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Chest Pain

You are relaxing or doing some activity at home. Suddenly, you experience chest pain and shortness of breath. What is your immediate reaction? Dial 911 and call an ambulance? Get in your car and drive yourself to emergency department (ER)? Have a family member drive you to ER? Or pop some antacid pills in your mouth and wait?

Well, while you are scratching your head for an answer, let us ask the question to Dr. Hal Canham, ER Physician at Medicine Hat Regional Hospital (MHRH) and Medical Director of Medicine Hat Ambulance Service.

“As a physician, I may be able to judge if my chest pain is of cardiac (heart) or non-cardiac origin. If I am not sure, then I will dial 911 and ask for an ambulance. My advice to people in general is to call 911 immediately if they experience chest pain. There may not be time for self-diagnosis,” says Dr. Canham.

Each year, close to half a million people in Canada come to ER with chest pain. Some have acute life threatening illness. Others may have nothing seriously wrong with them. Some may have history of coronary heart disease. Others may not.

What about Medicine Hat?

In an 18 month period (June/97 to Dec/98), the ER Department at MHRH sees 53,548 patients. Out of these, 50 patients are confirmed to have heart attack and are eligible for thrombolytic (clot busting) therapy.

Dr. Canham studied these 50 cases. What did he find? “A major concern became apparent immediately. Of the 50 patients with diagnosis of heart attack, only 15 had called for an ambulance! This confirmed our impression that there is underutilization of the ambulance service for chest pain patients in our community.”

Why call an ambulance? Isn’t it faster for me to jump in my car and rush to ER?

If your chest pain is due to heart attack then the outcome of your illness may be dictated by: 1) the speed and mode of transportation to ER, 2) your previous history of cardiac problems, 3) rapid evaluation of your condition by ER physician, 4) the use of “clot busting” drugs in a timely fashion.

In 1997, the Medicine Hat Ambulance Service purchased new cardiac monitors and defibrillators. The aim is to speed up the delivery of “clot busting” drug to eligible cardiac patients.

Our paramedics are now able to do 12-lead cardiac monitoring in patient’s own home immediately on arrival. This test is transmitted “live” to ER physician to diagnose heart attack before the patient arrives. The ER physician is then ready with “clot busting” drug if the diagnoses are confirmed.

There is also another important reason to call 911. Early in the course of a heart attack, patients are at risk of having the heart stop (cardiac arrest). The chance of surviving this is better in an ambulance with paramedics at hand then in your own vehicle.

Dr. Canham, what is your message to the people of our region?

“The Medicine Hat Ambulance Service is truly an extension of our ER Department and rarely is this more apparent then when you are experiencing chest pain or shortness of breath. Be aware of symptoms suggestive of a heart attack and call 911 early!”

Pain is the most frequent presenting symptom. It is deep in the chest, described as “heavy”, “squeezing”, and “crushing”. The pain may radiate to the neck or the arms. There may be weakness, sweating, vomiting or giddiness. Symptoms may vary. So do not waste time on self-diagnoses. One telephone call may save your life!

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Ingrown Toenail

“An ingrown toenail can make a big, burly guy wince and hobble like a wounded puppy,” says Dr Don Powell, president and founder of American Institute for Preventive Medicine.

Well, you wouldn’t call Andrew big and burly. He is a regular school kid who is not having fun with an ingrown toenail.

Andrew, accompanied by his mother Susan, is waiting for me in one of my examination rooms. Andrew is 13, and has trouble with one of the big toe nails. It has been digging into one corner of the overhanging skin resulting in infection and pain.

“Dr. B, Andrew is tired of pain and antibiotics. Besides the cost of the medication, Andrew has to miss many activities involving running and excessive walking,” says Susan. “Can you help?”

First, let me tell you something about fingernails and toenails.

The nails are appendages of our most versatile organ – skin. Besides nails, the skin has three other appendages – hairs, sweat glands, and sebaceous glands. Nails protect the tips of our fingers and toes.

The nail has a free end which we trim on regular basis. The two sides of the nail are under the skin folds. The root is at the base where the growth occurs. The average rate of growth of the nail is 0.1 mm a day or 3 mm per month. About 11/2 inches a year.

Fingernails grow faster than toenails. Both grow faster in the summer than in the winter. The nails grow rapidly in “nail biters” and slowly in people confined to bed. The growth is faster in males than females. Certain illnesses can arrest the growth.

What can go wrong with the nails?

The nail can be a window for physicians to suspect other illnesses. Normally, nails are flat and light pink. They are pale in anaemia. Nails in general and big toenail in particular can be sites of many problems. One of the common one being ingrown big toenail with infection and pain.

Infection of the toenails can be very serious in anyone who has diabetes or circulatory problems. It can result in gangrene and amputation.

“Dr. B, why do I have ingrown toe nail?”

Ingrown toenail of the big toe usually occurs when sweaty feet are encased in tight shoes. The situation gets worse when the nail is trimmed short and the corners are curved down. The side of the nail curls inwards and grows to form outer spikes. This causes painful infection of the overhanging nail fold.

Andrew looked puzzled. “Dr. B, what can I do about it?”

Keep your feet nice and clean. Wear roomy shoes and clean cotton socks. Allow the outer corners of the nail to grow over the skin margins placing small piece of cotton soaked in an antiseptic just under the outer corners of the nail. Cut your nails straight.

If all this fails then surgical treatment becomes necessary. Simple whole nail avulsion or wedge removal of the nail can result in more than 50 percent recurrence rate. The best results are obtained by removing the root at the same time. This is done under local anaesthetic in a doctor’s office.

About 10 days of tender loving care of the big toe after the surgery usually results in satisfactory outcome. There is about 10 percent or less recurrence rate.

Andrew was ready for the surgical remedy. This was accomplished with satisfactory results.

(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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Organ Transplant

“Don’t take your organs to heaven. Heaven knows, we need them here.” This is a slogan used by the Kidney Foundation of Canada.

Recently, we had “Organ and Tissue Donor Awareness Week”. This is a good way to remind people like me to sign the Universal Donor Card. So I check with my wife if I have signed one. She couldn’t remember.

I check my driver’s license. The new one has no donor card at the back. I check my Alberta Personal Health Card. I see my wife has witnessed my signature where I make “anatomical gift” of organs and tissues for transplantation and research upon my death.

Well, memory is one thing my wife and I should not donate to anyone!

In any case, events like “organ donor awareness week” reminds us of many things in life which we take for granted.

Donation of solid organs and tissues does not start when life ends. During their lifetime, family members and relatives of potential organ recipients help their loved ones when there is a need for liver, kidney, lung, and bone marrow transplants.

But lot more work needs to be done to encourage such donations after death for potential organ recipients who have no family attachment and are not emotionally related to deceased donors.

Why do we need to do this?

Because 150 Canadians on waiting list for organ transplants die every year. In 1997, more than 3000 Canadians were on the waiting list. Only 1600 transplants were performed due to shortage of appropriate organs.

Alberta has done little better. According to Alberta Health, our provincial donor rate has remained on average about 2 percent above the national rate.

Alberta Health’s Province-Wide Services 1998 Annual Report says that in 1997-98, there were 22 heart, 128 kidney, 31 liver, 126 bone-marrow, and 10 lung transplants in Calgary and Edmonton. This is a total of 317, compared to 291 for the previous year. But this is not enough.

How can we improve the situation?

This can be done by: 1) improving public’s awareness and acceptance of the importance of organ donation, 2) adequately train health care professionals to handle the sensitive issue of discussing the options with a grieving family.

There are 4 major stages to be undertaken before the organ or tissue is available to a potential recipient. These are: recognizing and declaring brain death, notifying the organ procurement organization, presenting the option of donation to the grieving family, and clinical care of the brain dead donor.

This is where the Palliser Health Authority (PHA) has made a difference by setting aside $15,000 to formalize the organ donation process in our region.

“Palliser’s contribution is significant indeed. The program is now up and running,” says Mr John Boksteyn, chair of PHA. Medicine Hat will be the first regional hospital to do this.

So, how can we help? 1) Make a decision to be a donor and share your wishes with your family. 2) Decide if you want your organs and tissues for transplant and/or for research. 3) Sign a Universal Donor Card on the other side of Alberta Personal Health Card.

Organs and tissues which you can donate are: heart, lungs, kidneys, liver, eyes, skin, bone marrow, veins, and pancreas. The list may not be complete. Age restrictions are now minimal. People over 80 years may still be good candidates.

So, think carefully. Make up your mind. Discuss with your family and sign the donor card. Otherwise it will never happen!

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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Coronary Heart Disease

A good heart is better than all the heads in the world. A healthy heart is, of course, better than all the sick ones!

But how many of us can claim to have a healthy heart?

Not too many!

Although over the past 30 years, death rate from coronary heart disease (CHD) has decreased by 50 percent, the number of people who have heart attacks has not declined. CHD remains the leading cause of death among adults. One of every 5 deaths is due to heart disease.

Our capacity to keep people alive after a heart attack has considerably improved, but heart disease can be very disabling.

How can we change this?

There are certain risk factors over which we have no control. You cannot change your age or genes. Changing sex may not prove worthwhile.

But there is hope! About 40 years ago, researchers recognized that high blood cholesterol level, high blood pressure, and cigarette smoking to be main risk factors for CHD. The good news is that these risk factors can be modified to improve our health.

In the last 7 years, the role of cholesterol in prevention of heart disease and heart attack is better understood and recognized. In most cases, cholesterol lowering diet is the first line of treatment.

If this fails then there are now newer and better drugs to treat this problem. Besides lowering cholesterol levels in the blood, the drugs also work on blood vessel wall and blood cells to reduce clot formation and narrowing. This results in better blood and oxygen flow to heart muscles.

High density lipoprotein (HDL) is good cholesterol. Low density lipoprotein (LDL) is bad cholesterol. And there is triglyceride. All three need to be modified.

When is the best time to have cholesterol level checked? Some experts suggest screening asymptomatic males in their 40s and females in their 50s. Your doctor is the best person to guide you through this. He knows your risk factors and decides at what age screening is justified.

The next modifiable risk factor is high blood pressure. The risk increases progressively with increasing blood pressure. And blood pressure increases with age. It is believed that after the age of 50, high blood pressure may be more dangerous than high cholesterol level.

About 20 percent of population have high blood pressure. Half of these people will have associated heart disease. The vast majority of people with high blood pressure go undetected or untreated. This is dangerous.

It is important that you have your blood pressure checked out by your doctor on a regular basis. He will be the best person to advise you on appropriate diet or medication if there is a problem.

The third important factor is cigarette smoking. Active and to some extent passive (second hand smoke) cigarette smoking is one of the most important modifying risk factors for CHD.

We are well aware of the fact that smoking is a habit hard to break. But Stanford University of California has a success rate of up to 70 percent among people who previously had a heart attack, says the Canadian Medical Association Journal.

A study done in Ontario and California shows that California has the lowest smoking rate in North America, in part because of the state government’s aggressive antitobacco campaigns. Only 19 percent of Californians smoke, compared to 31 percent of Ontarians.

The only way we can keep our heart healthy is to remind ourselves constantly that there are risk factors over which we have control. So have yourself checked out on a regular basis. Exercise atleast 5 times a week, eat healthy, and do not smoke. Having a good heart also helps!

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