Doctor as Patient III - Topical Nitrates

One of the reasons, amongst several, why Dr Dork endeavours to maintain anonymity, is to facilitate frank, unguarded disclosure and discussion of his myriad of medical maladies.

This is for Dr Dorks own benefit, of course, albeit he hopes that some of his readers find his perspective on being variously on both sides of the consultation of interest.

In the first of this series, Dr Dork broached some of his experiences as a cardiology patient. Dr Dork would like to apologise, particularly to his medical colleagues, who would likely have presumed further discourse of this nature, presumably on the use of transdermal patches in angina.



There are other uses for topical nitrates.

Dr Dork was once prescribed a medication called venlafaxine for depression. This is a type of antidepressant used fairly commonly by psychiatrists. As Dr Dork has mentioned before, however, he is a tad prone to adverse effects with many pharmaceuticals.

Venlafaxine gave Dr Dork two problems.

Firstly, it caused his blood pressure to rise. This is a fairly common event.

Secondly, there were some problems with peristaltic orificial output.

Many days of problems.

When service was resumed, due to the delay in ... egress ... there was, shall we say, some clamouring about the exit.

Someone broke the door on the way out.




As Dr Dork has demonstrated with the above oblique account, many people find it very difficult to broach these types of problems. Even when it is relatively easy to sit on the other side of the fence.

Especially for men, it could be argued. There are some challenges to the male ego that many find rather terrifying. We all know what comes next.


But it is no laughing matter. The causes of hematochezia can be benign, and can be very dire.


In case anyone is unsure, Dr Dork is talking about bleeding out the Rik Mayall. And about changes in bowel habits, to a lesser extent.


Dr Dork grew to love the taste of bran. Or, at least, to convince himself that bran is actually possessed of taste.

Compendiums

Dr Dork has been a mite preoccupied the last week, hence the scarcity of output.

Rather belatedly, he would like to mention that Change of Shift, the nursing blog carnival, is up at Emergiblog...and has been for a few days. Apologies, Kim.

Jumping the gun, conversely, Grand Rounds will be up later today at Envisioning 2.0. It is early evening here in Oz, and where the author of Envisioning, Fard Johnmar, is based, it is probably not Tuesday for some time yet.

Another planned themed topic this week, unfortunately, regarding aspects of the confusing American insurance systems. Well, confusing to Dr Dork, at least. Which isn't a particularly unusual event.

There are a few regular Grand Round type collections akin to the seminal creation of Nick Genes that Dr Dork would like to bring to the attention of any readers unaware of them.

Most tend to focus on the relevant area of expertise, but promote those from other disciplines contributing as well.

Apart from the above two, Dr Dork has so far become particularly aware of:

The Pediatric Grand Rounds, which Clark Bartram of Unintelligent Design established, are hosted often at his site - as per this week - but also at various other locations, as per the archive. These are published every second Sunday.

The Radiology Grand Rounds are generally produced by Dr Sumer at Sumer's Radiology Site, although there are guest hosts, and he has set up a handy archive as well. These come out on the last Sunday of each month.

Dr John Crippen publishes The Brit Meds, a collection of British medically related writing, each Sunday at NHSBlogDoc.

Those of us in the penal colony feel unloved, John. As perhaps do our colleagues from the religious pilgrimage.

Dr Dork is just kidding. He is sure there will be an Australian version, once some critical mass is reached.

(insert own joke about slothful Australians here)

Grand Rounds is published at various locations, each Tuesday, and there is a handy archive and schedule at Blogborygmi.

Change of Shift is generally published at Emergiblog, each Thursday.


Dr Dork has spent an embarrassing length of time today trying to organise some form of Grand Round linking omnibus to tack up in his sidebar, to no avail, and much vexation.

Dr Dork recommends perhaps bookmarking some or all of the above compendiums.

He also recommends unplugging your monitor before attempting to throw it through a window.

Cujo

Continuing an occasional series.

As someone who has lived only in Australia and the UK, it is fascinating, and frightening, to see the prevalence elsewhere of rabies, which those of us in Oz do not encounter. Apart from the odd bat lyssavirus in North Queensland, that is.



Dr Dork last exposed himself to the possibility of this nasty disease when in Indonesia a few months prior to the Bali Bombings.

Dr Dork strayed from the usual tourist path to a fair degree, and thus was taking appropriate malarial precautions. With associated amusing dermatological effects.

Dr and Mrs Dork visited a tourist site replete with a surfeit of semi-tame monkeys. These little guys were quite used to tourists, in no predatory danger, and would probably dance upon your outstretched palm if they thought there was a banana in it for them.

When you entered this park, you could purchase a bunch or two of (rather meagre) bananas, all the better to feed the unrestrained zoo within.

Dr Dork, like your stereotypical Western tourist, was wearing a shoulder bag containing photographic paraphernalia. Mrs Dork decided to store a few spare bananas in the shoulder bag.

Dr Dork was not aware of this at the time.

He was rather perturbed, in due course, to find himself surrounded by a collection of very demanding little simians. And their many, many teeth.

And a bite from such is rabies until proven otherwise.

Thus the benefit of vaccination, especially in one whom anything with teeth tends to find...teethable. Tasty. Worth a 'chomp' or two.

A bite, where rabies is prevalent, is rabies until proven otherwise, as far as Dr Dork is concerned.

Rabies is preventable. It is treatable.

If not treated, it is fatal.

More bl***y needles...

Iron Man

Dork takes it like a man

Revisiting preparations for a distant future jaunt, Dr Dork is planning having various immunisations updated.

Like many others born in the latter half of last century, some diseases to which Dr Dork's parents and grandparents were exposed had become eradicated (or virtually unknown) by the time he started playing with dolls setting fire to kittens pottering dorkily about.

For his psychiatric friends, Dr Dork is aware of his tendency towards neologisms.

Polio is one such affliction. It exemplifies many of the diseases that we now vaccinate against, which in their relative absence many of us become complacent about. In essence – an uncommon disease, that has nonetheless devastating potential.

Dr Flea has gone into some detail on the ramifications of poliomyelitis as part of his excellent vaccination series.

Dr Dork is not one to gamble with the health of himself nor his family.

The oral Sabin vaccine, now less commonly used, was a live virus preparation with a 1 per million (at most) possibility of contracting a strain of polio from the vaccine itself. The incidence has fallen so low, thanks to a program of eradication, that even this miniscule risk is too great, and the injectable Salk preparation, with no such possibility of disease inception, is used.

The major obstacle to complete eradication of polio, and the reason for an extra perforation in many, has been ignorance and misinformation.

Religious fundamentalism, to be blunt, is to blame for the ongoing existence of this crippling illness, and for many completely unnecessary deaths.

Grand Rounds

Grand Rounds for the week are now up at Signout.

Signout is an interesting blog from the Scienceblogs.com menagerie, written by a 1st year US medical resident.

A well thought out presentation this week, in the format of a scientific paper.

Unfortunately, at least in the opinion of the Dork and a few others, there continues this week the trend towards designated thematic content rather than non-specific editorial control by the host.

As an aside, Dr Dork apologises for the lack of normal posting of late, he has been a tad lackadaisical lugubrious lazy preoccupied.

The bloglines service is recommended as a way to keep track of sporadic posters such as Dr Dork, who has found it useful and fairly easy to use.

Earl Grey

It is not the local cup of tea here at Chateau Dork. So to speak.



Nonetheless, Dr Dork nominated Dr Flea for best new medical blog, and Dr Crippen for best overall blog. Which he is pleased to see they have won.

Irregardless of Dr Dorks tendency towards introspective navel-gazing, it is nice to see such deserving docs showered with accolades. Dr Dork can highly recommend both blogs as entertaining and enlightening reads.

Dusk till Dawn

Dr Dork is planning an overseas jaunt, hopefully in the not too distant future. He is re-acquainting himself with what little he vaguely recalls in the realm of tropical medicine and travel health. The below will likely be part of an ongoing series and is not intended to be definitive, comprehensive or suitable for personal medical advice. To reiterate...real, living patients with real health issues or concerns...should see real, living doctors.

Remember - Dr Dork is wholly a figment of your imagination...

Malaria

There are around 400 million infections worldwide, annually, as a ballpark estimate.

Between 1 and 2 million estimated deaths annually. That's 3 or so deaths per minute.

Most deaths are in young children.


There has been increasing resistance to antimalarial medications in recent times. Nonetheless, malaria is not only preventable, but eminently treatable.

Risk is greatest in Sub-Saharan Africa. 90% of malarial infections occur here. Mostly, deaths are in young children.

The risk of contracting malaria in SubSaharan Africa is around 1/50 per month of stay for a traveller, if no chemoprophylaxis is taken.

1 in 4000 travellers to high risk areas will die without prophylaxis.

In Australia, there are about 750 cases per year, with an incidence rate of 1.5/1000.

About 10,000 international travellers fall ill with malaria after returning home each year.

This is a drop in the ocean, in regards to the overall public health impact.

There are four different protozoan species causing malaria:

Plasmodium Falciparum (the nasty one that likes to eat your brain)
Plasmodium Malariae
Plasmodium Vivax
Plasmodium Ovale

The latter two like to set up camp in your liver but generally don't kill you.

P.Falciparum is most common on the African continent, P.Vivax in the Americas and Asia.

Transmission is, in essence, via infected blood.

Usually by the bite of an infected female Anopheles mosquito. Dr Dork has no idea why it is only females. This critter is found in most countries in the tropics and subtropics and loves to feed at night - hence "dusk to dawn".


The first step in malarial precautions is trying to stop the blighted little buzzing b*****s from biting you. Repellent with DEET (N,N-diethylmetatoluamide) is most effective, and at 35% strength gives around 10 hours protection. Clothing and bed linen/nets can be impregnated with a contact insecticide such as permethrin. A good spray of an aerosol insecticide before retiring is advisable, especially if rooms aren't adequately screened.

Longsleeved light clothing is preferable - mozzies are attracted to dark colours. Also to strong perfume and cologne. *What's the deal with safari suits, then ?

In summation -

1. Dress like Michael Bolton


2. Lather yourself with a neurotoxic chemical
3. Develop a noisome aroma

There is no vaccine. Not exactly a "Big Pharma" priority.

And, of course, the chemoprophylaxis - ie. preventative antibiotics. Dr Dork doesn't like taking antibiotics if he can avoid it - he tends to be rather prone to side effects, and recalls having a decidedly unpleasant anaphylactic reaction to penicillin when given it as a teenager.

No antibiotic provides 100 % cover.

Doxycycline

Taken from a couple of days before entering the malarious area, until 4 weeks after leaving. One 100mg tablet, once a day. Dr Dork likes that aspect - easy to remember. Not an option if up the duff (Dr Dork estimates his gut at 3 months gestation, oh dear) or prone to peptic ulceration or similar problems. About 1 in 25 get oesophagitis, and candidiasis is common. Interestingly, a small proportion develop an alarming propensity to photosensitivity and sunburn. Dr Dork is already ruling out this one for himself - he took doxycycline once before in the middle of summer. The result was amusing for all and sundry.



Mefloquine

This is the one that seems to have all the horror stories. The good news is that it is just one 250mg tablet, once a week, for a couple of weeks prior to entering the risk area and for a month after leaving. The bad news is the contraindication in psychiatric illness and cardiac conduction abnormalities. Pretty much rules that out - the Dork is well and truly bonkers, and has a questionable ticker to boot.

Apparently the risk of seizures/psychosis/major depression is generally low (1:10 000) but is potentially much higher in those of us with a history of psychiatric illness. Even those with their heads screwed on correctly have a 10% incidence of minor "neuropsychiatric" sequelae such as insomnia, mild agitation, and weird dreams.

That's two down for Dr Dork...

Malarone (atovaquone/proguanil)

Bit on the expensive side, but only one 25omg/100mg tablet once a day as with doxycycline. Also need to start only a day or two prior, but can stop just one week after leaving the malarious area. No good in the gestating, but after auscultating his gut throughout this posting Dr Dork is sure no fetal heartbeat is audible. That kicking must have just been last nights souvlaki...

This one needs good kidney function, and Dr Dork got such a good price for one he is pretty confident about the other. Generally pretty well tolerated, apparently, the odd headache or upset gastrointestinal tract. Dr Dork considers his persnickety bowel emotionally labile at the best of times so this won't be a new problem.

A quadruple dose of malarone also serves as emergency self-treatment for a few days if unable to obtain suitable medical care and one becomes unwell with suspected malaria. The Dorkbowel might be miffed if it comes to that, though.


The reason for the continuing antiobiotic use after leaving the area is referred to as terminal prophylaxis, as some malarial strains (especially P.Vivax, P.Ovale) tend to have dormant liver stages.

Furthermore, one needs to keep potential exposure in mind for a year or two after returning from a risk area, it seems - a pyrexia of unknown origin should generally be considered malaria until proven otherwise if you've recently been to a risk area.

What is it like if you actually have malaria? Dr Dork doesn't know. He has never seen a patient with acute malaria. Part of the reason for the death rate in travellers seems to be the vague nature of malarial presentation, and the tremendous potential for variability in incubation.

In extremis, especially with P. Falciparum, there is often anaemia, jaundice, neurological effects...but especially with milder strains it is described as generally a "flu-like" presentation.

Great. Dr Dork will be panicking over every sore throat for a year.


Risk assessment for the Dork itinerary has a lot to do with location and accomodation, it seems. This is to do with the distribution of various strains, which also varies with the time of year, and with regards to the expected degree of exposure to the mosquito culprit - such as whether you're sleeping in a plush hotel with screened windows or on the beach.

Dr Dork is one of those whom, for reasons unknown, seems especially tasty to mosquitos. There are all sorts of theories to do with blood type, various hormonal levels and whatnot - but no hard evidence as to why some have tastier blood according to mosquito connoisseurs.

Maybe Dr Dork should wear one of these.


More info:
CDC
WHO

Languorously Knackered

Dr Dork is tired.

Good tired.

Busy week at work. More urban ranging than usual today, running some errands. Excuse the pun.

Yet, the mood is good. Pleasant. Euthymic.

Call it what you will, the Dork feels good for having galavanted about today.

Exercise alleviates depression. Lifts the mood.

The effect is evident even now, when the black dog is at bay.


If you're feeling a mite down in the dumps, Dr Dork heartily recommends a spot of exertion.

Go for a stroll. Pummel a punching bag. Whatever suits.

You'll feel better.

Guaranteed.

Grand Rounds

Grand Rounds for this week are up at Six Until Me.

Six Until Me is one of many intriguing and perspicacious patient blogs Dr Dork has encountered. It is written by Kerri, an American journalist who has lived with type I diabetes for over 20 years.

Dr Dork is very impressed by the format of grand rounds this week - presented in the format of a lyric poem, and very well done at that.

Chauceresque !

The Clock Ticked One

It is now one year to the day since Dr Dork first appeared.

As can be seen from the first post, Dr Dork was originally created to enable easier commenting on other's blogs. The disclaimer was added later.

Dr Dork discovered the world of medical and health blogging late in 2005. Some of his early favourites were Intueri, Barbados Butterfly, Orac and the now sadly departed Shrinkette.

Dr Dork was unsure why he began blogging in the first place, but made an early attempt to synopsize his reasons. His reasons haven't changed, albeit he strayed a little towards the dark side after returning from his extended sojourn.


It has been good to follow the development of other bloggers, in particular those who began around the time of Dr Dork:

Dr Crippen of NHSBlogDoc is an entertaining, prolific writer who has grown into a powerful voice advocating NHS reform in the UK.

Dr Flea has also been leaping and bounding to new heights regularly, in particular penning a series of posts rationally discussing immunisation in children - notably at the risk of enraging the misguided zealots who troll the internet with the intent of flaming away rational discourse opposing their blinkered worldview.

And Shiny Happy Person, of Trick Cycling For Beginners, with whom Dr Dork feels much empathy. TrickCycling has, like Dr Dork, waxed and waned at times as it's author struggles with psychiatric illness. Dr Dork, with only unipolar dysfunction, has it comparatively easy.

As Dr Dork blows out his solitary candle, his wish is for a speedy recovery for Shiny Happy Person.

Doctor as Patient II - Depression

It is best to begin at the beginning.

The aetiology of depression is loosely described as biopsychosocial.

Biological

There is certainly an hereditary element to depression. A genetic predisposition. A biological component, independent of circumstances good or bad. Exactly where and how and to what extent is not well understood. Suffice it to say that the degree to which depression is biological varies from person to person.

Psychological
Much of the above paragraph can be reiterated with 'psychological' replacing 'biological'. the extent of causative contribution is quite variable. To simplify, one could say a pessimistic propensity is at play (Dr Dork never turns down an alliterative opportunity). Negative thinking patterns, whatever their genesis, are self-reinforcing.

Social
One way Dr Dork conceptualizes this impact is that, for a given degree of depression, the extent to which it is impairing can partially relate to one's social circumstances. For example, someone socially isolated is more prone to a greater degree of social withdrawal when depression develops than is someone with a close, supportive family and social network. Social factors such as excessive work demands, interpersonal conflicts, bereavements and the like can precipitate or exacerbate depression.

Alcohol and other psychoactive drugs, licit or illicit, could be classed as both a social contributor and a biological contributor, Dr Dork thinks. Alcohol, for example, can be alluring to the depressed and/or anxious for it's transient elevation of mood and anxiolysis, yet alcohol is a depressant of the central nervous system, and is known to accelerate, exacerbate and possibly initiate depression.

This triumvirate, the biopsychosocial model, is a fundamental element of medical school teaching. Although most salient in psychiatry, every doctor is taught to consider healthcare for each patient within the context of their individual biopsychosocial milieu. A patient is more than a broken machine, and doctors are more than technicians.

Depression, for Dr Dork, has been aetiologically related to all three elements.

Depression, for Dr Dork, has also had ramifications biological, psychological, and social.

In the extended Dork family, depression is not uncommon. There is something in his families neurochemical makeup that lends a certain predisposition to this particular ailment. When depressed, all sorts of 'physical' aspects manifest directly, what psychiatrists refer to as physiological shift symptoms.

Psychologically, Dr Dork shares many traits common amongst doctors. Perfectionism, fear of failure, unforgiving of one's foibles, with a record of placing one's own needs for sleep, nutrition, exercise and rest a distant second to his vocational demands. Furthermore, Dr Dork is in many ways the typical Australian male: poor at openly discussing his emotional needs, in denial of his own distress, maintaining a resolute facade to all, and attempting to drown his demons at times.

Socially, the tendency to overload himself has been a contributory factor at times. For Dr Dork, this has been another method of 'escape', at times, which is also doomed to fail. And in his dark times, the costs to relationships, family, career and finances have been steep.

For these many reasons has the black dog lingered long, in the shadow of Dr Dork.

That is enough for today. This is a long tale to tell, and not altogether pleasant in the telling.

More another day.

Change of Shift

Change of Shift is a blog carnival written by nurses and/or about nursing, begun by the always entertaining Kim of Emergiblog, where it is hosted this week.

A different perspective, one suspects, than Grand Rounds which tends to be dominated by doctor blogs.

Submission guidelines and more info on Change of Shift here.

A Whimsical Interlude

Maria of Intueri recently asked a group of medbloggers with delusions of literary grandeur to contribute to a creative writing project. The rules were simple: Each contributor would add one sentence at a time only, of any length, and never consecutively.

This is the result, presented for your amusement:

THE FIRST DRAFT

There was a lot of blood on the floor.

His foggy mind focused on the congealing pool closest to his head—-and the large shard of aquarium glass with green algae on one side—-and two thoughts circled each other: why doesn’t anything hurt, and where was his brand-new poisonous puffer fish? John’s first question was answered almost immediately as he tried to lift himself up off the floor.

Still leaking blood, which oozed slowly, as if afraid of what it would find, was another body, parallel to his own, head tilted away, neck twisted hard to the back.

He sighed with irritation; when he’d woken refreshed this morning between the Egyptian 700 thread count sateen sheets that Sadie had brought back from Paris he’d anticipated that today would proceed smoothly. Whenever Sadie was involved, though, nothing went smoothly: was it really that surprising that both she and John were vying for the exact same puffer fish that promised not only a financial reward of exactly 3.14159 million dollars, but also the guaranteed opportunity to work with the exacting Dr. Crust, who was internationally revered for his research in the use of pies as drug delivery systems?

He wiggled his fingers and toes and all seemed in working order, although there was tingling in his left ring and middle fingers and the left pinky was completely numb, leading him to wonder about possible nerve damage. His mind still on pies and puffer fish, John dragged himself towards the other body, afraid to look, though certain in his own mind of whose body it was.

He gasped in horror.

It was as if he were looking in a mirror: for years he’d had dreams—nightmares, really—of having a twin, but he’d dismissed them because they only occurred after Chinese take-out. Looking into his own glassy, lifeless eyes, he saw his own terror returning tenfold. He stumbled backwards and something fell from the pocket of his scrubs: the crumbled remnants of a pork pie.

“Damn!” John said to himself; not only had he lost the puffer fish he had intended to use to ingratiate himself to Dr. Crust, not only had he awoken to find his long lost twin brother lying dead beside him, but that traitor Sadie had incredibly eaten the last slice of pork pie and then stuffed the crust mockingly into his pocket before sneaking off.

But had she discovered the polonium-210?

John wasn’t sure what upset him more, the fact that Sadie may have discovered the secret to pies with wrinkle-defying moisturizer or the fact that his identical twin was the ugliest person he had ever seen in his entire life. But since there was no time to ponder such imponderables, he forced himself to his feet and headed toward the door, pausing, for old time’s sake, for the last time to lick the algae off the aquarium glass.

Mmm… tastes like pork pie, he mused to himself before his attention was drawn to the shifting, prickly sensation near his groin. The genetically modified puffer fish—the single, viable specimen—was poised in his lap, venomous teeth preparing to bite.

He was unaware that the puffer fish, intended for sushi, had been fed the stolen polonium-210. In its radioactive fury it had grown to immense proportions, puffing its chest in and out like a bull about to charge. John knew he was just seconds away from becoming a soprano unless he was able to dislodge this massive sea creature from his nether regions. His mind raced, faster and faster, sifting, sorting until it landed on the fire extinguisher hanging on the wall: could he use it as a puffer slougher?

When he saw his mind splattered on the fire extinguisher, he gingerly touched his head, felt the sticky blood oozing from the gaping hole near his ear, and wondered how he managed to launch his mind out of his skull at such a high velocity. Acting purely on innate survival instinct, John grabbed the tail of the fish, a split second before its jaws closed, and hurled it away towards the door, which opened to reveal someone he knew only too well.

“Dr. Crust… uh… how, uh… sir, sorry, I thought you were coming tomorrow,” John stammered, automatically reaching to straighten his tie. The enraged puffer fish dropped from where it had struck the wall above the door, and viciously latched itself to Dr. Crust’s nose!

“Aahhh, yes!” Dr. Crust screamed in simultaneous pain and rapture. “At last you have brought me my precious!”

Despite the preternatural grip that said fish had upon his facial protuberance, Dr. Crust smiled triumphantly and began to hum a tune: “The Dance of the Puffer Fish”. In disbelief, John stared as the puffer flopped to the floor and began, artlessly but in time to the music, to “dance”, while Dr. Crust laughed demonically and surreptitiously reached into his hip pocket. He pulled out a slender gold chain from which dangled a small, empty vial, an open locket that contained a sepia-tinted photograph of a smiling Sadie, and a flour-dusted hand mixer.

John spluttered in confusion: “I don’t understand this, Crust—what’s going on here?”

“Sadie left you this morning for dead, selfishly hoping to reach me first,” Dr. Crust explained, “she inexplicably forgot the puffer fish that promised a financial reward of exactly 3.14159 million dollars and the opportunity to work with me… perhaps it was the horror she felt after she killed your long lost twin who had coincindentally shown up that morning after his 30-year, worldwide search for you… sucks for him…” Dr. Crust shook his head.

“But,” he continued. “He really was the ugliest person I had ever seen and I still intend to open the biggest, the best and the only chain of fast-food sushi stores this side of Tokyo; how sad for Sadie that the only fish she’ll be working with will be a Filet-o-Fish sandwich from McDonalds.”

John was flabbergasted, and barely managed to blurt out: “We can’t let her get away with this, especially if she knows about the algae—and who taught the fish to dance?”

“As for her tenure at McDonalds,” replied Dr. Crust, “that may be a just reward for her maniacal egocentricity; however, as for the fish’s ability to do the merengue, that is another story altogether.”

“The merengue, Dr. Crust?” John asked angrily because the word on the street was that the pork pies would impart the ability to do the macarena!

“Won’t you join me?” Dr. Crust sweetly asked and, the anger melting from his heart and brains oozing from his skull, John, smitten, placed his arms around the good doctor and they began to dance along with the puffer fish, with smiles on all of their faces, before Dr. Crust remarked, “Now about that polonium puffer fish pie….”

FINIS.

Co-authored by:

Barbados Butterfly
Keith RN of Digital Doorway
Maria of Intueri
Kim of Emergiblog
Dr. Charles of The Examining Room of Dr Charles
Sid Schwab of Surgeonsblog
Shiny Happy Person of Trick-Cycling for Beginners
Tundra PA of Tundra Medicine Dreams
And Dr Dork

Grand Rounds

Grand Rounds are up at Dr John La Puma's Healthy News. The theme is one of Diet and Food.


Dr La Puma is an American Internal Medicine Physician who has written several books on aspects of diet and health and who apparently even hosts a television show about preparing healthy meals.

Lunch at Chateau Dork

No more blog awards !

There are now at least 4 different blog awards that Dr Dork is aware of being plugged via blogs he reads. Dr Dork hasn't been looking, this is just what has been seen via other health-related bloggers. There are probably many more.

Dr Dork was a little bit uncomfortable about this plethora of self-aggrandisement to begin with, and the squirming of his conscience has only increased as others, such as Dr Crippen and Dr Flea have voiced concerns similar to his own.

It's hard to avoid the allure of the 'ego-boost' of such a popularity contest... but Dr Dork is beginning to feel like he is whoring himself away bit by bit in service of, well, incorrigible narcissism.

Dr Dork can understand the appeal for non-anonymous sites. Arguably, such blogs, whether intended or not, have the potential to increase the professional prestige, or at least the visibility, of their writers. So there is professional gain, feasibly, from such accolades as the various blog awards. Free advertising, if naught else.

Sites that receive income from advertising links would also have a logical reason to seek such accolades as such will increase their traffic, and hence their income from said advertisements.

But for those of us who blog anonymously, for our own personal ventilation and expression, there doesn't seem much point to the whole exercise.

There is, furthermore, the argument that some of the sites hosting these awards are commercial sites. In otherwords, sites generating income for their owners, directly or indirectly. And some of these awards probably draw huge amounts of traffic to their host sites.

For some, to be blunt, traffic = dollars.


















So Dr Dork has decided to step back from further participation in this orgy of blogging awards. He wonders if it is like this every year ?

Cervical Erythema

DownUnder, our healthcare system has been struggling to meet adequate staffing levels for many years now.

This is most evident in general practice and in the public hospital system.

Both are, to be blunt, kept afloat by overseas trained doctors (OTDs) recruited into the Australian system. There has been a boost in medical school places in the last couple of years, but there will be a long delay before this has a positive impact. It takes at least 10 years to train a family G.P. in Australia, and even longer in many other specialties.

The OTDs are generally forced to work in "areas of need" for many years after entry. This entails usually one of two things - being forced to work in our struggling urban public hospitals, or (especially for GP's) to work in a remote and isolated rural or semi-rural area.

If Brits stopped coming here on extended "working holidays" and filling many of our junior grade hospital positions, the entire system would collapse.

What Dr Dork suspects is most challenging for OTDs, however, is that of ending up in the Australian bush for those of a different cultural origin.

 Image source

Rural medicine in Australia is very different from city medicine. Australia is vast, our population relatively small. And most of that population is concentrated in our urban coastal enclaves. In the bush, there aren't many hospitals. Or many specialists. Ancillary services may be a thousand kilometres away. Our indigenous people, to our great shame as a nation, are plagued by Third World health concerns whilst in our cities there are Botox clinics and 5-star private hospitals.

Dr Dork has worked in the bush. He still does, not infrequently. Dr Dork's grandparents were farmers, yet he still finds it hard at times to connect with and adjust to bush life. He can only imagine how hard it is for those coming to Australia from extremely different cultures in places such as Europe, Africa or even our Asian neighbours.

Dr Dork had this illustrated today quite explicitly. A patient came to see Dr Dork for a second opinion. This patient lived in a rural area, and had been under the care of a doc local to his area for a few weeks. From the name on the documentation shown to Dr Dork, this doc was clearly of Middle Eastern extraction. The care he had provided, as far as Dr Dork could ascertain, was perfectly appropriate.

Yet the patient was rather disenfranchised. Very derogatory in regards to the other doc.

The problem was not clinical competence. Perhaps communication with the patient had not been ideal as there was some degree of language barrier. But mainly, it seemed about race.

Dr Dork treats all his paients the same, he likes to think. Be they saint or sociopath.

For some the mask is harder to wear.

Absent poetry

Incorrigible Narcissism

The Medical Blog Awards

Dr Dork is honoured and somewhat abashed to have been nominated in the 2006 Medical Blog Awards in the Literary Medical Weblog category.

Having a look at the polls so far, it appears that all 3 of Dr Dorks regular readers have already voted, nonetheless it is worth paying a visit to Medgadget to check out the various nominees if you're looking for some excellent medical and health blogging to read.

The voting closes on Jan 14th. Dr Dork will be leaving up a link in his sidebar in the hope a few readers might inadvertently click on it - Dr Dork is considering posting a picture for his exiguous readers if he gets over 10 votes...you have been warned!

The AntiVax Hordes

In keeping with the recommendation of Dr Crippen, Dr Dork is adding his voice to the chorus of the reasonably minded and rational in regards to immunisation, as are many in support of the recent focus on this topic by Dr Flea.

In regards to the various childhood immunisations, and also for adults (especially when travelling), Dr Dork recommends you discuss your specific, individual situation with your specific, individual doctor.

If you haven't seen them yet, Dr Dork recommends having a gander at Fleas concise, coherent articles on:

Hepatitis B - Yellow Alert

Chickenpox - Dew Drops on Rose Petals

Whooping Cough - The Cough of One Hundred Days

Tetanus - Risus Sardonicus

Diphtheria - Strangling Angel

Haemophilus Influnzae Type B- Go Home and Die

Polio - The Can from Hell

Smallpox - On my Left Shoulder, A Very Great Fright

Urban Rangers and Egyptian Watercourses

Dr Dork was lurking around intueri recently. Amongst, in essence, waxing lyrical upon her resolutions for the forthcoming year, Maria happened to make mention of something or someone called "urban rangers".

The Dork followed the link and found this interesting site which is the work of a gentleman called Reinhard Engels. It is a collection of what he refers to as everyday systems. The urban ranger is by far the best of the lot, Dr Dork thinks.

In apercu: "We've invented one class of machine to spare us physical exertion, and another class of machine to inflict it back on us again, but in an infinitely more boring, painful, and useless manner."

Dr Dork likes this kind of thinking.

As has been discussed before, obesity is a major problem in all Western societies. It is tantamount to a pandemic. We Docs don't really care what our patients look like in an aesthetic sense, within reason, we care about obesity as it complicates, exacerbates and causes such a vast array of health problems, costs our society billions and our individual patients many years of life.

Dr Dork has straddled both sides of this fence. Before he dropped 30 kg (65 lbs) a few years back, he was guilty of the same rationalisations, defences and methods of denial that he now sees in his patients.

The urban ranger approach is simple : incorporate walking into your day. Walk to the local deli or the video store, don't drive. Walk to work, or at least to/from public transport routes.

Dr Dork used to say to himself he was too busy, too tired, not enough time, other priorities, too many restraining orders, too many complaints about his spandex bodysuit.


*Ahem*. Lets just say there is always an excuse if you want to find one.

Dr Dork found that the excuses tended to fade away when he ignored them. Kind of like a reverse Mr Stay Puft. Once he started exercising, he was less tired. He slept better, and woke up earlier, giving him more time. And so forth, for each apparent impediment.

Dr Dork now rarely drives. He walks or cycles to and from work, the local shops, nearby friends and family - whenever possible. Maybe hops a bus or train or tram part of the way.

Dr Dork doesn't bother spending many hours and dollars at the gym anymore - he gets all his exercise by simply incorporating it into his day.

Like a good urban ranger. Won't you join the Dork ?

Grand Rounds

Musings of a Distractible Mind is a highly entertaining blog written by Dr Rob, a multi-talented US Internist and Pediatrician.

It is certainly one of the most amusing medical blogs Dr Dork has had the pleasure of discovering since his return from holiday incarceration sabbatical exile hiatus.

Dr Dork has already learnt something he didn’t know about emus by visiting there today.

Grand Rounds is up - including soundtrack and explosion theme (!) here.