Odysseys of George

A lady in her late 40s presented with passing black tarry foul smelling stools (malaena) for a few days prior to admission. This was the second episode after the first being a few days earlier.She was admitted then but was discharged home on a negative finding on endoscopy. On the day of admission, she fainted at home after complaining of feeling lightheaded.

She was admitted and an urgent upper endoscopy was performed. As we were about to withdraw the scope in disappointment, I caught a glimpse of this near the fundus and got excited!

Any takers?
The man responsible has my name too! Ha Ha Ha
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Many divers are introduced to this complication of diving during their basic open water course. However, many still are unsure of what decompression illness is all about, even those at much higher levels in their diving career. To make things worse, many medical personnel are also unprepared to handle such cases due to its rarity or assumed rarity of presentation. This assumption is however incorrect as more and more indulge into the sport of scuba diving.

Decompression illness is a disorder caused by bubbles forming in body tissues or in the blood where they should never be.

The source?

The first source is bubble formation from nitrogen that has been dissolved in tissues during the dive. This is otherwise known as DCS (Decompression Sickness)

- During descent and diving, air is breathed at increased pressure, and therefore more of the nitrogen molecules from the air can dissolve into the blood. The nitrogen enters the blood in the lung capillary bed, and is distributed to the tissues via the arteries where, nitrogen leaves the blood and diffuses into tissues.

- The deeper the dive, the faster the nitrogen is taken up from the air we breathe, and the longer the dive, the more time it has to accumulate in the tissues.

- During the ascent, pressure falls and less nitrogen can remain dissolved in the tissues and therefore, the nitrogen diffuses out of tissues and into the venous blood of the organs, back to the lungs for elimination. Ideally, this elimination process occurs fast enough to dissipate the nitrogen molecules without bubble formation.

- However, different tissues in the body have differing rates of elimination depending on their blood supply. Those with very good blood supply tend to accumulate and dissipate nitrogen fast and are called “fast” tissues. “Slower” tissues such as tendons are often not a problem after a short dive, even if it is deep, because they don’t have enough time to accumulate significant quantities of nitrogen but they become more important during long dives, or repetitive dives, when nitrogen can build up over a long time. Then there are the intermediates or “medium” tissues such as the nerves and spinal cord, where the accumulation is fast but the dissipation is slow especially if the bottom time is long or ascent is slightly faster.

- When nitrogen is not dissipated fast enough, the pressure of dissolved nitrogen will exceed the ambient (surrounding) pressure at some point during the ascent and the molecules of dissolved nitrogen will form bubbles.

- Bubbles formed in the blood (usually the venous system) are mainly filtered as it passes the lungs and rarely enters the arterial circulation except in foetus and some with a vascular heart anomaly (patent foramen ovale).

The second potential source of bubbles in DCI is the introduction of air bubbles to the arterial circulation because of lung overexpansion. This is better known as Arterial Gas Embolism(AGE)

- This has nothing to do with dissolved nitrogen, or time and depth for that matter. Indeed, this problem can arise during ascent from depths as shallow as 1 – 2 metres. The most important rule in scuba diving is “to breathe normally at all times; never hold your breath”. This is because any air trapped in the lungs during an ascent (by holding the breath for example), will expand as pressure decreases. If there is sufficient over-expansion of the lung it may rupture some of the small airways and the associated blood vessels. Such damage is referred to as pulmonary barotrauma.

- This barotrauma causes introduction of air bubbles to the lung capillary circulation which are then circulated throughout the body as air embolus. Bubbles arriving in the circulation of the brain may cause stroke-like symptoms. These arterial bubbles are therefore considered very dangerous.

Embolus = foreign particles that float and travel freely in the blood e.g air, clots
Arteries = blood vessels that carry blood from the heart to the rest of the body
Veins = blood vessels that carry blood from the body back to the heart

Taken from various reading.
( To be continued )

Feed small kids small fish

Last updated: Monday, January 07, 2008

Small kids should eat only small fish to avoid building up dangerously high levels of mercury, Australian health officials warned on Sunday following research on three Asian families who fed their children a rice and fish porridge called congee.

Their children, aged 15 months to two years, who had eaten congee - known as juk in Korea and chao in Vietnam - had up to five times normal mercury levels, according to a report in the Medical Journal of Australia.
Stephen Corbett, a doctor with the Sydney West Area Health Service, told reporters that fish of the right type in the right quantity was good for children’s nutrition.

“Two to three portions a week and small fish for small fry,” he advised, warning that mercury at even relatively low levels could affect children’s development.

Fish to avoid

Dr Lisa Szabo, chief scientist of the New South Wales Food Authority, said that parents had to worry about only six types of fish: shark, broadbill, swordfish, marlin, orange roughy and catfish.

“In part it’s because they’re bigger,” she said. “But they’re also longer-lived and they’re predatory fish, which means that they eat a lot of small fish so that’s why they tend to accumulate the mercury.”

Prior to hosting the Grand Rounds last week, I was interviewed by Nicholas Genes, for the Pre-Rounds Medscape Med Students.

The interview article was actually posted on the 12th November. Please feel free to check it out.

Surgeon Dives Deep to Display Photos of the OR and the Ocean Floor

Posted 12/11/2007

Nicholas Genes, MD, PhD

What does a starfish have in common with a gallbladder? They both possess a fascinating beauty, at least when photographed by Dr. Geeverughese C. George. A surgeon and frequent traveler, Dr. George shares his photos and thoughts online at The Odysseys of George. In our recent correspondence, Dr. George discussed his background, photography, and some of the differences in Malaysian medicine.

Dr. Genes: For a surgeon, you sure seem to live life to the fullest! Is that your interpretation of your site’s motto, “Vita non est vivere sed valere”?

Dr. George: Well, living life to the fullest is something I aim for everyday. There is more to life than just work and career achievements. I enjoy travelling and thus I try to take some time away to do this. Diving was always something that interested me, but due to some reasons, I only managed to do it a few years ago — and since then I’ve never regretted it and never looked back. It has also made me indulge in photography more, as the beauty beneath the seas is awesome.

The Odysseys of George hosts Grand Rounds
December 11, 2007

Dr. Genes: What camera do you use underwater? Is it the same as what you use for your pathology and OR photography?

Dr. George: I am using a “point and shoot” camera, and have yet to invest in a dSLR. I am using a Canon G7 with Ikelite casing and a strobe for underwater lighting. I use the same camera for my land and OR shots.

Dr. Genes: Because of your travels, you may have a better idea of what medical careers are like in other lands. How is Malaysia different? You’ve mentioned that half of Malaysian men smoke, that you see a lot of complications from uncontrolled diabetes; how does that affect your practice or your work schedule?

Dr. George: Malaysia is a developing country, and therefore there aren’t as many specialists or subspecialists as in the Western community. The health awareness here is just coming around, but we are still very far from reaching good or excellent healthcare service and goals.

Dr. Genes: How long have you been a surgeon? Are you specializing?

Dr. George: I am a general surgeon with interest in upper gastrointestinal surgery. I have been a surgeon for 3 years now.

Dr. Genes: How did you discover blogging? Do your colleagues know about your online activities?

Dr. George: Blogging came as an “incidental finding” while trying to find a mode of communication with my sister, who migrated to Australia. Then, my friends helped me get the hang of it, and the rest is history. Many here know of my blog, and I am not anonymous. Blogging is common, but whether it is accepted by my hospital is yet unknown. I suppose if I breach rules, then they wouldn’t be too happy.

Dr. Genes: What are some of your favorite posts? What do your readers seem to like on your site?

Dr. George: My favorite posts are actually my medical and diving ones. I notice that most readers are not too interested in political topics — they tend to respond more to my photography, which is very encouraging.

Dr. Genes: Readers will have an opportunity to see more of the world through Dr. George’s eyes when he hosts Grand Rounds on December 11, 2007. Visit his site to see the best in online medical writing from doctors, nurses, researchers, students, and healthcare professionals, all arranged and organized by Dr. George.

Thank you!

It was an honour when I was asked to host a blogrounds. Grand Rounds is the weekly collection of the best in online medical writing. Each week, a doctor, nurse, patient or healthcare professional hosts Grand Rounds and compiles links to noteworthy posts about medicine.

Well just to inform all my fellow bloggers worldwide, that I will be hosting the Grand Rounds on the 11th December 2007 and submissions are welcomed. Please send your best articles to my email as is on my blog, drgcgeorge[at]gmail[dot]com, with the subject as Grand Rounds.

The deadline for submissions will be on Sunday 9th December 2007 at midnight(GMT+8). Please also give a brief summary of your submission.

Thank you

As I sat in my clinic, another doctor walked in and carefully unfolded a neatly wrapped paper. He then showed me the contents and asked me to guess what it was.

I know it isn’t clear, but care to guess?

“They look like gravel”, I answered. He smiled and said he thought as much. The story…..

This lady was told to have gallstones and decided to seek the aid of a traditional healer. This traditional healer took a lemon and started to rub it on her abdomen. He then cut the lemon and lo and behold, he showed her these stones and told her that it was gallstones!

I guess she was a little bit smarter as she second guessed him and decided to show these stones to us.

What shocked me is how many more people are out there believing such scam! Well, this is how gallstones look like!

or

So, please, traditional medicine is meant to be complementary but not primary treatment. And like what some would say - there are no simple way - no pain, no gain!