Category: Medicine Hat News

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Preventing Accidents

Out of this nettle, danger, we pluck this flower, safety, says William Shakespeare in Henry IV.

To parents with young children, the Safety City Society is that beautiful flower which teaches our children about safety from age 3 to grade 6. This is wonderful because what happens to our children in the first 6 years of their lives largely determines how well they are able to learn in school, how they can cope as adults, and often, how healthy they will be as adults.

Last week, the Safety City Society of Medicine Hat had their annual general meeting. Here is what I learnt.

In Alberta, average life expectancy is 81 years for women and 76 years for men. According to Alberta Health and Wellness, we can make it to this age if we don’t smoke and are able to avoid injury.

How can we do this? First, let us see what is killing Albertans. The top 5 causes of death are: heart disease, cancer, lung diseases, stroke and injuries. The first 4 causes are directly or indirectly related to smoking. The 5th cause is due to falls, motor vehicle accidents, poisoning, suicide, work place and farm injuries. And injuries kill 4 people daily. Just like losing a family of 4 everyday! This has not changed in the last 5 years.

Why injuries are hurting us? Thirty six percent of fatalities are related to drinking and driving. Four out of 5 collisions occur in cities. Rural Alberta sees 72 percent of fatal collisions. Afternoon rush hour accounts for 30 percent of all collisions. Friday sees the most collisions and Sunday has the most fatalities. So, where and when can we take our family out?

Should we blame the government? No. It is us…. the drivers!

Drinking and driving takes its own toll. Driver errors account for 89 percent of collisions. And we make the same mistakes over and over again: following too closely, running off the road (rural areas), turning left across the oncoming traffic, running red light, and changing lanes without shoulder check.

We know seat belt save lives and reduce the injury rate. But recent study, released by the RCMP shows only 60 per cent of rural drivers in the Palliser health district use seat belts and that only 57 per cent of rural passengers buckle up. We are the third worst ranking health district of the 17 surveyed. That is not good!

But the impressive work is done by the people at the Safety City with the help of dedicated workers and donors. They teach our children about helmet awareness, seatbelt safety, train safety, winter safety, traffic safety, bicycle safety, pedestrian safety, bus safety, Halloween safety, home safety, and organize car seat clinics. All this on a shoestring budget!

The Board Chair, Dorothy Patry says: At Safety City we envision that very soon this community, will no longer accept “accidents” as inevitable, instead many “predictable and preventable” injuries will be significantly reduced.

This can only be done if we learn to be patient and careful at home, at work and on the roads. Let us slow down and enjoy the drive!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Hemorrhoids

“What’s up, Dave? You don’t look happy!”

“Doc, its my hemorrhoids again!”

Dave has had symptoms of haemorrhoids for sometime. His main complaints have been bright rectal bleeding on the toilet paper and itching. About five years ago he was investigated for other colon and rectal problems and nothing abnormal was found.

He has been able to control the symptoms by using high fibre diet, having regular bowel movements, application of ointment, taking care of local hygiene and hot baths. He resists any temptation to strain at defecation.

Generally speaking, when patients complain about hemorrhoids, they really mean they have a problem in the rectal area. Besides hemorrhoids, one has to keep in mind conditions like: fissure, fistula, infection (abscess), inflammation of the rectum (proctitis), polyps, and cancer.

Like a good detective, the physician can eliminate these conditions by taking a careful history and do a physical examination – including the dreaded digital rectal examination. Patients also need tests like flexible sigmoidoscopy (examination of the rectum and distal colon) and in some instances colonoscopy (full examination of the colon).

“So Dave, what has changed?

This time Dave has painless bright rectal bleeding not only on the toilet paper but also outside of the stool. Blood drips after a bowel movement. Dave has been advised in the past not to ignore any bleeding from the rectum. Painless bright rectal bleeding (usually with or following bowel movements) immediately warns a physician to check for cancer.

“Doc, does every patient with rectal bleeding require colonoscopy to rule out cancer?”

No. I use age 40 as a cut off point. Patients under 40, who have no personal or family history of colon polyps or cancer or their bleeding is not associated with diarrhoea then I advise them to have flexible sigmoidoscopy as the first line of investigation. This is an office procedure requiring less bowel preparation and no sedation. It examines 60-cm. of distal colon and rectum.

Five years ago, Dave had a flexible sigmoidoscopy and this was normal except for internal hemorrhoids. Now Dave is over 40, and should undergo colonoscopy. This is a same day procedure in hospital, requiring full bowel preparation a day before, and sedation during the procedure.

Dave returns to the office after the colonoscopy. This is normal except for internal hemorrhoids. Since Dave continues to bleed off and on, he requires more than conservative (high fibre diet, no straining, local hygiene, ointment, hot bath) management.

“Doc, what are my options?”

Dave’s options depend on the size and the type of the hemorrhoids. External hemorrhoids usually require no treatment unless there is a painful blood clot in the blood vessels. This can be drained in the office under local anaesthetic with almost instant relief.

Internal hemorrhoids vary in size and symptoms. Grade 1 internal hemorrhoids do not prolapse. Grade 2 internal hemorrhoids prolapse on defecation but reduce spontaneously. Grade 3 internal hemorrhoids prolapse and require manual reduction. Grade 4 internal hemorrhoids prolapse and cannot be reduced.

Barron’s rubber band ligation is recommended as a first line treatment for Grades 1 and 2 and Grade 3 that do not respond to diet or local preparations, says an article in the Canadian Journal of Surgery. It says that rubber band application is an office procedure that does not require general anaesthetic and time off work. It is associated with fewer complications and less pain.

Surgical removal of hemorrhoids under general anaesthetic should be reserved for Grade 4 and some Grade 3 patients who do not respond to rubber band ligation. Recovery period is prolonged and more painful than rubber band ligation.

Dave has Grade 2 internal hemorrhoids and has successful rubber band ligation in the office. Dave is a happy man again!


This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Appendix

If cholecystectomy is the most common elective general surgical procedure then what is the most common emergency general surgical procedure?

Well, this time it was Tamara’s turn to find out!

One night, Tamara could not sleep. She tells her mom, Susan, that she is having tummy ache. In the morning, Tamara has no desire for breakfast and reluctantly goes to school

Before lunch, Susan gets a phone call from Tamara’s school. Tamara has fever, tummy ache and vomiting. Susan takes Tamara to the Emergency Department. The physician on duty finds that Tamara is very tender in the right lower quadrant of the abdomen. In fact, slight pressure on the area causes Tamara to jump.

The ER physician makes a provisional diagnosis of acute appendicitis and consults the general surgeon on call. The surgeon confirms the clinical impression of the ER physician and explains to Tamara and her mom that the best treatment for this condition is emergency removal of the appendix.

“Doctor, what about tests to confirm the diagnosis?” asks anxious Susan.

Although most patients with this kind of clinical picture end up having blood and urine tests and plain abdominal x-rays, the diagnosis of acute appendicitis remains a clinical one. These tests are valuable when the diagnosis is not clear. That happens in about 20 percent of cases.

“Doctor, can the surgery wait till tomorrow?”

No. Once the diagnosis of acute appendicitis is made then the appendix should be removed within the next few hours, depending on the condition of the patient. If ruptured appendix or abscess is suspected then the procedure should be undertaken within couple of hours. If the patient is not “toxic”, then 4 to 6 hours’ wait is reasonable. But the surgeon makes the call on the timing of the procedure. With his experience, he will be right most of the time.

“Doctor, what is the risk of delaying surgery?”

Perforation (ruptured appendix), peritonitis and death from “toxic shock”. From time to time, people have died from ruptured appendix. The reasons are: delay in presentation to a doctor (quite often people think it is flu and stay home and self-medicate), and unusual presentation leading to delay in diagnosis.

Once the diagnosis of acute appendicitis is made then it is better to remove a normal one then risk perforation and subsequent complications. About 10 to 20 percent normal appendectomies are acceptable in a surgeon’s carrier.

“Doctor, don’t we need an appendix? What happens after it is removed? Is Tamara going to feel anything different?”

No, we do not need the appendix. Its function in the immune system is not clear. It does not serve any useful purpose as a digestive organ in humans. It is believed to be gradually disappearing in the human species. Absence of appendix causes no adverse effects.

About 110 appendectomies are done at Medicine Hat Regional Hospital each year. Historically, appendectomies have been done since 1880. Leonardo da Vinci was the first to describe and illustrate the appendix in 1492.

Tamara has a successful uncomplicated appendectomy. Couple of days in the hospital and one week at home should get her back to school feeling happy and healthy. Most patients have uncomplicated recovery. Hopefully, Tamara will not be an exception.


This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Gallbladder Surgery

What is the most common elective surgical procedure done in the western countries? Well, Susan knows the answer. Here is her story.

During the Christmas holidays, Susan has to rush to the Emergency Department as she develops severe pain in the right upper area of the abdomen where the liver and gall bladder reside. Pain is associated with vomiting.

After history and a physical examination, the emergency physician makes a provisional diagnoses of biliary colic i.e. pain due to gallstone. Susan gets a painkiller and gravol. She settles down and is discharged home for further investigations.

The first line of investigation is ultrasound of the abdomen. This test will check for problems in the liver, gall bladder, pancreas, aorta and kidneys. It may pick up problems in the stomach. The test is not 100 percent full proof but it is a good, non-invasive, and cost effective first line of investigation. For gallstones, quite often this is the only test required.

The ultrasound confirms Susan has gallstones. She is referred to a general surgeon. For most symptomatic gallstones, the best curative treatment is surgical removal of the gall bladder – cholecystectomy.

Each year, in Medicine Hat Regional Hospital, approximately 250 gall bladders are removed. About 95 percent of them laparoscopically- through four buttonholes. Patients are admitted to the hospital on the same day. Most patients are discharged within 24 hours of surgery with minimal complications. Most patients return to work within 7 days of surgery.

Compare this to the olden days when a patient would be admitted the day before surgery, have a long scar, stay about 5 to 7 days in the hospital and have 6 weeks of recuperation. A major life disruption when you think that this is the most common elective procedure done in western countries. And gall bladders have been removed for the past 116 years!

Observations of human gallstones go back to an Egyptian priestess at Thebes, around 1500 BC. Her mummy, when given to the Royal College of Surgeons Museum in London, was seen to contain a well-preserved gall bladder with 30 stones; unfortunately it was destroyed during the German bombing of World War II, says Dr. Knut Haeger in The Illustrated History of Surgery.

There are two types of gallstones: cholesterol stones (80 percent) and pigment stones (20 percent). Most cholesterol stones are mixed in nature. They are formed when bile becomes supersaturated with cholesterol and there is precipitation of cholesterol micro-crystals. This is a simple explanation of a complicated event in cholesterol gallstone formation.

Incidental finding of gallstones require no treatment if they do not cause any symptoms. Most symptoms are related to blockage of the gall bladder or one of its ducts by a gallstone. Cholecystectomy has minimal complications rate during and after surgery. But every procedure has some risk involved and should be undertaken after careful deliberation with the surgeon.

Susan is on the waiting list to have her gall bladder removed. She does not want to experience the pain of biliary colic again. Let us wish her good luck and speedy recovery!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems. They believe in ELMOS!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!