Odysseys of George

A 14 year old boy, presented with sudden episode of bleeding per anus. Both OGDS and colonoscopy was negative and the bleeding persisted. He was then referred to us for an angiogram.

Any idea?

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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!

Welcome to Odysseys of George. I received many submissions of which I had to make a choice. As the morning comes, I greet you with the scones and tea I laid out for you earlier.

Now, I present to you, Grand Rounds 4.12 with a diving theme. Gear up your booties and wetsuits and carry along your tanks as we backroll into the depths of the medical blogsphere.

As important as the fishes are to the sea, so are our patients are to us, healthcare providers. There were many articles on patients and their ordeal but these took to my attention.

As we descend, Trauma Queen puts up with fat chance of getting an ill lady into the ambulance. This article would probably make you put down your meal immediately and reassess yourself. And if you think you have put on the extra kilos and wish to shed them surgically, then perhaps Christian Bachmann could give you the statistics! And if you think that the topic of obesity stops here, Sandy Szwarc gives us a reality check that obesity has become the greatest threat to the lives of pregnant women.

Marine lives are extremely sensitive but not as sensitive as this almost comical post submitted by Susan Palwick of an ER patient who causes duress among the ER staff for being racist.

Diving into the underwater world is a like exploring a dream or fantasy. What more would it be for these sick children as their dreams becomes a reality. ValJones writes on Tear Jerkers a heart wrenching story of the efforts by Make-A-Wish Foundation to make these children’s dream a reality.

As we continue to descend, we find a wide variety of marine life.

The variety of marine life and their colours begin to stand out even more for Dean Moyer’s patient who had Lasik eye surgery done. However, Dr. T found himself becoming the patient and he writes about it in his blog as Post-op Dr T.

Swimming in a file, these batfish appears to adhere to certain etiquette. Talking about etiquette, Counting Sheep wrote a nice article on the 11 rules of the Operating Room!

These cleaner fish, reminds me of the hard working and dedicated nurses we have taking care of our patients.
Why Should I Be A Nurse? by Kim relates an article she had wanted to write for a long time but what touched me was of course, the greatest reason for choosing to be a nurse ……

Sometimes we tend to follow the pack not realising the we as physicians have certain stands to make. An example to this would be as Toni Brayer wrote about the Physician’s ethical and legal role in Force Feeding prisoners.

As we reach the depths of 28metres, we meet these graceful yet feared creatures of the sea.

However, these creatures have become controversial issue as many of them lay dead for their fins.

Controversies occur in medicine too. One of such is “The Blasphemy of C-peptide Removal” by DiabetesMine.com. The issue is that there is some scientific evidence indicating that C-peptide can improve neuropathy, kidney function, and high blood pressure in Type 1 diabetics — and yet insulin manufacturers have done away with the C-peptide, some say, because they don’t find it profitable. Or is the evidence strong enough?

Then we have patients who are so misconstrued in their thinking that expensive means excellence as KOLAHUN writes the Costs of Medicine.

Henry Stern poses a controversial question, “Why would someone buy meds and then not take them?” in his article Drugs Don’t Work and perhaps after reading his article, we wonder whether we are all doing something of that sort too!

But some pharmaceuticals seem to change their marketing strategies.
Rx drug maker directly engaging bloggers? writes Dmitriy Kruglyak. A biopharma specializing in drugs to treat and manage neurological diseases, sleep disorders, cancer, pain and addiction are hosting a webcast featuring a Q&A with Jeffrey M. Dayno, MD, VP of Medical Services on Thursday, December 13, 1:30 – 3:00 p.m. EST. Check it out!

And as we begin to surface, we realize the need for government agencies and marine groups to unite and maintain the marine life, just as in health services too.

Prudence writes passionately about the role of religion and health when the government of Phillipines clashes with the church as the church manages to hinder the country’s progress in controlling STDs and other reproductive health problems.

Another Milk in the Wall by Disease Proof talks about an issue where there would be lunch wardens patrolling the lunchroom to make sure all kids finish their milk. “We don’t need no thought control…Teachers leave them kids alone,” goes the classic Pink Floyd song.

Then perhaps Nancy Brown, would insist that children and teens in the United States need more milk, sunshine, and exercise!. But then again these are two totally differing issues or is it?

Diving has become my passion and hobby and having a hobby is important. Some are into techno and others into land based hobbies. There were two articles in this, which were,

Digital Pedometers by Joshua Schwimmer who has found a weight loss gadget which counts steps for his patients. Since counting the steps yourself is impractical even for the truly obsessive, the best way to target 10,000 steps a day (roughly equivalent to half an hour of walking) is to use a pedometer.

And for those with love for the outdoors, Paul Auerbach, takes this opportunity to make you aware of the International Journal of Wilderness. The journal is published three times a year.

And if all this reading has caused you to develop neck pain, Jolie Bookspan has some tips to fix the pain. Hopefully, once you feel better, we can move on to next week where SHP, a junior psychiatrist, will host the Grand Rounds 4.13.

Before we set off for the festive season and holidays, I shall strongly urge you to get aid from Nurse Hilary to help you beat the holiday blues, thanks to Mother Jones. Kerri Morrone, on the other hand, writes about the willpower it takes to make it through the holiday season without tossing all health cares to the wind.

Merry Christmas and Happy Holidays to all!