Monday, October 21, 2013

A Medical Whodunit? And A Cautionary Tale

A Medical Who-dunit? Or A Cautionary Tale

This post starts as a medical mystery and ends as a cautionary tale and a general advice column. But before I get to telling you my cautionary tale let’s talk semantics first. When you say you are sick or ill what does that mean? It merely means you have a set of aches or pains or complaints which you go show to a doctor and then he hears them/sees them/checks them and tells you that you are "suffering" from such and such a disease. The Annals Of Internal Medicine has a pithy description of this:

"Illness is what you have, when you go to see a doctor. Disease is what you have, when you come out of seeing a  doctor" 

 So even the American academy of internal medicine agrees that a disease is just a name applied to a group of likely symptoms very similar to those named in a book somewhere. You might have that disease or you might not. It requires, usually, more investigations to confirm or deny. Everything else is an educated guess. Sometimes the only way to confirm that the disease is indeed what you have is to start the treatment and observe. If the prescribed medicines work for you and you get relief from your symptoms (or illness) you are considered cured of your disease. If not, then the process starts again, right from the investigation stage.

But is this all there is to health? Mere absence of any symptoms or illness or disease? If you say No then you are right. And the World Health Organization agrees with you too. The WHO says health is

"Not mere absence of disease,
But Physical, Mental and Emotional well-being"

If you read that again you can see that health is a very simple concept of wellbeing in everything and even a little emotional turmoil is considered sickness. But this fact is not easily accepted by our society for when someone complains of emotional turmoil what does society say to him or her? Chin up, be brave, ride it out, accept it, move on, it happens to everybody. All these platitudes merely cover up the fact that society does not accept anything other than physical pain as illness and visible symptoms as disease.

Say for instance one of you constantly misses his train to work every day because the trains are late or overcrowded or canceled at the last minute and this causes constant emotional turmoil. Would you consider that man as a sick man because of his emotional suffering? Or say someone suffers under impossible work conditions, long hours, bad superiors, unappreciative colleagues and work involving unthinking drudgery, causing daily emotional turmoil in daily work. Would you consider that person as sick and accept that his work which has made him sick? Or would you say that as long as he is able to work normally he is healthy?

And the answer to that question is exactly the cautionary tale I am about to tell you.

The other day I had a call over from a ward to attend a patient who had been admitted for occult blood in the oral cavity. To translate it into normal English, the patient had woken up from sleep to find blood in his mouth and had rushed to the hospital to get admitted saying he was vomiting blood. Now the reason for bleeding into the mouth without any obviously visible injury (like being punched) may range from cancer to tuberculosis and to everything in between. But under the keep it simple stupid principle the most obvious reason to rule out was gum disease or gingivitis as it’s known medically.

The reason for this is that gingivitis (gum disease) is widespread and almost every one of us has at some stage or the other has had it with or without us knowing about it. And its also one of the most easily curable of diseases. You just have to brush with the right tooth paste (preferably an imported one) and gum disease disappears. Or so says the omnipotent doctors (practicing in America or Britain) who act in Television commercials (seen the Sensodyne Ad? Parodontax Ad?). But nothing in life is that simple, especially infections involving bacteria or viruses is not. It’s an almighty hell of a battle inside our body daily- us trying to fight off the bacteria which are trying to live off us.

So even the best brushing with a will - diligent brushing ten minutes a day/three times a day (including nights) might not prevent gum disease. Because, for one thing, the bacteria in the mouth cannot all be eliminated with brushing them away - they can hide in other places like tongue, tonsil and throat and come back again. For another, bacteria develop resistance fast and using the same toothpaste with same medications in it for a long time means the bacteria are no longer affected by the toothpaste's antibacterial action. And finally we come to the one reason no one talks about- stress. Emotional stress or mental stress has an enormous role to play in our body’s immune system and stress can make us weak and easy prey for bacterial infections.  

And so when the patient had complained of blood in the mouth and after they had checked out and dismissed all the frightening diseases (like cancer) first, the attending postgraduate students had diagnosed the patient as suffering from the common disease of gingivitis or gum disease and having told the patient to brush properly had closed his case file and marked him for discharge the next day. But someone else had decided at the last minute that an expert opinion is needed and asked for a consultant's all-clear before finally closing the file.

And that’s how I ended up being summoned to check out the patient, the last thing pending before they sent the patient home. Which was quite a lucky thing for him as events turned out, for I cracked the real case which the others had dismissed so easily as obvious. But i will get to that. When i first entered and saw the patient i read the case notes top to bottom. But I was not satisfied with the reason given there of the blood being due to gum disease. It seemed too obvious and easy a solution and my Sherlock Holmesian instincts were aroused.

Something prompting my subconscious, I examined the patient again trying to find some other reason till at last I found it on the roof of the mouth. This is an area which normally nobody bothers about so someone had missed it when admitting the patient. But on the roof of the mouth there were many small bleeding spots called purpura from which blood was dripping into the patient’s mouth. And intrigued by this finding when I checked his blood test results again, I found that his blood levels were dangerously low. 

I arranged for blood substitutes and drugs to increase his hemoglobin levels- under the treat first and ask questions later policy and then sat down to talk with him. I slowly got him to loosen up and drew out the following. He told me that he was a police constable in the traffic department and his work consisted of standing still in one spot all day long. And consequently when he came home after the day's work he had severe leg pains and cramps and couldn’t get to sleep easily but spent tossing and turning half the night. He had visited a local doctor who had prescribed him sleeping tablets to help him go to sleep.

It was at this juncture that I made the connection. I asked him the name of the drug and it was as I had suspected. I asked him how for how long the doctor had told him to take it and how long he had continued to take it. The patient confessed that the doctor had specified that it was to be taken for only ten days but the patient had kept the prescription and automatically renewed it himself from the medical shop and had been taking the drug for months continuously. And there was the reason. Some drugs have dangerous side effects when taken long term, especially drugs prescribed for sleeplessness, which can cause bone marrow depression and consequently reduced production of blood cells.

So there was the case in a perfect link -the reason for the patients bleeding in the mouth was a drug overdose, which had caused reduced blood levels, which had caused increased bleeding tendency, which had caused purpura in the palate, which had caused blood to drip into the mouth, which had frightened the patient and brought him to the hospital on a complaint of vomiting blood. Voila. Elementary my dear Watson. Case Closed, I take a bow.

And all this was because the patient had been stressed enough in his job to need sleeping tablets every day. So should we blame this man’s condition on his stupidity in taking a medicine daily for many months without telling anybody? Or should we blame it on the stress on his life which drove him to take it like that? Which is the real culprit here- the medicine or the stress? If we can go back and read the WHO advice again which I have quoted above- it says that health is not just absence of disease but wellness in everything - physical, mental and emotional. So the emotional sickness of a stressful job can really cause you ill health and make you develop un-looked for diseases. And that is the cautionary tale I wanted to share with you.

One final thought to leave with you- self-diagnosis and especially self-medication is playing with fire. And that’s putting it diplomatically. 

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