Posts

Posted on

Making a Mountain out of a Molehill to Prevent Skin Cancer

A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)
A boat sailing on River Nile in Aswan, Egypt. (Dr. Noorali Bharwani)

The other day a gentleman asked me, “Doctor B, I have a mole. Do you think I have melanoma?” I didn’t think he had a mole. I thought it was a skin tag. He said, “OK doc, tell me what does a mole look like and when should I worry about it.”

Defining a mole is not easy. People use the word very loosely to describe any blemish on the skin as a mole.

The majority of moles appear during the first two decades of a person’s life, with about one in every 100 babies being born with moles. Acquired moles are a form of benign new growths, while congenital moles, or congenital nevi, are considered a minor malformation and may be at a higher risk for melanoma. Moles are also known as nevi. Most of them have no malignant potential. But real moles and sunburns have a potential to become cancerous.

Real moles are skin growths that are usually brown or black. During sun exposure, teenage years and pregnancy, these cells multiply and become darker. They can be anywhere on the skin, alone or in clusters. Most moles appear in early childhood and by the age of 20, one can have anywhere between 10 to 50 or more moles. Some moles may appear later in life.

Most moles are benign. The only moles that are of medical concern are those that look different than other existing moles or those that first appear after age 20. If you notice changes in a mole’s colour, height, size or shape, you should have these moles checked. If the moles bleed, ooze, itch, appear scaly or become tender or painful then it is time to have them removed and checked for cancer.

The following ABCDEs are important signs of moles that could be cancerous:

  • Asymmetry – one half of the mole does not match the other half.
  • Border – the border or edges of the mole are ragged, blurred or irregular.
  • Colour – the colour of the mole is not the same throughout or has shades of tan, brown, black, blue, white or red.
  • Diameter – the diameter of a mole is six millimetres or larger.
  • Evolution – are the moles changing over time?

Melanoma is one of the three common skin cancers. The other two are basal cell carcinoma and squamous cell carcinoma. Melanoma is the most serious form of skin cancer. If diagnosed and removed early then the cure rate can be excellent. Once the cancer advances and spreads to other parts of the body, it is hard to treat.

Does melanoma occur in children? Yes, approximately two per cent of melanomas occur in patients under the age of 20 years and about 0.4 per cent of melanomas occur in pre-pubertal children.

We can reduce the risk of skin cancer by protecting against sun exposure and sunburn. Natural protection (shade) is considered the best protection. And sunscreen (SPF 15 or higher) should be adjunct to natural protection. Wear sun protective clothing. Wear wide brim hats. And use eyeglasses that block both UVA and UVB light.

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

Posted on

Doctors acting as Good Samaritans – are they liable for the care they provide?

Water fountain at Strathcona Island Park in Medicine Hat, Alberta, Canada. (Dr. Noorali Bharwani)
Water fountain at Strathcona Island Park in Medicine Hat, Alberta, Canada. (Dr. Noorali Bharwani)

A Good Samaritan is one who helps a stranger. Is there anything like a bad Samaritan? I don’t know.

“The parable of the Good Samaritan is a parable told by Jesus and is mentioned in only one of the gospels of the New Testament”, says an article in Wikipedia. So the concept of a Good Samaritan is not new. But in the present era of litigation, some people are reluctant to help a stranger in an emergency situation. For some, including physicians, nurses and paramedics, it is second nature to help strangers in physical danger.

“When an individual suddenly becomes ill or injured, doctors instinctively stop in the midst of their vacation, their business trip, or their work and offer assistance as good Samaritans, often under trying conditions”, says an article in the Canadian Medical Protective Association Bulletin (CMPA). The CMPA’s job is to provide legal assistance to doctors.

What are the physician’s ethical obligations?

  1. The College of Physicians and Surgeons of Alberta view physicians as having an ethical duty to do their best to attend to individuals in need of urgent care.
  2. The Canadian Medical Association’s Code of Ethics states that physicians should: “Provide whatever appropriate assistance you can to any person with an urgent need for medical care.”
  3. Quebec has its own code of ethics for physicians, which is enshrined in law, with similar requirements.

Are there legal obligations and risks?

The article in the CMPA bulletin says that legal obligations and risks can be more difficult to determine. Because emergencies can happen anywhere, at any time, physicians may find themselves being asked to provide emergency care in a variety of legal jurisdictions – within Canada or in another country, or in international airspace or waters if on an aircraft or ship. Different locations can mean different legal obligations.

Three things to remember about legal obligations:

  1. In Canada, most jurisdictions do not impose a legal duty or obligation on physicians to provide emergency medical services.
  2. All jurisdictions, however, have legislation that protects physicians who voluntarily provide emergency assistance at the scene of an accident or in an emergency.
  3. Quebec is the only province in Canada that imposes a legal duty on physicians to come to the aid of a person in a life-threatening emergency. Quebec’s Civil Code protects physicians from liability for that care.

CMPA does not think courts anywhere would criticize the conduct of a physician who in good faith treated a person in need of urgent medical attention. The CMPA does not know of any proceedings commenced against Canadian physicians in Canadian courts or in foreign courts alleging negligence in providing emergency medical attention as a good Samaritan.

CMPA says that when its members provide care in an emergency as good Samaritans they are generally eligible for CMPA assistance regardless of where the emergency care was delivered – anywhere in the world. Former CMPA members who act as good Samaritans are also eligible for CMPA assistance; they do not have to retain membership solely for this possibility.

With that in mind, the CMPA encourages its members to consider assisting when confronted with an accident or with sick or injured individuals in urgent or emergent circumstances.

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

Posted on

Some Drivers Continue to Ignore Distracted Driving Law.

Tomb of Camões in the Jerónimos Monastery, Belém, Lisbon. (Dr. Noorali Bharwani)
Tomb of Camões in the Jerónimos Monastery, Belém, Lisbon. (Dr. Noorali Bharwani)

In September, it will be four years since the distracted driving became a ticketable offence. But some drivers continue to ignore the law.

As of May 1 2015 the fine for breaking the distracted driving law is $287. If a driver is exhibiting more risky behaviour, they can be charged with driving carelessly and receive a fine of $402 and six demerit points.

Is that going to prevent people talking on the phone, drinking coffee and smoking a cigarette, sometimes all at the same time?

From my casual observation, I would say no because it is hard to enforce the law.

My impression is there are too many other things going on in the city to keep the law enforcement people busy. Distracted driving offence may not be high on the priority list. I may be wrong on this. It would be nice to see some statistics.

As we know, while driving, it is illegal to:

  1. Use a hand-held phone while talking, texting and/or e-mailing
  2. Operate electronic devices like video players and laptops
  3. Manually program GPS units or portable audio players
  4. Read or write
  5. Engage in personal grooming

Drivers are allowed to use hands-free mobile devices that are activated by a single touch or are voice activated, eat a snack, or drink a beverage while driving.

The law also says that members of the public can report a distracted driver to their local community station. The complainant must be able to identify the driver, vehicle and be willing to testify as a witness in court. I wonder how many people would have time to do that.

It is important to know there are some exceptions to this law:

  1. Emergency personnel such as fire rescue, EMS and police are exempt from using hand-held radio communications and electronic devices while performing their duties.
  2. Calling 911 in an emergency, or to report an impaired driver as part of the Curb the Danger program, is permitted while driving under the distracted driving law.

According CAA/AAA most drivers are distracted by outside object/person/event (29.9 per cent), adjusting radio/CD (11.4 per cent), other vehicle occupants (10.9 per cent), and something moving in the car (4.3 per cent). Other distractions are using another object/device, adjusting car’s climate controls, eating/drinking and using cell phones.

Statistics show that drivers engaged in text messaging on cellular phone are 23 times more likely to be involved in a crash. Driver distraction is a factor in about four million motor vehicle crashes in North America each year.

According to Alberta Transportation, international research shows that 20 to 30 per cent of all collisions involve driver distraction.

These indeed are grim statistics. There is more information on this subject on the internet and Alberta Government website. The question remains – is the law meant to be self-regulated or do we have enough manpower to enforce it? Have we made a dent in the tragic consequences of distracted driving?

We are into a holiday season and the weather is conducive and enticing to people who want to speed and break the law. Can we prevent that?

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

Posted on

Should You be Worried About Nipple Discharge?

To drink or not to drink - Cordoba, Spain. (Dr. Noorali Bharwani)
To drink or not to drink - Cordoba, Spain. (Dr. Noorali Bharwani)

“Nipple discharge is benign in most instances and is the third most common breast-related complaint, after breast pain and breast mass,” says an article in the Canadian Medical Association Journal (CMAJ May 19, 2015).

About 50 per cent of women in their reproductive years have nipple discharge, which are physiological. This kind of discharge is usually from both breasts, milky, green or yellow fluid expressed from multiple nipple duct openings and often associated with nipple stimulation. Usually these patients do not require surgery if the ultrasound and mammogram is normal. Discharge may spontaneously disappear.

Nipple discharge you should be worried about are spontaneous and often from one breast. It may arise from a single duct or be associated with a breast lump or new skin changes. It can be bloody, serous (clear thin plasma fluid), green or black.

About 15 per cent of these patients will have breast cancer. About 50 per cent of these patients will have benign intraductal papilloma (benign growth in the duct), and 20 per cent will have ductal ectasia.

Ductal ectasia of the breast (also known as mammary duct ectasia or plasma cell mastitis) is a condition in which the lactiferous breast duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal women.

Intraductal papillomas are benign growths of the nipples in women close to menopause. They are usually single. Generally they are not seen on mammography. Surgical excision is indicated to rule out malignancy. These papillomas are the most common cause of bloody nipple discharge.

What can be done for women with nipple discharge?

Women with nipple discharge should be investigated. Mammography (sensitivity may be decreased in younger patients) and retroareolar ultrasonography should be performed in all cases of pathologic nipple discharge. Galactography, and more recently, magnetic resonance imaging, can be helpful in identifying an involved duct or papilloma. Patients with a palpable mass or a mass identified on imaging should undergo needle biopsy to exclude carcinoma, says the CMAJ article.

Milky discharge in patients who are not pregnant or lactating (galactorrhea) is often due to medications. Milky nipple discharge from both breasts is appropriate during pregnancy and lactation, and it can last up to one year after delivery or after breast-feeding has stopped.

In patients who are not pregnant but are lactating should have prolactin levels checked to exclude endocrine disorder (> 20 ng/mL). Medications such as:

  • Psychotropics, antihypertensives (e.g., reserpine, methyldopa, verapamil),
  • Opiates, prokinetics (e.g., metoclopramide) and
  • H2-blockers (e.g., cimetidine) can cause galactorrhea.

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