Screening for Heart Disease.

I really hate to see people spend money unnecessarily on all sorts of screening tests and exercises.

What i'd like to do with my blog is to give a run-down of screening tests that doctors use for different disease conditions. Hopefully, with more knowledge, the general public won't fall prey to all-inclusive yet very unnecessary screening tests.

Let's talk about heart disease.

Your heart basically never rests until the day you die. The heart and lungs have a great relationship, the heart receives deoxygenated blood from the body, pumps it out to the lung s for reoxygenation and the Oxygen rich blood comes back to the heart to be pumped out to the whole body. That's the simplified version.

Let's say you do a Ramly Burger-Kopi susu lemak manis-Kuey Tiaw goreng everyday diet, work till 11p.m, party till 5 a.m and repeat that. Add smoking, new onset diabetes and stress. You've got a great recipe for heart disease.

A little mantra my Senior residents used to say: Smoking + Diabetes + McD=Heart Attack on legs.

What are signs & symptoms of heart disease?

1. Sudden death (65% of men, 47% of women)
   
2. Heart attack
   
3. Chest pain on exertion (angina)
4. Chest pain at rest (Unstable angina)
5. Shortness of breath on exertion.
6. Dizziness, fatigue
7. Erectile dysfunction i.e impotence

Of course, as you very well know, most people have no symptoms until it's too late.

What are the risk factors for heart disease?

• hypertension (high blood pressure)
• diabetes
• high cholesterol: TG, LDL & HDL levels are important
  
• smoking
• obesity
• stress
• male gender
• family history especially of heart disease in a 1st degree male relative <55>
• exposure to pollution with high proportion of particulates in the air
  

How do we calculate your risk?

It's important that before a doctor carries out screening for heart disease that your medical history is taken and that history of any other illnesses in close family members is noted.
From there, your doctor can use the Framingham score or the Assign risk calculator to calculate your risk level of heart disease or death from heart disease risk within the next 10 years.

Risk paremeters assessed:

1. Systolic blood pressure: >140 mmHg already confers increased risk
   
2. Smoking: the more you smoke, the higher the risk
3. Diabetes: having diabetes puts you at increased risk.
4. Family history
5. Triglyceride levels & LDL levels (Bad cholesterol)
   
6. HDL (good) cholesterol levels

What tests are used for screening?

1. Resting ECG: a look at conduction of electricity across the heart.

2. Stress test: measures heart rate and changes in heart rhythm and blood pressure in response to stress (i.e exercise and increased demand). Sensitivity (pick up rate) of

Treadmill test: sensitivity of 67%, specificity of 70%

Nuclear test: sensitivity of 81%, specificity of 85-95%

reference: American Heart Association journal, Circulation.

Stress test may only pick up stenoses that block >75% of your blood vessels supplying the heart itself.
3. Pharmacologically exercised stress test: if someone is unable to physically walk/run, the heart can be challenged using certain medications.
4. Some centres may offer Coronary Calcium scoring via CT scan. The idea is basically that as you get older, more calcium is deposited in your blood vessel lining.
5. The best and "gold standard" to pick up heart disease is an Angiogram. However, this is normally done on clinical judgement: i.e if your history, risk profile and resting ECG is grossly abnormal, a doctor may opt immediately for an Angiogram as it is both diagnostic and therapeutic (may do balloon angioplasty/place stents to unblock the heart at the same time).

Blood tests

To assess risk of heart disease the following blood tests may be ordered:

1. Fasting blood sugar
2. Fasting serum lipids: Triglycerides, HDL, LDL and TC
3. If needed, thyroid studies (associated with high TG)

During an acute attack of chest pain/suspected heart attack:
1. Troponin I/Troponin T : specific to cardiac muscle but certain illnesses may elevate this level
2. CKMB

LDH is no longer used.

References:
Circulation, Fletcher et al. AHA Exercise Standards for Testing. 201:104:1694
http://www.americanheart.org/presenter.jhtml?identifier=4568
www.accessemergencymedicine.com/updatesContent.aspx?aid=1001232

My clinic nurses:

on the left is Laila and the slightly taller lass is Sha. They are cheeky!.lol.

http://travel.nytimes.com/2007/01/14/travel/14next.html?ex=1326430800&en=8ed9c25f6cf22852&ei=5088&partner=rssnyt&emc=rss

Laos is really amazing. I was lucky enough to traipse around Southern Laos last July. Spent about 2 weeks going through Cambodia and Laos. We started off in Phnom Penh. I took an instant dislike to it, hopped on a bus to the Cambodian-laotian border the next day. It was a terrible 8 hour journey. A couple from Britain had their camera stolen....by someone who was on the bus!. Unfortunately the bus driver did not help at all.

At the border, we had the good fortune to meet up with Mr. Ritchie, a hospitality and tourism student who ran a side business getting tourists across the border. For USD 10, he got you on a boat to go across the river, a car ride to the border station, pass both border guards and to the islands of Si Phan Don.

Si Phan Don (4,000 islands) is very relaxing. There's absolutely nothing to do except smoke pot, sleep, read, sleep...you get the picture. We moved fast, the very next day departing Si Pan Don to head to Pakse (largest southern town) and a bus to the easternmost part of Laos. That was a bit of a downer. No one could help us out at all, no bikes/motos for rent, no tourist info centre, no knowledgeable folks. We stayed overnight and then headed for the Paksong Plateau.

Paksong was the highlight of the trip. Lots of waterfalls, friendly folk, coffee-yummy yummy coffee and cool weather. Stayed in Paksong and Pakse for about 4 days. Pakse had a really good Indian store . The proprietor spoke Malay!. It turnd out he had worked in Sabah for 8 years.Imagine that.

Of course, at the end of the trip i went to Angkor. Worth visiting again.

Wow. Thanks to the absolutely cool ppl who are organizing the Jens gig. Not to be rude..but how?.how did you get Jens Lekman to come?. After all, this is the dude whose album is entitled "Why are you so quiet Jens?". A cold, quiet, Northern place..yep i can imagine him there. But here in noisy, sunny, at times ferociously hot K.L?. Wow.

Well, last night was grand because my team; Manchester United Kicked ass. Otherwise, it would have been a bad night. The den of sin was a good stop. Very short stop though as Elsa, Beth, Mikey Owen, Tim, Chris all wanted to get clubbing before 11p.m. Something about not paying a RM 40 cover charge for the opening night of a new club on Asian Heritage Row. That's all fine and dandy. Riddle me this: why the heck charge so much on opening night?. Why not make it free, hook ppl in and then charge appropriately?. It's so exclusivist. My favourite gigs (not in K.L), in no order:
1. Jon's hardcore band and Thrush Hermit playing their respective final gigs. Fireworks, massive neon band sign, bleeding knuckles. Sigh.
2. Piggy's last show (ska-calypso band). Piggy had it all, stand-up bass, horns, dancers...the most loveable artsy Halifax band ever.
3. Bullfrog : Montreal group who had Kid Koala on turntables. Loved 'em to bits
4. The Herbaliser in Montreal. Fan-effing-tastic.
5. Depeche Mode in Montreal....what can i say?. I hope i'll end up living there.
6. Mariza at the KL Philharmonic. She was otherworldly.

I had a great time at the Mosaic Music Fest last March. I saw Pat Metheny, Kings of Convenience, Afro-Cuban All Stars and a ballet. This year's fest as Rachel Yamagata and Femi Kuti. Check out www.mosaicmusicfestival.com

Right now, i like Feist, The Stars, Amy Milan (eventhough i feel like checking her into rehab), Paolo Nutini and Coltrane with Hartmann.

This is a killer weekend. Working with ditzy,dyed blond,hyena-ish woman later this evening. I fervently wish for her death or that she gets a job in a galaxy far,far away. If stun guns and executions were legal; Dr.Self Obsessed, Dr.Maladict and her would be tops on my list. Err, i don't have a list because you know killing is just wrong...

Yesterday night started out nice. A good dinner at most excellent vegetarian Indian place Saravanan Bhavan.I had Channa Bhatura, Paneer Naan and Veg Mutton Gravy. Sadly, Little Havana; our next stop was crap. Crap band, oblivious staff :"Jens Lekman?, tickets?... dunno lah (Jens is playing Little Havana on Jan 20!)". We stopped by No Black Tie and chatted with Isaac and Zarul. Nice guys, really fun. Waltzed out and headed to Zouk to go to the Loft. Our entry was barred as they suddenly have a dress code. No sandals. That's it. KL's music scene sucks.

Laundry: cold, arty, pretentious, too yuppie-ish.
Cotton Club: great atmosphere, crap bands for the last 3 visits
No Black Tie: beautiful, great atmosphere, fantastic music, too bloody expensive.
Zouk:sucks dinosaur eggs
Zeta: i like it, but since the band has to cater to the hoi-polloi the music turns me off (Sorry Bernie).

Tonight, heading to Den of Sin for good music, good friends and chill-out. Thank god for Elsa and Beth, without 'em, we'd have mo place to party.

On the 23rd of December, the group financial controller, Mr. Malkit came to "talk". Basically, he said he had received complaints from Dr.Self Obsessed and Dr.Maladict that i was "not billing enough", "temperamental" and not working enough hours. Right. He also claimed that Dr.Z and Dr.M have mentioned this repeatedly to me but i have not changed. Actually, i am so sure they didn't because i took written notes of what they have said to me!!!!.

This is what Dr.Maladict told me to do for billing:"If someone has Peptic Ulcer disease; you give them Zantac. But on the claim sheet, you charge for Nexium (RM 127)". Right. He also says he wants me to change the practice to a 60K/month business. By doing this billing crap.He DID NOT SAY..you can't take a locum unless you are dying.He DID NOT SAY oh this person complained about you.HE NEVER BLOODY SAID ANYTHING WORTHWHILE.

This is a summary of what Dr.Self Obsessed said: "blah,blah,blah TLC...Blah,blah,blah Use this drug combo". He DID NOT SAY :a patient complained. He DID NOT SAY: oh you can't take locums. Instead, when he gave me the wrong meds and i couldn't even stand up because of giddiness he called Mr. Malkit to COMPLAIN that i was taking locums. I nearly crashed my bloody car because i was having a severe headache due to the medicine Dr.Self Obsessed gave me.

I said that no, actually they never talked about this at all. If they had, i wouldn't have done any of these tremendously obscene things.

Now, Mr.Malkit says Dr.Z: "just won't work with me at all". Dr.Z has NO APC, is NOT REGISTERED WITH THE MMC and does illegal things and FALSIFIES APCs in front of his staff.Whatever.

Working at evil clinic again. Have given 5 people Typhoid vaccines, seen one case of migraine and had one young lad say..."but i need Dr Z to look at my face!". So, i ushered him gently out (am mellowing in my dotage) and saw other cases.

Background: I had a high stress but very stimulating job as an ER medical officer (doctor). Developed bursitis, then suddenly all my joints wouldn't co-operate and finally diagnosed with Osteoarthritis. This started in July, diagnosed in late August and physiotherapy until now. In December, developed excruciating left groin pain that i thought was a pulled muscle. My chiropractor checked it out: it was a huge lump of unknown origin with involvement of my psoas muscles. My GP, Dr.Z said i had an STI.HUmph. I was afraid it was a fibroid or ovarian cyst ...or cancer. In the ER, you are exposed to a lot of radiation...in the end it was not anything anyone could explain to me...

Through this, i put in my 208 hours,sometimes 230 plus hours a month. I took half days for therapy. It turns out i couldn't!. However, since i am working with NO appointment letter at all since October 1st: how the heck would i know?. Anhow, said company have turned out to be all lying assholes, including colleague and now former GP Dr.Z.

C'est La Vie.

FROM Medical tribune www.medicaltribune.net:Binge drinking risks CV health

In brief,the cardiovascular benefits of moderate alcohol consumption do not apply to young people. In fact, binge drinking may put them especially at risk for developing atherosclerosis.

In a 15 year follow-up of >3,000 young drinkers, U.S researcgers found a direct dise response between alcohol concumption and coronary calcification. The prevalence of atherosclerosis increased significantly in ppl who drank >14/drinks per week. [Am. J. Epidemiolo 2005;161:423-22].

In the elderly,moderate alcohol consumption of 1 unit-2 units confers slight protection against CV disease.

Another Night in the ER.

It was a pretty good night last night.Busy till the mornng but doable. I was team leader again (3 nights in a row!). I think the first night was the worst. However,instead of >200 people a day,our statistics have shown that only about 120 ppl come a day.A marked reduction since the world cup started. Hmm, that means a lot of cases that don't really need to be seen are seen!

Last night itself,within the 10 hours;there were nearly 50 patients in the cubicles (NON ACUTE,and i mean NON ACUTE). A lot came after 10p.m. In the ER,it was okay. However,in the Resuscitation room it was full!. A lot of people come really late at night. When i arrived at 9,the cubicles were empty. Then,at 920,just as the ER was filling up;there were 10 files in the cubicles!. A lot of it were cases that could have been seen in a GP clinic. Not even 15 minutes later,there were 16 files. I sent three doctors to cover it and had to cover the ER and Resusc.

None were urgent enough to be seen immediately. Most cases would not even be seen at a GP clinic in canada. It was complaints like fever for 1 day with obvious causes like coughs and colds. I've been in worse shape and still out and about.

Some silly parents had not even given their children fever medication (which they had at home) and had not sponged nor bathed their child nor pushed fluids. I say silly because in the time they wasted to come,with high temperatues,their children could have fitted if predisposed. A general IQ level before procreation?. There's a distinct lack of sense.

What to do when your child has a fever?

1. a fever is a temperature more than 37-37.5 degrees centigrade.

2. paracetamol is adequate. Please don't be silly and ask for "more power medicine lah". Aspirin is not recommended at all.

3.It will go it's course. It will not go away just after one day. Don't be silly. Don't start saying "doktor bodoh" just because the fever doesn't resolve after one day. Who's bodoh lah?. Have you bothered even reading up?. Do you think there's a magic pill for everything?.

4. Tepid sponging is the best way to cool a child down. Take room temperature water(from the tap),soak a hand towel in it,wipe it all over especially the head,abdomen,armpits and groin. Yes,it's uncomfortable. It does the job and works even better if someone else fans the poor child too. I've done this since i was 9 for all my siblings and cousins. When i was sick,this was done to me. Please don't be stupid. If you care for your child,just do it. Don't show your concern by being abusive to staff who are trying to help you. One lady had time to make up a graph to chart her child's temperature and subsequent fitting.What she didn't chart is that SHE DID NOT DO ANYTHING IN HER OWN POWER to decrease the temperature.What she did do was YELL at my staff nurses. In the pediatric ward,no one wanted to go near her or the child except the consultant who had to. This lady is a typical Malaysian lady who is abusive but incompetent. My nurses had their hands full and had tried to teach her how to do the sponging but she refused.Insisted on Voltaren suppositories.

5.Please do not bundle up the poor kid .How's the heat going to dissipate?.

6.Encourage the child to sip,sip,sip. Of course no one wants to eat or drink.Even adults are like that. However,the body requires more water when there's a fever. Chldren get dehydrated easily as their bodies are composed of more water.

7.A child is adequately hydrated when they pee often,the pee is yellowish or clear (not concentrated), they have tears, their mouth and tongue is moist.

8. If the child has persistent temperature >38.5 despite all these measures,go to a GP first!. Some infections like tonsillitis have very high grade fevers. Most viral fevers are high grade reaching 40 degrees. The key is hydration,cooling down,rest and meds at the right time.

9.if your child vomits everything out or has decreased urine frequency or the pampers are not soaked as usual,come to the ER. please don't overexaggerate,i had one mum last night say her son vomited everything out the whole day. he did look dry and lethargic and since he could not keep anything down (ACCORDING TO THE MUM),we placed an IV cannula to replace the fluids lost. Only after 30 minutes,she said she had given me the wrong idea and he had only vomited once.This was after she spent the 30 minutes whingeing saying it was too painful,must we put this is in.... You daft woman!.DO NOT LIE!.

10.if your child has a heart condition,kidney problems,endocrine conditions,please come immediately.

I keep reading in the newspapers about when to seek the doctor. These articles in the Star's Health section are good because it is done by a group of peers. Some of the articles done by pharmacists are dodgy. In fact,i've had so many horror cases because of "i got the drug from the pharmacistlah,he say good one" that i'm surprised they don't get sued. PHARMACISTS ARE NOT DOCTORS. In Canada, Australia, UK,NZ they DO NOT HAVE THE POWER TO PRESCRIBE. Don't believe me?. Check it out.

Emergency?.What emergency?

City folk are soft. KL people in general are silly when it comes to their health. They'll jump on any bandwagon,buy any supplement, cuss out doctors yet not really take measures to prevent illnesses. Nor do KL folk have any sense regarding what is an emergency or not. Last year, Dr Chua Soi Lek released a statement regarding abuse of the ER by the public. Yeah,he's right. Cases that should not be seen at all in hospital (in any developed country) will insist and persist in showing up to emergency. These people are the worst. They are relatively healthy, a lot very cheapskate, silly and abusive towards emergency staff. They show no respect or courtesy at all from the moment they come in.Yet,they play the victim. Look,let's go over the triage system.

Triage basically a french that means to sort out. During the Napoleonic wars (most innovative techniques were developed on the battlefront), surgeons had to quickly suss out who would benefit most from intervention. If someone was dead or injuries too grievious they were tagged black and left. People with broken limbs an breathing and talking would benefit most and tagged urgent. People who coud walk,stand,shout..well they could hold off and get themselves to treatment tents.

How it translates NOW:
triage 1: you re a goner if we don't resuscitate you NOW

triage 2: you have a potentially lethal condition.May progress to triage 1.

triage 3: no life-threatening presentation of illness.sometimes a 3 may be changed to a 2. Illness is dynamic. If you sicken,of course will change the level of your priority.

triage 4:as my specialist say...they can m*****. normal vitals,waiting time here and oz is 4-6 hours. Don't bitch,don't shout,you actually should not be seen at all in the ER.

In the Emergency,anyone who's seen by the MEDICAL ASSISTANT-who's a paramedic is assessed at the door. For some reason, just because the majority are male,the public assumes they are doctors. They are not. They have specific skills and are trained to recognise danger signs. ANY danger signs noted, these patients are pushed into the ER. At a red box,the team immeditely sees the patient. Notes whether or not this person is an impending collapse (TRIAGE 1/Resusc) or may have a life-threatening event: heart attacks, strokes, irregular heart beats, diabetic complications, asthma attacks, trauma.

However, a lot of people get very tetchy and yell if you ask very important questions. I have never,ever had anyone in Canada or Turkey or Nepal,shout at me because i was trying to do my job i.e save their lives. Malaysian people are extremely rude. Surprisingly,they are taken aback if you are stern with them. In fact,i polled all my colleagues. Most of us were trained in Australia, Ireland and the U.K. We bothered coming back because our families are here. However, we are all shocked at how poorly the Malaysian governmentand public treats the medical community. Why the brain drain?. Because neither the government nor the public respects our profession. Trust me,i have offers from the private sector here and other countries too. I stay because i really like emergency medicine and because my family needs me. Whenever i want to leave,someone will sicken from worry. This is blackmail.

I think the best thing to do now,in this platform; is to highlight what makes this job interesting. What's fascinating. What we could also do without?. If your doctor asks you,"what is the problem tonight?"; just bloody answer. PLease don't say "i have file here ahh,you just look lah". Look,this is Malaysia. The records people can't be bothered to even answer their bloody pagers to retrieve your file from the records office. At 2 bloody a.m. Plus,if you are not responsibe enough to know your medical problems and your medications,what does that say about your attitude to your health?.

A worrying trend is the tendency for a certain group of people to use the hospital as a dumping ground. Elderly parent,child with chronic problems,mental problems...get dumped in hospital. Yes,ALL ethnic groups do this although we see a certain group do it very frequently. There's elderly neglect going on in Malaysia and it stinks.

The worst thing about being exposed to The Ugly Malaysian is that a lot us eventually get fed-up and return to the countries where we are trained. It's not even the pay. It's the respect, quality of life and the chance to bring up your children in a more civilized society. Say what you will about social breakdown. from what we've seen and experienced,things are definitely better for our profession abroad.