Year: 2008

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A Dirty Wound Can Be Dangerous

During my recent family holiday, we took a day trip to a very small island of Barbuda. Barbuda is a flat coral island with an area of only 68 square miles. The island’s population of 1500 live in the village of Codrington. It is renowned for its beaches which are natural, sprinkled with pink sand, and miles long.

We were with a group of other tourists including a family doctor from England who stayed at the same hotel as we did and knew I was a surgeon. So, here we are, climbing rocks and exploring a cave. I turned around to take a picture, tripped and fell on a rock. My right leg sustained a deep nasty dirty wound with blood gushing all over the place and a piece of my precious skin and flesh lying on the bloody ground.

There was momentary panic amongst my fellow tourists when the English doctor announced with confidence, “Don’t worry, he is a surgeon!” That lightened the situation with several people offering their shirts to use as a bandage to stop the profuse bleeding.

In my mind I knew this was a serious situation. I immediately thought of two very life threatening outcomes from this episode, loss of limb or life from tetanus or flesh-eating disease. Before my trip, I had a booster dose of tetanus toxoid vaccine. But what about flesh-eating disease?

Flesh-eating disease is a form of streptococcal infection that leads to death of tissues. It is a deep-seated infection under the skin. It progressively destroys fat, fascia and muscles. The condition is also known as necrotizing fasciitis.

Streptococci (invasive group A hemolytic streptococci) may act alone or in combination with other bacteria. The infection spreads rapidly. Shock and multi-organ failure are common. Mortality is high, up to 58 percent.

Fortunately, the disease is not that common. In Canada, it is estimated that 90 to 200 cases of necrotizing fasciitis occur each year. From time to time the disease hits the headlines. Then there is long silence before another case is reported. This leaves people wondering what is this all about.

The most famous case of flesh-eating disease was Loucien Bouchard, the former premier of Quebec. He luckily survived and had to have one leg amputated.

It is not a new disease. The condition was first described in a specific body region by Fournier in 1883 and as a more generalized condition by Meleney in 1924.

Early diagnosis of this condition is not always easy. The diagnosis is clinical. Initially, it is hard to differentiate from ordinary infection of the skin. But gradually patients get very sick. The pain is more severe than the clinical findings. There are only minor changes in the skin in early phases. Unfortunately, the current state of knowledge on diagnoses and management is limited.

If the diagnosis is in doubt then surgical exploration is the best way to go. The characteristic finding is of grey, edematous fat, which strips off the underlying fascia with a sweep of the finger. Deeper changes are invariably more widespread than the skin changes.

Tetanus and flesh-eating disease are two extreme examples of how small things can get out of hand if no action is taken right away. There are many other kinds of infections which can affect dirty wounds. Even clean wounds like surgical incisions can get infected. Although the incidence of that happening is very low compared to a dirty wound.

If you sustain a dirty wound, including stepping on a dirty nail, make sure the area is thoroughly cleaned, your tetanus vaccine is up-to-date, you receive appropriate antibiotics to prevent infection and carefully monitor the progress of the wound. Before you travel abroad, make sure all your vaccines are up-to-date. Freaky things happen when you least expect it.

As for my leg, it is still there. The healing process is slow but I think I will be alright.

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Doc, My Feet Hurt

Dear Dr. B: I have been walking a lot this summer. My feet hurt and that restricts my activities. What I can do about it?

Like back pain there is no perfect cure for all ailments of the feet. Most of us are on our feet longer than any other part of our body. So our feet receive the biggest brunt of all the damage we inflict on ourselves.

Feet problems present in different ways with pain, deformity and swelling.

About 10 per cent of the general population suffer from feet pain, and in the elderly it is much higher – ranges from 53 to 95 per cent. Proximal plantar fasciitis (inflammation of the fascia – a thick tissue which runs from the heel to the ball of each foot) is the most common cause of painful feet in clinical practice, and is twice as common among women as among men.

Metatarsalgia (pain in the forefoot in the region of the base of the toes) is probably the most common cause of foot pain among middle-aged women. Most women in this age-group have been exposed to high-heeled shoes over many years.

There are many other conditions which cause painful feet. Some of these are: plantar warts, corns, calluses, ingrown toe nails, hammer toes, flat feet, bunions, arthritis, gout, stress fractures and some others.

Treatment for most of these conditions remain the same: elevate and rest your feet as much as you can – but with the busy schedule we keep, not many of us have time to do that. Other management points are: lose weight, use pain killers, hot or cold compresses, arch support, good quality fitting shoes, foam cushions to relieve pressure on painful areas, and keep feet clean and dry.

Gout and other types of arthritis may require anti-inflammatory medications. Ingrown toe nail can be surgically fixed in a doctor’s office. Some conditions require injection of cortisone to relieve inflammation and pain. Physiotherapy can relieve many ailments of the feet.

One may have to try different combinations of therapy to find relief.

Foot is a complex structure and needs to be treated with respect. There are 26 bones in our foot and they are held together by ligaments. In addition to that, there are variable numbers of accessory bones called sesamoids.

Foot is divided into forefoot, midfoot and hindfoot. When one stands normally, the body weight is equally distributed between the heel and the ball of the foot. The weight distribution depends on muscle contraction.

“Studies have shown that relatively small changes in muscle balance and tone can result in significant changes in the load distribution of the foot,” says Dr. William Hamilton in the Surgical Anatomy of the Foot and Ankle. The normal function of the foot depends on the bones, ligaments, and muscles acting in concert.

A lot depends on how you stand, how you walk, how you run, what you wear, how much you weigh, and how much care you take of your feet. Foot pain and deformities are widespread. So, treat your feet with respect. Without them you cannot go too far comfortably!

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Breast Cancer in Young Women

It is quite common to see young women with breast lump worrying about cancer. This worrying should not be underestimated nor it should be blown out of proportion. Breast cancer in young women is uncommon. Again, one has to define what is young.

Definition of “young” is defined by different researchers as patients younger than 30, 35, 40 or even 50 years. This limits the amount of information you can gather because the number of cancers in each age group is not that high.

Here are few points to remember about young women who present with a breast lump.

Epidemiological studies in the U.S. show that 2.7 per cent of all cases of breast cancer occur in women ages 35 or younger and 0.6 per cent in women younger than age 30. According to a collective review article on this subject in the Journal of the American College of Surgeons (June 2008), women diagnosed at age 35 and younger tend to present at a more advanced stage of breast cancer and have poorer 5-yeare survival than older pre-menopausal women.

There are several concerns to be taken into consideration when a young woman is diagnosed with breast cancer. She will be worried about fertility, she will go into early menopause from the treatment and there will be psychological and emotional toll on the family, especially young children. The young lady will face a significant challenge to maintain her image and sexuality. The young patient needs to be treated as a whole and not as “just another patient with breast cancer.”

These days all patients (what ever their age or illness) are treated by multidisciplinary teams. The teams take into consideration all anxieties which may affect a patient’s treatment and outcome. But certain patients require special care and attention because of the uniqueness of their illness. Young women with breast cancers fall into that category.

Can we predict which young woman will get breast cancer?

The review article says there is currently no accurate tool for predicting breast cancer risk in young women. A Swedish population-based study found 48 per cent of women younger than 40 had a family history of breast or ovarian cancer. Another study has shown that breast cancer is less common in African-American women than Caucasian women but African-American women develop breast cancer at an earlier age and has worse prognosis than Caucasian women.

Why do young women present with later-stage breast cancers?

One of the reasons is that this population group is not screened as vigorously as the older women. Screening mammography is not recommended for women under 40 (low sensitivity and specificity due to dense breasts) and in fact it is controversial to screen women before the age of 50. In the last few years, some studies have discouraged women from doing breast self-examination (BSE). They argue that BSE leads to unnecessary biopsies.

The review article says, “Currently, it is recommended, although not specifically supported in the literature, that women with a family history of pre-menopausal breast cancer should begin mammographic surveillance 10 years before the age that their relative (i.e. mother, sister) was initially diagnosed.”

Some studies recommend doing an ultrasound alone or in combination with mammography to evaluate a breast lump in a young woman. There are other modalities being tried, such as digital mammography and MRI and these methods are showing promising results when one or more test are combined to evaluate a breast lump in a young woman.

The bottom line is, any suspicious dominant breast mass be biopsied even if the tests are negative. This principal applies whether the woman is young or old. Breast cancer in young women is uncommon but a breast lump in that age group should not be ignored but be thoroughly investigated.

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Don’t Tase Me, Bro!

Don’t tase me, bro!

These words were first uttered by Andrew Meyer, a 21-year-old fourth-year undergraduate telecommunications student on September 17, 2007 in a University of Florida lecture hall when he was forcibly escorted from the hall by the security officers because he would not stop questioning U.S. Senator John Kerry. He was pinned down on the floor and was about to be tasered when he spoke these words. Since then these words have become part of our lexicon.

In November, 2007 Robert Dziekanski, a Polish immigrant to Canada was tasered at the Vancouver airport and subsequently died. About two weeks ago, a 17-year old was tasered in Winnipeg and subsequently died. Death after being tasered has been reported many a times. “In fact, media reports to date have documented over 300 such deaths, 20 in Canada. Critics charge that tasers are too dangerous, that independent studies evaluating their safety are urgently needed and that a moratorium should be placed on their use,” says an article in the Canadian Medical Association Journal (CMAJ).

But Taser International (makers of Taser) has always maintained that taser is not directly responsible for any deaths. It has never been proven in a court of law that taser has directly killed anybody. The company says that taser cannot stop the heart. United Nations has classified the taser as a form of torture.

A news item in the July 15, 2008 issue of the CMAJ says, “Taser International Inc. suffered its first product liability suit loss in roughly 70 instances after a California district court ruled that it was 15 per cent responsible in the death of a 40-year-old drug suspect who died after receiving simultaneous shots from 3 tasers used by police officers. The jury awarded US$1.02 million in compensatory damages, as well as US$5.2 million in punitive damages, for Taser International’s failure to inform police that extended exposure to electric shock from the device could lead to cardiac arrest. The company said it plans to appeal the decision.”

Taser International and law enforcing agencies consider Taser as a valuable tool for subduing criminals and safeguarding the lives of law enforcement personnel. Others consider this as a potentially lethal weapon. What does medical science think?

In the May 20, 2008 issue of the CMAJ, taser is described as “an emerging and increasingly popular medical device.” The review article in the CMAJ says that Taser has potentially lethal effects in animals and humans. But Taser International says that Taser is safe and has sponsored research to prove this point. Has any independent medical research institution sponsored research to prove this point?

Taser International says that taser does not kill but a medical condition; “excited delirium” kills the person after being zapped by a taser. Excited delirium is not a recognized clinical condition. But it is being suggested by certain people that taser should be used to treat excited delirium. Does that mean taser now be considered a medical device? Can taser satisfy rigorous scientific standards through clinical trials before it is accepted as a medical device?

CMAJ article says, “New and independent research, both epidemiologic and biological, into whether tasers can kill is essential to settle this issue. Also, law enforcement agencies could be made to open up their databases on taser use for independent analysis, on the principle that the assertion that tasers have saved lives of police and suspects alike, while plausible, should be proven, not merely asserted as fact.”

I wonder when will this happen. In the meantime, don’t tase me, bro!

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