability to walk more than 30 meters certainly takes the fun out of shopping!

Other silent killers can be discovered in your lipid profile, with Cholesterol and its fractions HDL and LDL being intimately connected with your heart’s health. Detecting abnormalities now can mean that you can get through the deadly 50-60 year age bracket with clean coronary arteries and a clean bill of health.

There are so many conditions that can affect your enjoyment of the future, but can be discovered early. Renal (kidney) function and liver function can be monitored through an annual check-up, as can prostate size (indicated by the PSA blood test) or breast tumors (by mammogram).

My hospital has check-up packages, but unfortunately asking “What package should I have,” is like asking “How long is a piece of string?” However, there are some general guidelines depending on your age and your personal and family medical histories.

If you are a non-smoker, under 30 years old, play sport every weekend, train regularly during the week, have never visited a doctor other than childhood immunizations and have grandparents alive and well, then a very simple general check-up is all that is needed. You are not at high risk, but it is good to have a baseline to compare against as you get older! If everything is normal, then a repeat check every two years will be fine.

If you are under 40 years of age, but have given up the regular training and weekend sport, you are in a somewhat different situation. Your ‘risk’ category is higher and now is the time to look at your cardiovascular system in particular. Lipid (blood fats) profile and a check on your red and white cells and a blood sugar reading will cover most major future problem areas. If both grandparents are still around, and your check-ups have been normal, then continue your biennial check-ups, but if the grandparents have popped their clogs, then step up the frequency to annually.

By the time you are in the 40-50 age bracket, now is the time you should be looking at exercise stress tests and vascular screening. Now is also the time to apply yourself to correct any lifestyle factors which are going against your general health. By the way, if you are female then you should throw a Pap Smear into the annual equation as well.

But it gets worse! When you pass the magic 50 number, you are considered to be ‘at risk’. If you have become overweight, smoke cigarettes and get no exercise, then you have a much greater risk. If you are a male, then you should add in your prostate screen, the PSA blood test.

By the time you pass 60, then it is prudent to check everything from head to toe. Really! If you are having any doubts about your health, then it might be worth the indulgence.

If you have been having some symptoms of ill health, or have a poor family history, then discus these with your doctor before deciding which check-up package and add-ons you should have. The important factor is to get into the habit of regular check-ups. Your family will thank you.

HEADLINES [click on headline to view story]

The waiting list

Growing old – the end game

Feeling a little ‘liverish’ today?

True tales from the examination couch

Check-ups. Worthwhile? Or a waste of time?



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