Hot Weekend

Like many others, we sweltered over the weekend. But that was nothing - to hear that over 100 people have lost their lives in bushfires in Victoria is devastating. We are yet to hear from all our friends, but we hope that no-one has been injured. At the end of the day, property is replaceable but people aren't.

Maybe it is a reflection of how close we choose to court danger, or how deceptive the risk can be. In any case it is a demonstration of the power of natural events. Sadly this is not the first time, nor will it be the last time - but that should not stop us from picking ourselves off the ground, dusting off the ashes, and building anew. The trees, grasslands, scrub and fauna all do it, and so should we.

It is still disturbing to think about how serious these bushfires have been, I can only divert my ponderings with some clinical content.

Tips for dealing with major burns
Rule of Nines
When assessing the area of burns, a handy rule is that of the nines. Not very precise, but quick and dirty does the job. I have heard this rule attributed to multiple people - so I guess it doesn't matter so much. The palm is around 1% and can be used to estimate smaller burns.

• Head & Neck - 9%
  
• Chest (Front) - 9%
  
• Chest (Back) - 9%
  
• Abdomen (Front) - 9%
  
• Lumbar Region & Buttocks - 9%
  
• Each Arm - 9%
  
• Each Leg (Front) - 9%
  
• Each Leg (Back) - 9%
  
• Miscellaneous (Groin / Perineum) - 1%

Adjust in children because the head is bigger (18% instead of 9%) and legs are smaller. Generally I send anything approaching 10% or affecting a critical region (head & neck, perineum, skin flexures or joint lines) to a specialised burns centre.



Burns Thickness
We used to be taught to classify burns as first, second and third degree. It doesn't really matter - either the dermis is intact and a burn is capable of epithelialising on its own (partial thickness) or it cannot (full thickness). Note that whether or not it requires skin grafting does not define the burn thickness - this is based on a multitude of other clinical factors.

If a patient has more than partial thickness burns, do not understimate the depth of the burn. Eschars need debridement firstly to assess the depth of injury and secondly to reduce compartment syndromes and contractures. In burns of the chest and torso they may limit respiratory excursion.

Fluid Losses
Patients with significant burns will lose large amounts of fluid through exudative and transudative losses. Fluid replacement is frequently overlooked. This is most essential over the first 24 hours, but is ongoing until the wound is healed.

Hopefully that will be enough tidbits to keep you busy. And may you all stay safe.

I Don't Understand the NHS

This is probably the domain of Dr Crippen but the more I read about the NHS the worse it seems to be.

What does the NHS Centre for Involvement do?


And do they really really need a National Knowledge and Question Answering Service?. I thought that's what AskJeeves, Universities and libraries were for. Before you know it there will be a Ministry of Truth.

Too bad the NHS' Jargon Buster service doesn't explain what "Involvement" and "Question Answering Service" mean, because it sure as hell has redefined what a Spine is!

Perhaps it is a function of the fact that the NHS is one of the largest employers in the world (over 1.5 million) that they have to find pointless activities for people to do? I vote that they shut down one of these departments and hire more doctors and nurses.

Happy New Year Blah Blah Blah

After a long break, I have decided to resume my intermittent blogging. I know that it has been some time, and that many of you may have moved on to more regular and more exciting blogs, but nevertheless, I still have the urge to vent.

So I hope that you have all had a good Christmas, Hannukah, New Year, and New Year.

Part of the reason that I have been quiet is that I now find myself on both sides of the fence. All of a sudden, I have been planted inside a palace of power, a domain of dominance... an institution of influence. But enough of the alliterations. I have frequently complained about the powers that be - now even though I may be a speck or a fly on the wall I can see some of the machinations that lead to my complaints, and I am not impressed.

Partly I am not impressed by how bureaucratic and slow large organisations work. Partly I am not impressed with my own lack of enthusiasm at changing any of this. Nominally I may attend a committee that can change things. But I realise now how competing interests dilute progress. And I also see how committees have to justify their own existence.

So I am conflicted - I have better things to do with my time, but I still want to be on the inside, looking for an opportunity to improve things, even a little. Perhaps I am merely a pawn being played by others, but it means that I must be even more careful about what I write and blog about, lest I inadvertently divulge state secrets, or even worse my identity.

And so I leave you with two little tidbits for today:

1. This blog has been nominated for the Inaugural Australian Medical Blog Awards set up by DrCris at AppleQuack and Scalpel's Edge. If you think I deserve it, vote for me. Otherwise feel free to nominate another Australian Medical Blogger, like The Girl.

2. A fascinating piece from The SMH on the fraudsters allegedly dodgy dealings at Advanced Medical Institute. You may recall that these are the group that run are associated with the Heart Check group from my post here and here:

• Authorities launch investigations into sex ads company - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  Authorities launch investigations into sex ads company
  Kelly Burke, Rachel Browne and Alex McDonald
  The Sydney Morning Herald, February 1, 2009
  
  

  Erectile dysfunction king … Jack Vaisman, founder and owner of Advanced Medical Institute and (inset) one of his controversial former billboards. Photo: Jacky Ghossein from SMH

  
  
  AUSTRALIA'S king of erectile dysfunction, "Dr" Jack Vaisman, is being investigated by government agencies in two states.
  
  The NSW Office of Fair Trading and Victorian Consumer Affairs confirmed last week they were examining the operations of Mr Vaisman's company, the Advanced Medical Institute (AMI).
  
  NSW Fair Trading Minister Virginia Judge has asked dissatisfied customers to come forward with their complaints of alleged unconscionable contracts and undeliverable guarantees.
  
  Mr Vaisman claims almost 500,000 men over the past decade have responded to AMI's billboard-sized promises of longer lasting sex.
  
  The NSW regulator believes the disaffection is probably much higher than the actual complaints received as men are too embarrassed to lodge formal complaints over the $4000 contracts which commit them to 18 months of "treatment" and severely limit their access to the company's money-back guarantees.
  
  The thriving business predicated on men's sexual-performance anxiety has delivered millions of dollars to AMI coffers and spawned more than 20 clinics in Australia and New Zealand, and, most recently, a discreet consultancy in London.
  
  Last year AMI, registered as a public company on the US NASDAQ, posted an almost 50 per cent increase in gross profit, from $8million to $12million, in the July to September quarter alone - profit the company attributed to its more effective advertising campaigns (at a cost of $500,000 a quarter), increased brand name recognition, and the effectiveness of its products.
  
  Yet AMI's founder and owner Mr Vaisman, a portly Ukrainian migrant in his early 60s with a good suit and a comb-over, denies he is a very wealthy man. Comfortably off, he'll concede. But far from accumulating personal wealth, Mr Vaisman claims he is delivering savings worth millions of dollars to Australian taxpayers every year.
  
  "All my consultations, we never use Medicare," he said. "Can you imagine if 90,000 impotent patients went to their GP every year? At $45 or $50 a consultation, what would happen? The Government would lose millions of dollars."
  
  Sexual dysfunction, says Mr Vaisman, is a quality of life condition and if you want quality of life you have to pay: "It's like if you want a better car or you want a better house, you pay more money."
  
  Mr Vaisman is under fire from multiple corners, but that is hardly new. In 1996 his former company, On Clinic Australia, was prosecuted for importing $500,000 worth of unregistered drugs - the charges were proved but no conviction was recorded, with the Court of Criminal Appeal acknowledging the probably inadvertent nature of the offences.
  
  Aside from much-publicised run-ins with the Advertising Standards Bureau, there has also been attention from the Australian Competition and Consumer Commission over allegedly misleading claims relating to his controversial treatments and AMI's promises of guaranteed results or money back. Mr Vaisman rejects the latter allegation outright: "We cannot guarantee a result but we always guarantee money back."
  
  Meanwhile, the chorus of caveats and criticisms from the medical fraternity multiplies monthly.
  
  Dr Chris McMahon, associate professor of the Australian Centre for Sexual Health, has dealt with former AMI patients, and alleges the majority have not received what they thought they paid for.
  
  AMI's apomorphine-based nasal spray has not been the subject of clinical trials, so its efficacy remains untested, he says.
  
  "There's a certain logic to it," he conceded. "I could also argue that because Panadol is effective as a tablet for a headache we could crush it up and put it into some K-Y Jelly and rub it into the scalp. Now we all know that is ridiculous - the way that you would prove or disprove that is to do a clinical trial."
  
  The non-profit Impotence Australia receives on average about five complaints about AMI each week. When patients fail to respond to the nasal spray, lozenges are offered but invariably the patient ends up facing injection therapy, the association's chief executive, Brett McCann, says, which is where many men will draw the line.
  
  "[I've seen] one guy who had only one arm … It is pretty difficult to inject when you've only got one arm. He said he would never have agreed to it had he known."
  
  But formal complaints are comparatively rare, says Professor Basil Donovan, from the University of NSW's National Centre in HIV, Epidemiology and Clinical Research.
  
  "Men are too embarrassed to come forward," he said. "It is an area prone to exploitation."
  
  The Australian Medical Association has expressed concern that some of AMI's initial customer contact does not involve a registered medical practitioner. Moreover, the company's practice of conducting phone consultations is unlikely to identify health issues such as heart disease, stroke, obesity and diabetes that can often be underlying causes of erectile dysfunction, AMA president Dr Rosanna Capolingua says.
  
  Dr David Malouf, the vice-president of the Urological Society of Australia and New Zealand, says the treatments AMI offered at large mark-ups could be provided at a much cheaper rate by a GP.
  
  "But the reason [GPs] don't is because these treatments are less effective than others, such as Viagra, Cialis and Levitra."
  
  Such mainstream treatments are also largely without the horror side effects sometimes associated with injectibles, says Dr Malouf, warning that 30 per cent of men may develop local pain at the site of the injection.
  
  "I've seen bruising, scarring, curvature of the penis and priapism [persistent painful erection]. I had one patient who was treated with one of these agents. He was given a sheet of paper with a number to call if anything went wrong, which it did. He was effectively told [by AMI] 'there is nothing we can do, you have to go to a hospital emergency department' … That case of priapism was so severe, it permanently damaged his erectile function. He went from having a mild erectile problem to having a non-functioning penis. And he was a young guy, too."
  
  Dr Malouf says he also had a 17-year-old boy who was prescribed treatment for premature ejaculation from an AMI clinic: "I would have thought that was entirely inappropriate."
  
  When The Sun-Herald put this to Mr Vaisman last week, he said: "If a patient asks for help, does it make any difference of the age?"
  
  The following day, public relations firm Wilkinson Media issued a statement saying AMI had a policy of not providing treatment to people under the age of 18.
  
  Mr Vaisman has never been registered as a medical practitioner in Australia, a sacrifice made, he claims, to stay in this country. With a mother, wife and daughter to support - the former two suffering serious health problems - a year-long hospital internship was out of the question when the Ukrainian-trained doctor arrived in 1987: "This was the price I had to pay for my freedom."
  
  That much of the clinics' work with clients takes place over the phone is logical, Mr Vaisman argues, as erectile dysfunction is very much a self-diagnosed condition.
  
  "If a patient says to the doctor, I cannot get an erection, there is no test that can prove or disprove this, you have to take his word."
  
  It is also an effective technique, he says, in protecting anonymity.
  
  With the exception of occasional crustiness or bleeding around the nose, Vaisman says his nasal sprays have practically no side effects. The risk of priapism is no more prevalent with the use of injectibles than with more conventional treatments such as Viagra, he adds, while AMI's 24-hour hotline is available to advise in such emergencies.
  
  Mr Vaisman says Impotence Australia, one of AMI's most vocal critics, is in direct competition and accepts sponsorship from large pharmaceutical companies such as Viagra's manufacturer, Pfizer.
  
  Impotence Australia declares it accepts sponsorship from pharmaceutical companies on its website, but denies the direct competitor claims made by Mr Vaisman.
  
  "We're not offering any treatment," said Mr McCann. "We refer people either to GPs or sex therapists or we give general information."
  
  Mr Vaisman describes himself as a pioneer: "We have a lot of criticism. But I am fighting for what I believe is right. I am a fighter."

  
  
  
• Why erectile dysfunction client wanted his cash back - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  Why erectile dysfunction client wanted his cash back
  Kelly Burke
  The Sydney Morning Herald, February 1, 2009
  
  AT THE age of 35, Nick* was appalled when he started experiencing difficulty maintaining an erection during sexual intercourse with his partner.
  
  The Advanced Medical Institute's "Want Longer Lasting SEX?" billboards seemed to be screaming at him from every corner.
  
  Nick succumbed to their promise. He confessed to the first male AMI consultant that the "open relationship" he had been coerced into by his girlfriend - she could seek other sexual partners - might be the underlying cause of his physical problem.
  
  The consultant listened and left. Next came a female consultant who told Nick that regardless of his relationship status, there would be no improvement unless he received drug treatment. She left. Then came the "deal closer".
  
  "She was upbeat, articulate and very pushy. When I baulked at signing a 12-month contract committing myself to drug treatments worth around $3000 … she basically made me feel as though I was making a mistake I would suffer for later."
  
  Nick said he was pressured to buy a month's supply of nasal spray and a gel for about $350. The spray had limited effect and the gel did not work on him. When he asked for a refund, the company refused, arguing there were no guarantees the products work for everyone.
  
  Months later, Nick's relationship with his partner became exclusive. He says his erection problems vanished, without the assistance of medication.
  
  * Name has been changed to protect identity

  
  
  
• From Siberian gulag to 'this beautiful country' - The Sydney Morning Herald
  (Click to Expand)
  
  
  

  From Siberian gulag to 'this beautiful country'
  Rachel Browne and Kelly Burke
  The Sydney Morning Herald, February 1, 2009
  
  

  Rags to riches .. Jack Vaisman. Photo: Jacky Ghossein from SMH

  
  
  JACK/Jacov/Jakov/Javov Vaisman/Vaysman/Waterman was born in Moscow/Ovruch/Odessa/Kiev/Ukraine/place unknown on August 23 and 28, in 1945 and 1946, according to the personal details provided by the company director and shareholder to the Australian Securities and Investments Commission.
  
  But life has long been complex for the self-proclaimed former Soviet political prisoner, whose path to Australian citizenship was smoothed by a former prime minister.
  
  Trouble started for the young doctor, who had graduated from the Donetsk State Medical University in 1968, when he applied for an exit visa in the mid-1970s. He says his application to leave the Soviet Union resulted in his expulsion from the university, where he says he was associate professor of gynaecology.
  
  In 1980, as he was preparing to conduct an operation, the KGB came calling.
  
  Vaisman says he spent the next six years as a prisoner in Siberia, first logging forests then building a power station.
  
  "In winter it's minus 62 … the birds drop dead mid-flight," he recalls. "The prisoners were loaded on to the truck and every half-hour we were told to get off and run behind the truck, otherwise we would be frozen before we came to the job. Every morning you wake up in the barracks and somebody is dead. "Nobody knows why, nobody cares. It took me almost 1½ years until they realised I was a doctor."
  
  On one occasion Vaisman was told by the prison's chief commander that if he did not cure him of gonorrhoea in three days he would be executed.
  
  "I treated him in two days … I saved my own life."
  
  Throughout the 1980s, Vaisman's parents-in-law, who had emigrated to Australia, had been lobbying Bob Hawke.
  
  Vaisman's name was on a list Hawke took to Moscow in 1987, the former prime minister has confirmed to The Sun-Herald, and petitioned for his release.
  
  In 1987, while still on parole, Vaisman was told he and his wife, daughter and mother were free to leave the country if he left his papers behind. Vaisman arrived in Adelaide with two suitcases and $200. Six years later, using $9000 he had saved from his jobs in a service station and a mattress factory, Vaisman opened his first clinic.
  
  "I don't believe in God, but every morning I pray," says Vaisman. "I am in this beautiful country of opportunity. I came without language, without money, without anything, but I had an aim and I am here … I tell my grandchildren, some time you will remember that your grandfather brought you to this beautiful country. He risked his life, he risked his career, everything, to bring you to the best country in the world."

  
  

Scan Me, Scan You

"Mrs Burns?"

40 heads turn around in the outpatients waiting area as I call for the next patient. "Mrs Burns?"

A chubby elderly lady stands up with her daughter and they make their way into the windowless consulting room.

It's a fairly standard consultation. Her GP has referred this moderately obese woman in her late 50s with two episodes of colicky abdominal pain over the last six months. An ultrasound shows some small gallstones but no CBD dilatation. LFTs are normal.

It's clear that the problem is not reflux, and it has only happened twice - after Christmas dinner and a big Easter Lunch. Diagnosis: Biliary Colic.

"There's really no need to worry, Mrs Burns. The likelihood is that you will get some discomfort, maybe some diarrhoea, if you eat a very fatty meal, such as fried food. There's a very small chance that the stones could block the bile duct or gall bladder and that you might get inflammation or infection, in which case you would get quite unwell and should come to the Emergency Department. Otherwise, I would only recommend surgery if you were to develop frequent pain whenever you eat."

"Are you sure it's not cancer?" says the daughter. "My boyfriend's father's second cousin's next-door neighbour had pain like this and they found a cancer in his pancreas. He died in agony after five operations. They say it's a hidden killer."

I struggle to keep a straight face. "There is no reason to think that a cancer is there. Your mother's bowel actions are normal. Her weight is, er, stable. The blood tests are normal... at this time. I think it is just the gall stones. I'm happy to keep an eye on things, and if things were to change then I'd consider a CAT scan, but there's no reason to do that now."

"Wouldn't it be too late if she had symptoms? Why not scan her now? We don't want to end up like that bloke on the news." I sigh, silently to myself. Last week a poor chap died of a subarachnoid haemorrhage because the experienced ED physician decided that a 35 year old man with a long history of migraines didn't need yet another CT brain for yet another headache.

I could give the spiel about unnecessary radiation exposure. I could talk about blowing out the public healthcare budget and our taxes on inappropriate investigations. Or I could reach for the request slip.

"Leave the young man alone, dear. He's told us what the problem is. Don't you trust him?"

I smile to myself as I show them the door. The patient herself has let me off the hook, and highlighted the inter-generational change in "health consumer" behaviour. I cross my fingers and hope I'm right.

That was my 100th blog post. I realise that as an irregular blogger it is challenging to build up a large readership but I hope that those of you who happen to stumble upon my blog find it interesting and thought-provoking. Please keep up your comments, as that is the only way to know that somebody actually reads my blog!

The Unwanted Child: Part 2

As a followup to my earlier post, The Unwanted Child, I thought that I would link to more recent reports in this case.

Basically the parents have been unsuccessful in their lawsuit, and I breathe a sigh of relief (as a medical professional). For more information, follow these links.

• Lesbians fail in lawsuit over child (SMH) (Click to See)
  

  Lesbians fail in lawsuit over child
  Melissa Jenkins
  July 25, 2008
  
  THE lesbian mothers of IVF twin girls have lost a legal bid to sue their doctor for the cost of raising one of the toddlers.
  
  The women, whose names have been suppressed, sued a Canberra obstetrician, Sydney Robert Armellin, for more than $400,000 for implanting two embryos instead of the requested one.
  
  The ACT Supreme Court yesterday ruled in favour of Dr Armellin, and ordered the couple pay his legal costs.
  
  The couple, whose combined income is more than $100,000, sought $398,000 from Dr Armellin to cover the cost of raising one of the girls, including fees for a private Steiner school in Melbourne. The girls are now aged four.
  
  The court was told the twins' birth mother had lost her capacity to love and the couple's relationship suffered as they became mired in everyday tasks associated with raising two children.
  
  Dr Armellin's lawyer said it was common for parents to experience a loss of freedom.
  
  The couple said it was Dr Armellin's responsibility to ensure his patient's wishes were carried out at Canberra's John James Memorial Hospital on November 12, 2003.
  
  Dr Armellin said the birth mother only told him she wanted one embryo minutes before she was sedated, after previously signing a form consenting for up to two embryos to be implanted.
  
  Justice Annabelle Bennett said Dr Armellin had not breached his duty of care to the birth mother and was therefore not negligent.
  
  The women did not mention in a conversation with clinic staff the day before the procedure that they wanted only one embryo implanted, Justice Bennett said. "The plaintiff had the right to choose the number of embryos to be transferred, they also had the responsibility to communicate that decision," she said.
  
  AAP

  
  
• Court dismisses IVF negligence case (ABC News) (Click to See)
  

  Court dismisses IVF negligence case
  Posted Thu Jul 24, 2008 6:26pm AEST
  Updated Thu Jul 24, 2008 6:31pm AEST
  
  Lawyers for a Melbourne couple suing for the wrongful birth of their child have not ruled out appealing a judgement in favour of their Canberra obstetrician.
  
  The women went to Doctor Sydney Robert Armellin for IVF treatment in 2003, but two embryos were implanted instead of one, resulting in the birth of twin girls.
  
  The court heard evidence that the birth of the twins had a dramatic impact on the couple's careers and relationship.
  
  They sued Dr Armellin, seeking $400,000 in compensation to cover the cost of raising one of their twin girls.
  
  But today Justice Annabelle Bennett dismissed the application, saying the fertility clinic staff and the birth mother failed to confirm the number of embryos to be implanted and staff did not follow it up.
  
  She said this meant that Dr Armellin was not negligent, and she ordered the couple to pay his costs.
  
  The lawyer for Dr Armellin, Kim Burke, says her client is relieved but understands the court's decision could be appealed.
  
  "Well I've not yet read the judgment so obviously we'll look at the judgment carefully to see whether there are good grounds and if we're advised by the plaintiff's representatives that they intend to take that step well, we'll take the appropriate steps ourselves," she said.
  
  The lawyer for the women, Thena Kyprianou, says the couple are disappointed by the decision.
  
  "They said that they're shocked and that they would consider their options further once we have an opportunity to read the judgment," she said.

  
  
• IVF negligence case shouldn't have gone to court: AMA (Click to See)
  

  IVF negligence case shouldn't have gone to court: AMA
  Posted 2 hours 5 minutes ago
  
  The Australian Medical Association (AMA) says the case against a Canberra obstetrician for the wrongful birth of their child should never have made it to court.
  
  A Melbourne couple went to Dr Sydney Robert Armellin for IVF treatment in 2003, but two embryos were implanted instead of one, resulting in the birth of twin girls.
  
  The women then tried to sue Dr Armellin for $400,000 to cover the cost of raising one of the children.
  
  Justice Annabelle Bennett yesterday ruled the doctor was not negligent, saying the fertility clinic staff and the birth mother failed to confirm the number of embryos to be implanted and staff did not follow it up.
  
  AMA ACT president Dr Paul Jones says the judgment is a good outcome.
  
  "The AMA's view is that if there's an outcome which is a healthy, live baby that these things shouldn't end up in the courts," he said.
  
  "I think the medical profession in general will welcome this case."
  
  Dr Jones says ACT laws surrounding IVF treatment need to be clarified to avoid legal action.
  
  "In other jurisdictions they've already moved, for example in Queensland, and I understand there are moves in New South Wales to change the law to clarify these very difficult points," he said.
  
  The lawyer for the lesbian couple says they are still deciding if they will appeal against the ACT Supreme Court judgment.