Odysseys of George

There are a few principles to follow

1. Recognition of the snake
– this is important as the antivenom to administer depends on a correct identification.
– I suppose you can learn about the common snakes in your area or take a picture of the snake or draw it or if the adrenaline level is high and your neuronal function is a little numb from the events then you can try killing the snake.

2. Immobilisation
– the venom tends to spread rapidly mainly by way of lymphatic system
– application of bandages and splints as to immobilize the injured part and the patient is ultimately important.
– application of tourniquet should be sufficiently tight and not to the extent to prevent blood flow.
– Calm the patient down. Make sure you and the patient are in a safe area. Otherwise there will be two to treat.

3. Get to a nearby health facility early

4. The controversies

– Washing the wound
– some areas like in Australia they do not really recommend washing the wound as they can swab the wound for venom identification in their test kits. Others believe washing the wound would reduce the venom load. Personally I feel that washing increases movements and most of the venom is already deposited deep within the subcutaneous tissue.

- Cutting the wound and sucking the venom
– this is definitely not recommended anymore as the first rule in first aid is not to put oneself and your patient in danger. Drinking vinegar does not reduce the risk. But I notice many American based documents actually recommend suction without cutting and the special suction device kit for snake bites. Then again do we carry one everytime?

I wonder how many qualified first aiders carry a mask/face shield with them all the time? The face shield / mask is for mouth-to-mouth resuscitation and I keep one in the car and one in my wallet.

A 65 year old lady presented with an painful swelling over the umblicus which was progressively worsening. This was associated with more frequent episodes of vomiting and the inability to open her bowel and pass wind. Her abdomen was progressively inceaasing in size and this percipitated her already failing heart and poorly controlled diabetes causing her to be breathless and even more swollen. She was also morbidly obese. She was definitely not one of the best of patients but surgery is definitely indicated – earlier the better for her with such poor background history.
The diagnosis : Intestinal Obstructon from incarcerated / strangulated paraumbilical hernia.

It looks small but remember she is big.

This is the hernial sac which had an a short segment of the transverse colon stuck within the sac together with some omentum.

Sorry about picture quality – did not realise my batteries were dying.

The end result,

She got better and have started eating on day 2 after surgery. Yesterday night 4 days after surgery, I visited her to wish her Selamat Hari Raya before the long break and cought her munching away on some butter bun secretly while lying on her tummy as not to be seen by the nurses — no wonder her blood sugars does not seem to be coming down. And obviously her heart failure has subsided making her feel much better. Then again, some habits are hard to die and some lessons in life are too painful to learn.

I love to write in parts – makes me feel I am writing a story!

A hernia is a protrusion of an organ through a weak defect of the layer or tissue that covers it. Many types of hernia, the commonest being the inguinal hernias. My favourite however are what we call as the ventral hernias. These are protrusion of an organ within the abdomen through the anterior (ventral) abdominal wall . Examples:

Well, these are the commoner forms of ventral hernias — incisional (top 2 photos) and paraumblical hernias. Incisional hernias as the name states are hernias through the weak scar tissue from previous surgery.However, the defect or better known as the hernial neck, is usually broad and therefore seldom gives rise to strangulation. The paraumblical hernia however,occurs through a defect close to the umblicus and therefore the neck is narrow and the risk of strangulation is higher.

Surgery, whether laparoscopic or open is the only option in reducing the hernia and repairing the defect.

Open repair of the third photo

Laparoscopic repair of the first photo

Hernias left alone can lead to certain complications such as irreducible hernias, strangulated hernias and obstruction to the intestines.That brings me to part 2.

I received a call. This was yesterday. Across the line, I hear a familiar voice tainted by her sobbing. Through those, I heard the message that made me shiver. ” My cousin, she is 20, had a fit and collapsed.” Being in the medical line herself, she continued,”She arrived to the hospital with a GCS(Glasgow Coma Scale) of 3, intubated her and done a CTscan which shows a huge bleed within the brain. The Neurosurgical doctor saw and said that they cannot salvage her.” Silence was my response. Then the advice came and she felt better. I informed my colleagues in that hospital to have a look on my behalf. Then, I realised, probably as being part of the Transplant Organ Procurement (TOP) team for Selayang, I had to impress upon this doctor of organ donation.

Lying there in the hospital is a 20 year old lady who is brain dead but otherwise healthy. She will not survive. Then the faces of those who are in need flashes across. The baby with biliary cirrhosis whose only hope is a healthy liver. Another young lady with young kids to care for but cannot because she will slowly succumb to her failed kidneys. Another man with a large dilated heart failing with every contractions. Nobody sees them, nobody talks about them. All the above will survive for long if they replace their dysfunctioning organs.

Lying there is a 20 year old lady, who for once in her life during her dying hours can make the biggest selfless contribution and save at least another. The commonly transplanted organs are kidneys, heart, liver, lungs and pancreas while the transplantable tissues are eyes, bones, skin and heart valves. Thus a single donor can save the lives of a number of people.

But even the doctors are hard to convince! Some are reluctant to talk or find it shamefull to talk about it. I myself occasionally have difficulties even after successfully convinced at least 2 families to proceed with donations. I am young at this, I agree but there is no awareness created and a sense of need to approach this issue more seriously. This is not a topic thought in medical school and during your early years as a doctor unless your superiors were keen for organ donation little is learned and far from understood.

Is it enough just to sympathize or sholuld you push for donations for your other patients in need when an opportunity comes in however painful it may be!!

Patient’s relative in the grief of the moment do not take to such topics well unless they have had friends or family who have encountered similar issue. Often, the doctor would be seen as unjust and uncaring. We are sorry for being so blunt some times. Communication therefore plays an important role. I am happy I managed to attend a course on this but does the other doctors get the same opportunity? The TOP team are thought on how to communicate, counsel and pick up the bad non verbal cues and cool down the situation quickly rather then get entangled.

Normally, once a patient has been identified, some test are done to confirm that there is irreversible brain death. The doctors involved in confirming brain death are not involved in the transplant procedure.

The issues that came about were initially of religious matter.
For the Buddhist
From the Buddhist point of view, the donation of organs after one’s death for the purpose of restoring the life of another human being clearly constitutes an act of charity – which forms the basis or foundation of a spiritual or religious way of life.
href=”http://www.mst.org.my/MSC_religiousview_BuddhistAttitude.htm”

For the Muslims
The matter was discussed at the National Fatwa Committee meeting on June 23 and 24 in 1970. The committee, assisted by a panel of medical experts, made the decision to allow organ transplantation based on acceptable juridical principles.
href=”http://www.mst.org.my/MSC_religiousview_IslamandOrganDonation.htm”

For the Christians
The Christian Federation of Malaysia encourages all Christians to share Christ’s love with those who are in grave need of replacement for their dysfunctional organs. This should become an integral part of Christian education at home and in the church.
href=”http://www.mst.org.my/MSC_religiousview_AChristianPerspective.htm”

For the Hindus
a Hindu should do whatever is in his means, to eradicate sorrow and sufferings of others. To this end he may donate anything, including his organs, while living or at the time of death. If he can save the life of a patient by donating one of his organs.
href=”http://www.mst.org.my/MSC_religiousview_HinduismandTransplantation.htm”

The other is the ability of the family to say yes to their dying member of the family. For example, I have agreed for organ donation and sustain irreversible head injury, will my family members give consent on my behalf to proceed with the donation? Perhaps yes if I have clearly raised my views to them. What if I haven’t? Is holding a pledge card sufficient for family members to consent?

This is not a comfortable topic to talk about at home for most Asians. But talking about death should not be a taboo. Your wish once put forward makes it easier for beloved members of the family to act on your behalf. Is it fair to make others responsible for such a decision? So what would you do?

Some facts about over local scene:

Organ Transplant

The first organ transplant in Malaysia was a living related renal transplant that took place in Hospital Kuala Lumpur(HKL) on Dec 15th 1975. Since then a total of 1,005* renal transplants have been carried out in the country.
Heart transplant which is only carried out in Institut Jantung Negara(IJN) was first performed on Dec 18th 1997 and 15 heart transplantations have been done since then.
Liver transplant programme was started in 1995 at Subang Jaya Medical Centre(SJMC), and later in Selayang Hospital. To date, about 50 liver transplantations had been carried out with majority from living related donors to paediatric recipients.

*(Source:National Transplant Resource Centre, 30-11-2003)

Tissue Tansplant

Corneal transplants have been performed in Malaysia since the late sixties with a total of 1,231* reported cases.
Bone marrow transplant service was first started in University Hospital Kuala Lumpur for paediatric patients in 1987 and later for adults. This was followed by other centers in HKL (1994), Hospital University Kebangsaan Malaysia (HUKM) and SJMC. Up to November 2003, a total of 634* bone marrow transplantations had been performed, of which 372 were for paediatric and 262 for adult cases.
The first National Tissue Bank was set up in Hospital University Of Science Malaysia (HUSM), Kubang Kerian in 1991. The bank collects, processes, stores and provides tissues such as bone, skin, and amnion from both human and animal sources, to be used by surgeons nationwide as biomaterial or tissue grafts to replace diseased tissues. Total of 4,170 tissue grafts had been done until now. Bone banking services also started in HKL in 1993, a total of 483 grafts had been performed so far.

*(Source:National Transplant Resource Centre, 30-11-2003

Well as in the banner above, October is the official breast awareness month. In accordance, Selayang Hospital is holding a month long campaign with its official successful launch was on the 4th of October 2006. The campaign, led by our Breast & Endocrine Surgeon, Ms Azlina Firzah, was the first of its kind in Selayang Hospital.

According to the National Cancer Registry Report 2003, 31% of all cancer occuring among females were of breast cancer making it the leading cancer in women. In Selayang, women of above 30 have been reported to have breast cancer. Just today, a lady in her late 20′s were diagnosed to have breast cancer. There is no race predilection as breast cancer is the leading cancer in women of all races. If not mistaken the risk of a women getting breast cancer at present is 1 in 18. It could be higher than that as many cases are not reported.

Who is in charge? Women! Self breast examination is the single most important screening tool to pick up any lumps early. Sadly, many still feel reluctant to examine themselves and those who do and do find a lump, becomes worried and fearful of seeing a doctor. Some resign from examining themselves because they are worried they may find a lump. Breast cancer like most other cancers if diagnosed early has a better outcome. But yet, fear appears to be a dominant deterrent.

Once a lump is detected, triple assessment is performed to confirm and secure the diagnosis.
This consist of Clinical Assessment(history and breast examination), Radiological Assessment in the form of ultrasound or mammogram maybe both, and lastly a pathological assessment (Fine Needle Aspiration Cytology or Core Needle Biopsy).

Upon confirmation of the diagnosis, clinical staging is performed into Stage 1,2,3 or 4. In Stages 1,2 and some stage 3, the primary treatment is surgery. If possible, breast conservation surgery(BCS) maybe an option but post-operative radiotheraphy is a must. In all whether BCS or mastectomy, an axillary dissection is also performed. This is because axillary nodal status is the single most important prognostic factor in breast cancer.

After surgery, systemic treatment is usually required as even in early breast cancer, some cancer cells could have already travelled away from the primary source and these are called micrometastases. These may not show up until much later when they are reactivated and present themselves as secondary deposits in the lung, bone or liver. Thus, breast cancer is looked upon as a systemic disease and can be very challenging. Active after treatment monitoring and follow-up is therefore of importance.

Sites to check out:

http://www.radiologymalaysia.org/breasthealth

http://www.radiologymalaysia.org/breasthealth/BCWA/aboutbcwa.htm

http://www.radiologymalaysia.org/breasthealth/MBCC/index.htm

http://www.cancer.org.my/can_det_centre.htm

Strange? No, it actually looks like a butterfly from the front. The wings being the two right and left lobes, the body – the isthmus and the antenna – the pyramidal lobe, all of which are parts of an important structure in the body called the thyroid gland. It secretes a hormone for daily bodily functions called thyroxine. So?? Such a beautiful organ can go wrong in 3 ways:
1. Function — too active or too passive ( hyperthyroid / hypothyroid )
2. Size — it can just swell up and press onto the trachea or esophagus causing difficulty in breathing or swallowing
3. Combination of both
Medications can be used to control the function but surgery is usually the option for size or when medical treatment fails to control the dysfunction.Problem? — Surgery has a risk of injuring the nerve that supplies the vocal cords and in a case of one sided damage it causes hoarseness of voice and if both sides are damaged then it can cause loss of voice and difficulty and noisy breathing. thus the worry for both patients and surgeons though the risk is actually very small.

Well, there was this lovely 60 year old lady who came to see me for an swelling over the neck which had increased in size significantly over the last 6 months. A fine needle biopsy, an ultrasound and a CT scan all pointed to a non cancerous origin and made me more worried because clinically this looked and felt malignant.

So, after explaining in depth and a trip to redang, I came back to wiggle my scaple along the lady’s neck. So off I went chop!chop! swish! .. oops! maybe not! continue…… as the hours passed a huge 10cm by 8cm by 6cm left lobe mass was removed together with the nodular right lobe and isthmus. Total thyroidectomy done. At the end, it was a lesson in anatomy as all the structures were very visible.

Well, surgery went well. Though exhausted I was happy that her voice was salvaged.The butterfly gland was sent to pathology for reporting.

Probably will have a part 2 for the later outcome. Interested??