Author: noorali

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Animal Bites

“When your best friend bites…” is title of an article in the Canadian Journal of Infectious Diseases (CJID). It’s not about human friends who bite but it is about animal friends – dogs and cats.

Dogs and cats are very important to millions of Canadians. It is estimated that there are more than 100 million cats and dogs owned as pets in Canada and the United States. Do these domesticated animals bite? Of course, they do! I know it and many of you have been victims of these domesticated animals. In fact, one to two million dog bites are reported in both countries every year.

The CJID article says that up to 85 percent of dog and cat bites are caused by the victims’ family pet or by a neighbour’s pet. About half of these bites are considered to have been provoked. And 5 to 9 year old males sustain dog bites most frequently. So, let us not blame our animal friends for all the injuries.

And injuries are many. According to the Canadian Injury Reporting and Prevention Program, injuries related to dog bites account for one percent of all visits to hospital emergency departments.

These injuries are more serious in children than in adults. Children are more likely to be bitten on the face, neck and head in upto 70 percent of cases. Children account for the majority of the 10 to 20 deaths from animal bites that occur annually in the United States, says the CJID article.

Is this acceptable? Can we reduce the injury rate? After all, dogs are our best friends!

We should encourage dog owners to take responsibilities with regard to training their pets. This should include discouraging aggressive behaviour when animals are young, says the article. We should teach our children and adults about the risks involved in provoking dogs and other animals. Should we certify certain breeds as being dangerous and not fit to be pets? This is debatable.

What is the appropriate treatment for dog and cat bites?

Your physician will enquire about the status of tetanus immunization and give you a booster dose. He will assess the risk of rabies and arrange appropriate prophylaxis. The wound will require cleaning with removal of dead and dirty tissue. You may require prophylactic antibiotics.

The immunization status of the animal in question should be checked. The local animal control agency should be notified so that they can quarantine the animal and keep it under observation for up to 10 days to see whether clinical symptoms develop, says the author of the CJ ID article.

Dogs and cats can be dangerous. They can be lot of fun as well. Especially for children. But we have to be careful. We do not want fun to turn into fatality.

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Washing Hands

How many times have we seen people walk out of public washrooms without washing hands?

How many times have we seen restaurant servers wipe tables with wet cloth and then take orders without washing hands? Do we know what is going on in the kitchen? How clean are those counters at fast food restaurants where they make and dispense sandwiches? What are the hand washing habits of these servers?

What about the health care workers? Do they wash their hands after examining each patient?

In 1996, the American Society of Microbiology (ASM), did a telephone survey of 7000 Americans, 94 percent said they always washed their hands after using the toilet. But researchers, observing actual behaviour in public washrooms in five cities, found that wasn’t the case. Only 68 percent washed their hands!

A study conducted this year by ASM showed similar results. So ASM’s campaign to improve hand washing habits of Americans has not changed much among men or women, although more women tend to wash their hands than men. It is a question of instilling permanent behavioural change. And that is not always easy. So, this year’s ASM campaign slogan (DON’T GET CAUGHT DIRTY HANDED!) is to keep reinforcing this behaviour (www.washup.org).

What about the health professionals? Are they any better? An editorial in the British Medical Journal says, “Many studies have confirmed that doctors decontaminating their hands between seeing patients can reduce hospital infection rates. Nevertheless, healthcare workers still fail to wash their hands and fail to appreciate the importance of doing so.”

In one study, 50 to 95 percent of physicians reported washing their hands before patient contact. But this contrasted sharply with the observed frequency of just 9 percent! The editorial says that role models are important in hospital practice. Junior doctors washed their hands more often when senior doctors set an example. Poor practice habits are also picked up at patient bedside. Junior staff stop washing hands when they see senior staff do not bother to keep their hands clean!

About 150 years ago, it was found that if doctors performing autopsies washed their hands before delivering babies, then they could reduce mortality due to post delivery infection of the uterus from 22 to 3 per cent.

What about the people working in cattle industry? Health Canada says that failure to carefully wash hands after working around and with cattle can lead to infection with a type of E. coli bacteria. The resulting illness occasionally causes kidney failure and in rare cases, death.

These bacteria cause “hamburger disease” with symptoms of stomach cramps and bloody diarrhoea appearing two to eight days later. These symptoms last 7 to 10 days. In Canada, five cases of hamburger disease per 100,000 people were reported in 1995. In some cases, especially among people with immature or weakened immune systems, such as children or the elderly, infection with this bacteria leads to kidney failure.

So, if your mother tells you to wash your hands before meals then she is right. Hand washing is one of the most important means of preventing the spread of infection. Hand washing should be regarded as part of the normal duty of care. DON’T GET CAUGHT DIRTY HANDED!

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Stroke 2

Are you afraid to stroke? I am! So are millions of people.

My dad used to say: better to die of a heart attack than be disabled by a stroke. His wishes were fulfilled when he died peacefully at the age of 80. How many of us will be lucky like him?

Stroke, also called cardiovascular accident, is the third leading cause of death in Alberta and is the fourth leading cause of death within the Palliser Health Authority. When compared to rest of Canada, Alberta has the third highest rate of death from stroke.

In the last column we said that help is available for ischemic (lack of blood supply) stroke if we do so within three hours of onset of symptoms. This short window of opportunity is a significant barrier to successful treatment of acute ischemic stroke. And the second major barrier is the lack of public understanding of what the symptoms of stroke are.

Try to remember acronym MENDISH. This will help you remember the symptoms of stroke. M is for sudden memory loss. E is for eye problems like temporary loss of sight in one eye or double vision. N stands for numbness or weakness in the face, arm or leg. DI is for dizziness. S is for slurred or garbled speech. H is for recent onset of severe headache.

Dizziness and headache can be symptoms of many other problems. But if you have dizziness and headache in association with symptoms mentioned in earlier paragraph then you should call 911. Waiting for symptoms to resolve because they appear to be minor reduces your chance of receiving the clot busting drug tPA.

Is it safe to receive tPA therapy?

The chief hazard of tPA therapy is bleeding in the brain. In one study, 6.4 percent of the patients given tPA had bleeding in the brain compared to 0.6 percent of those given placebo. Death rate in the tPA and placebo groups were similar at three months (17 percent in the tPA group and 20 percent in the placebo group) and at one year (24 percent and 28 percent respectively).

Then what is the real benefit of tPA therapy?

The real benefit is prevention of paralysis and long-term disability. And the results are good.

“Of the patients treated with tPA, 31 to 50 percent had a complete or near-complete recovery at three months, as compared with 20 to 38 percent of the patients given placebo, and the benefit was similar at one year”, says an article in the New England Journal of Medicine.

Heart and Stroke Foundation has invested lot of money in finding treatment of acute stroke. It is one of the organizations helping Calgary Regional Stroke Program spearhead the development of resources to use thrombolytic (clot busting) therapy for acute ischemic stroke. Their three years of efforts has resulted in improved patient outcomes, shorter times from symptom onset to treatment and acceptable complication rates.

Now we have established similar treatment protocol in Medicine Hat Regional Hospital. It is for us to be vigilant and recognise symptoms early. The window of opportunity is short – only three hours! So, remember MENDISH and remember 911!

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Stroke

Dear Dr. B: What is meant by “brain attack”? Is it something to do with acute stroke? Is there a treatment for acute stroke in Medicine Hat? Yours, Afraid to Stroke (ATS).

Dear Mr. ATS: When blood supply to the heart is cut off then it is “heart attack”. When blood supply to the brain is cut off then it is “brain attack”!

One of the common reasons for a heart attack is a clot in coronary artery. One of the common reasons for a brain attack is a clot in one of the brain arteries.

Many lives have been saved by administrating clot-busting drugs to a heart attack patient within the six hours (window of opportunity) of starting the symptoms of chest pain. Similarly, the window of opportunity for brain attack is three hours.

Brain attack, if not recognised or treated early, will lead to stroke (paralysis). As many of us know, stroke leads to significant disability, dependence, complications and sometimes death.

Until recently, there was no good treatment for acute stroke. But in the last three to four years, significant work has been done to show that if clot-busting drug (tPA) is given to patients within three hours of starting the symptoms of paralysis, then the chances of full recovery are significantly improved.

The problem is, when a person experiences sudden weakness or numbness in the arm or leg, or has sudden visual disturbance then he will wait, hoping that it will improve. Sometimes it does – called transient attack. But quite often it may not and by the time he calls the paramedics it is more than three hours. Sometimes a day or two has gone by. Then that person is not eligible for clot-busting treatment.

So it is important for an individual, his family, friends or co-workers to recognise symptoms of stroke, call an ambulance and rush to the hospital emergency within couple of hours of starting the symptoms. Otherwise we lose that window of opportunity.

Do we have treatment (clot-busting medication) for acute stroke in Medicine Hat?
Yes. A protocol for the treatment of patients with acute stroke, who show up at the hospital within three hours of onset of symptoms, was established recently at the Medicine Hat Regional Hospital. So far three patients have been treated successfully. These patients would otherwise have been paralysed and institutionalized for long-term rehabilitation.

Is this a well-established and safe treatment?

Some people think this is still controversial. But a recent review article (September 7) in the New England Journal of Medicine says: “Safe and effective treatment is now available for patients with acute ischemic (where blood supply is cut off) strokes. Intravenous thrombolysis (clot-busting) with tPA is safe and improves outcome if treatment is initiated within three hours after the onset of symptoms”.

Nothing in life is hundred percent safe. Every treatment has likely complications. But two things are important: early recognition of symptoms of stroke and rushing to the hospital emergency within three hours. Otherwise, you do not benefit from clot-busting treatment.

In the next column, we will explore this subject little further, explain the symptoms, look at the likely complications of the treatment and examine the work done in Calgary with the help of Heart and Stroke Foundation.

So Mr. Afraid to Stroke, help is there if you seek it on time!

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