Published in July 2005 in The Ottawa Citizen

With summer approaching, an understanding of summer heat upon the human body can help prevent heat-related illnesses.

The body has four means of dissipating heat: conduction, evaporation, radiation and convection.

Conduction is the transmission of heat through a substance like blood, water or other tissues. The muscles, warm from exercise, can dissipate heat directly to the skin surface. Blood can absorb great quantities of heat from the muscles and other tissues. It will return to the heart and then circulate to the small blood vessels in the skin. During exercise, the blood vessels dilate to allow greater quantities of blood to transfer heat to the skin surface.

The skin will radiate heat into the surrounding air and environment just like a space-heater. Sweat on the skin surface can absorb the heat and evaporate to reduce body temperature.

As the air warms around the body, it will rise. Cooler air moves in to replace it and absorbs body heat. This cycle is called convection and explains why fans help cool us.

Each mechanism works best within a specific temperature range. At temperatures less than 20ºC, radiation, convection and conduction will dissipate most generated body heat. Above 20ºC, evaporation of sweat is the primary means of heat dissipation.

Children do not sweat as much as adults and produce more heat for the same level of activity. They need to generate greater levels of heat before they do sweat.

Overweight individuals do not dissipate heat as well compared those of normal weight. The elderly have a decreased thirst response, and a reduced ability to circulate blood to the skin surface. Their blood vessels do not dilate as well as younger adults.

Certain medications can contribute to the risk of heat illness.

As temperature and humidity increase, evaporation becomes less effective. On a hot city day, core body temperatures increase because of radiant heat  from the sun’s and hot concrete surfaces.

Evaporation accounts for 85 percent of heat loss during vigourous exercise (a 70 kilogram athlete can lose one to two litres of sweat per hour). Failure to replace water and salt loss further compromises conduction and evaporation.

Adapting to the effects of heat during exercise over a specific time is termed acclimatization. This allows one to adapt to the increased demand to dissipate heat. Fluid replacement is essential for this process to work.

The five types of heat-related illness from mild to severe are; heat swelling (edema), heat cramps, fainting from heat (heat syncope), heat exhaustion and heat stroke.

Heat edema occurs in people who have not undergone acclimatization. Fluid leaks out into the tissues of the feet especially when standing for prolonged periods. Leg elevation reverses this process.

Heat cramps are painful abdominal, arm or leg muscle spasms occurring when too much salt and water is lost. This is a warning sign of pending heat exhaustion. Drinking water, juice or sport drinks and eating salty foods will relieve the cramps.

If there is no cool-down period after exercise, fainting is a risk. Blood pressure can drop when quickly transferring from a sitting to standing position. Dehydration worsens heat syncope. Lying flat with legs elevated rapidly reverses this condition.

Heat exhaustion occurs with excessive sweating in a hot humid environment. Body fluid volume is lost. The core body temperature increases from 38ºC to 40.5ºC. Symptoms include profuse sweating, fatigue, headache, dizziness, visual disturbances, lack of appetite, nausea, vomiting, vertigo, chills, muscle weakness, rapid heart rate (tachycardia), low blood pressure (hypotension) and skin flushing.

The person must be moved to a cool area. Applying cool water-soaked cloths helps. Elevate the legs. Those who are alert need one litre of oral fluid replacement per hour for two to three hours. Disoriented or unresponsive people require emergency treatment. All need a thorough medical evaluation at the hospital.

Heat Stroke is the most severe form of heat-related illness. Body temperature exceeds 40.5ºC and leads to multi-organ damage and failure. Altered mental status is a critical determinant of heat stroke. This medical emergency needs prompt evaluation and treatment.

Preventing heat-related illness is straightforward.

• Stay in air conditioning if possible.
• Drink lots of water before, during and after any outdoor activity.
• Avoid drinks with caffeine or alcohol. They will increase fluid loss via urination.
• Increase the amount of time you spend outdoors every day little by little.
• Take frequent rest breaks while outdoors on hot days.
• Avoid direct sunlight and stay in the shade when possible.
• Wear light-colored, loose-fitting, open-weave clothes.
• Avoid activities that require helmet use.
• Try scheduling activities or workouts early in the morning or late evening. Avoid heavy outdoor activity between 10 a.m. and 6 p.m.

Enjoy your summer.

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Originally published in The Ottawa Citizen Friday, November 12, 2004
Original Title: Infection control for dummies

Infection control can be a complicated matter, especially for viruses that spread as easily as the flu. The flu can spread through direct hand-to-hand contact, via airborne droplets (fomites) after a sneeze, and with contact with recently touched surfaces such as doorknobs, telephones, countertops and desks.

Preventing infection does depend upon “boosting your immune system,” but not in the way some believe it to be.

Our immune system begins at birth as a bunch of raw army recruits. They are healthy and strong but lack experience at recognizing and fighting the enemy. With training and combat they gain experience and become more efficient in their role as a standing army. Some are selected for special-forces duty and reconnaissance missions. They are able to track down and identify their target so that the army can move in and destroy it.

Our immune system follows this analogy. It has the potential to respond to threats from viruses and bacteria. Indeed, it will respond well to minor threats such as colds and minor cuts and scratches. But other pathogens, like the measles virus, polio, diphtheria, meningitis, typhoid and hepatitis, among others, can overwhelm the immune system. It tries to fight back, sometimes succeeding but with great collateral damage to organs and other structures.

If the system is trained to recognize these pathogens before the war, it stands a greater chance of protecting the body. This is the underlying reason why vaccines work.

Vaccines stimulate the immune system to develop antibodies, the body’s special forces that will seek out, identify and target the invader for the main battle group. Without these specific antibodies, the immune system is not co-ordinated to quickly prevent the attack and damage; you either lose the battle, suffer collateral damage or play a game of attrition — a draining experience.

Some argue that exposure to the pathogen is the preferred route of developing immunity, as opposed to using a vaccine. Indeed, the infected person will create antibodies and immunity if they survive the real infection. But this may come at a cost of permanent damage.

The vaccines contain either killed or weakened strains of the organism that have orders of magnitude less potential to cause harm compared to the original virus or bacterium.

Indeed, some will disagree with me and cite Internet references or studies that indicate the opposite. The response is that the studies to support vaccine use far outnumber the ones that imply the opposite. There is no conspiracy.

The flu vaccine is a “best assumptions” vaccine. It is predicated on what flu virus strains we expect will come into Canada and the United States from other regions of the world. If the assumption proves incorrect or incomplete, the importance of proper hygiene practices becomes more apparent.

What other infection control measures can people take for the upcoming flu season?

If you have the flu, isolate yourself from others and do not go to school or work. Wearing a properly fitted surgical mask and goggles with side protectors will help prevent catching the virus from an infected person or transmitting it to a caregiver.

Ineffective hand washing after sneezing into a tissue or coughing into the hand will leave viral/bacterial organisms on the hands. The perfect cleanser does not exist. However, a combination of products will offer substantial protection.

Soaps are excellent detergents and remove grit, grime, dirt, soil, and other organic compounds. The non-antimicrobial soaps fail to remove resident disease-causing bacteria from the skin but do remove some transient bacteria. Sharing a plain soap bar has the potential to spread disease because it can become contaminated.

Numerous studies indicate that alcohol (ethanol) washes dramatically reduce hand bacteria and viral counts after washing for 30 seconds. The alcohol gels should be used for at least 20 to 30 seconds and cover the entire hand and under the nails. Apply about a nickel- to quarter-size blob in the palm. If the hands dry in less than 15 seconds, insufficient gel was used.

There is an antiviral flu medication available called Tamiflu. It must be used close to the onset of the flu and will only reduce, not eradicate the symptoms and duration of the illness.

Carry a small squeeze bottle of alcohol gel with you and use it routinely to prevent the usual winter colds and flu this season.

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Originally published in The Ottawa Citizen October 18, 2004
Original Title: The HN factor

New information and reports of bird flu have shifted attention to the possibility of a new flu pandemic. The most lethal pandemic in our history occurred from 1917 to 1919 killing an estimated 20 million to 50 million people.

The World Health Organization (WHO) released a statement this month encouraging governments and pharmaceutical companies to begin production of bird flu vaccines.

To date there has not been any documented human-to-human transmission of the bird flu virus, but it is the high mortality rate for those who have caught it that has garnered attention. Millions of chickens have been killed during the past few years to contain the latest incarnation of the bird flu.

Why does the flu pose such potential danger, what are its origins and why does the vaccine change every year?

Imagine a beach ball with a small stick trapped inside it. Covering much of the beach ball’s surface is gritty sand. This is what influenza looks like under an electron microscope. The stick is the genetic material that infects us. The beach ball is the shell that protects the genetic material until it can invade our cells. The grains of sand represent the pieces of protein called antigens protruding out on the shell surface.

The antigens are designated with the “H” (hemagglutinin) and “N” (neuraminidase) monikers. For example, the bird flu has a designation of H5N1.

If our immune system is sufficiently primed for this viral invasion it will attack the antigens on the shell. The shell will break open and the immune system’s cells move in to destroy the genetic material before it causes disease. Our bodies develop immunity with each exposure to the flu virus and with each vaccination.

Many viruses slowly mutate or change over time. Most healthy people can adapt to these minor changes.

Epidemics and pandemics occur when the virus (usually Influenza A) undergoes a radical genetic change over a short time. This occurs when a human and bird virus both infect an animal simultaneously. The viruses swap genetic material, forming a new strain.

Because the immune system has never seen this new strain, it has no counter-measures to fight it; the body is defenceless.

Scientist Yoshihiro Kawaoka, of the University of Wisconsin-Madison and the University of Tokyo, looked into why the Spanish flu was so lethal. He stated, “We found that just one gene called HA, hemagglutinin, is sufficient to make a benign virus pathogenic.” The results of the study were reported in the journal Nature.

“One of the hallmarks of the 1918 Spanish flu is hemorrhage in the lungs,” said Mr. Kawaoka.

The suspicion is that the Spanish flu originated from birds. The research team wanted to look for clues within the genetic code of the virus that could help predict future lethal strains before they had a chance to spread.

Those most vulnerable are people over age 65, pregnant women, young children and those with chronic illnesses like asthma diabetes. Hospitalization rates for children under the age of two who have the flu are equal to those over 65.

The historical record of flu pandemics, the last in 1968, indicates a cycle of roughly 20 to 30 years; we are overdue. The WHO’s concern is that the world is unprotected against the bird flu virus, hence its recommendation for vaccine development.

The vaccine’s ability to protect you is determined by how closely they can match the strains that will arrive in North America each year. With a close match, protection rates against clinical influenza approach 70 to 90 per cent.

The flu vaccine contains dead viruses; it does not cause the flu. The vaccines cause side effects less than five per cent of the time. These commonly include a low-grade fever and fatigue for eight to 24 hours after immunization; minimal discomfort compared to the actual flu.

The vaccine is recommended for:

• Persons 65 years of age or older;
• Residents of nursing homes and chronic care facilities that house people with chronic medical conditions;
• Adults and children who have chronic heart and lung disorders, including children with asthma;
• Adults and children who with chronic diseases including diabetes mellitus, kidney failure, anemia or poor immune system function;
• Healthy pregnant women in their second or third trimester;
• And you!

Ottawa Public Health does not recommend the vaccine for people with:

• A previous allergic reaction to influenza vaccine;
• An allergy to eggs or thimerisol;
• A changing neurological condition;
• A history of Guillain-Barre Syndrome;
• A history of Oculo-Respiratory Syndrome.

Studies in the United States demonstrate marked cost savings to the health care system and increased work productivity. In one study, vaccinating working adults reduced absenteeism by 50 per cent.

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2. Chickenpox Vaccine is Effective
3. New flu vaccine production process

Originally published in The Ottawa Citizen September 20, 2004

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Originally published in The Ottawa Citizen August 26, 2003
Original Title: Under the hood

The human body is like a car with its own built-in obsolescence. With proper care and maintenance, we can extend the quality and years of life. Cars are a good example of how benign neglect can lead to numerous breakdown and repair cycles until the car eventually falls apart.

Indeed, women seem to be more aware of this reality than men are. Women take better care of themselves and actively participate in preventing negative health consequences. Men usually wait for the car to break down before driving, pushing or towing it to the nearest garage never asking for directions along the way. It is usually through firm persuasion from their partner that men will pay a visit to their doctor.

Regularly scheduled maintenance is important for disease prevention and wellness promotion. However, not all people require the same diagnostic tests, treatment or reparative procedures.

The longstanding tradition of complete “physicals” is a waste of healthcare dollars. There must be evidence to prove that medical interventions, procedures, counseling, social service strategies, behaviour modification techniques and treatments are effective at each stage of a person’s life. This approach follows the central tenet of “do no harm”.

Patients, through no fault of their own, think that a complete physical exam gives them a ‘clean bill of health’. Taxpayers foot the real bill for a medical service that does not yield useful results. Indeed, routine physicals, x-ray tests, wide spectrum blood tests and other procedures that scans for potential disease is like walking with outstretched hands in the dark. You may feel something but you are not sure what it is. It may be safe or potentially dangerous. The only way to know is feel around further to try to ascertain risk.

Routine testing is fraught with false positive results. These results oblige the physician to forge ahead with further testing to prove or disprove the veracity of the initial test. Patients unnecessarily experience fear and angst. So much for “do no harm”.

Focused regular examinations targeting age-specific risk factors provide information that is more relevant.

The Canadian Task Force on Preventive Health Care (http://www.ctfphc.org/) helps fulfill this role. The Task Force rates a wide variety of preventive health interventions using evidence-based research and recommendations. They try to answer whether these procedures provide accurate, reproducible and clinically relevant results. Other health prevention organizations use this information to target their specific clientele.

The Task Force determines the relevance and evidence of certain procedures, examinations and data collection based in part on age, race, family history and past medical history.

It applies a letter grade rating scale to define the usefulness of each medical procedure, screening test and physical examination process for specified age groups.

For example, a common test many assume to be of value is a chest x-ray to screen for lung cancer. The Task Force rates this as “fair evidence to exclude” (a “D” grade) from an annual physical exam because it does not reduce lung cancer rates.

The Task Force breaks the population down into to specific categories: prenatal and perinatal, pediatric, men and women 21 to 64 years of age, pregnant women, men and women greater than 65 years and patients with first degree relatives with disease.

The 21 to 64 year old age range subdivides further. For example, colon cancer screening usually begins at age 50 and not earlier because there is little evidence to support colonoscopy in a younger patient with no family history of the disease.

The content of your annual general check-up may vary over time because of these different categories and targeted goals.

Let us look at newborn care and the recommendations for a woman over 65 years of age.

Newborn care is an area that benefits from the incorporation of these criteria into clinical practice. The “A” recommendations include checking for a “lazy eye” (amblyopia), child maltreatment, hip dysplasia, a hearing exam, childhood immunizations (tetanus, diphtheria, polio, whooping cough, hemophilus influenza B, hepatitis B and chicken pox), checking for disorders of physical growth, iron deficiency, exposure to tobacco smoke and counseling parents for injury prevention.

Specific recommendations for women over 65 include ongoing screening for breast cancer, testing for cognitive deterioration or impairment, evaluation of falls and injuries, treatment of high blood pressure, providing pneumococcal pneumonia vaccine (pneumovax) and an annual influenza vaccine. Other recommendations include treatment and prevention of osteoporosis, hearing tests, PAP smears for cervical cancer screening, prevention of household and recreational injuries and vision testing.

A screening test often ignored asks patients whether they wear their seat belts and how they position the belt and whether they use a helmet when cycling, rollerblading, skiing or skate boarding. Automobile and sports injury rates outnumber some common disease rates.

There is also fair evidence (“B” grade) to support the effectiveness of advising regular physical activity for the primary prevention of cardiovascular heart disease and hypertension, obesity, type 2 diabetes and osteoporosis.

These lists are by no means complete. They provide a framework for care. The website has detailed information and reports that explain why they are included or rejected as therapeutic or diagnostic options.

I recommend a visit to the Task Force website to review what maintenance schedule you should be following. Bring this information to your next scheduled check-up. Both you and your doctor can develop a five or ten year health prevention and treatment plan tailored specifically for you.

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen July 8, 2003
Original Title: What your doctor wants to know

Preparing medical and family history and other details in advance helps a family doctor tune into your needs.

Your first full checkup with your new family doctor (should you be fortunate enough to find one accepting new patients) addresses more than a full physical exam. This appointment should include your family, past medical and sexual histories, medication lists, allergies, lifestyle choices and, for women, a gynecological history.

Forty-five minutes may not be enough time to complete this survey and physical exam. Preparing this information before your appointment will provide more time to focus on your pertinent concerns and the physical exam.

Sometimes it may be necessary to split this comprehensive exam into two visits because of time constraints.

The past medical history includes your vaccination record and a chronological record of any serious illnesses, previous surgeries, traumas, fractures and infections such as chicken pox, HIV, hepatitis and pneumonias.

Provide a list of any medication allergies and the reaction you had (hives, blotchy red rashes, difficulty breathing or throat tightness).

Bring all your pill bottles with you. It is easy to forget medication names and the dose.

A complete list of medication, including herbal or “natural” remedies, helps determine the potential for adverse drug interactions.

Your family history should include siblings, your parents and grandparents. Find out if they suffer or suffered from:

- Asthma.

- Coronary artery disease, heart attack, high blood pressure, stroke, elevated cholesterol levels.

- Thyroid disease.

- Diabetes.

- Ulcerative colitis, Crohn’s disease, or other intestinal disorders.

- Rheumatoid arthritis and other auto-immune disorders.

- Depression, anxiety, bipolar disorders and other psychiatric illnesses.

- Cancer of the breast, ovary, colon, stomach and prostate gland.

Many of these illnesses are inheritable. The family member’s age when first diagnosed with the illness is important.

Your sexual history should include your sexual orientation, your age when you first had intercourse, the number of previous partners over your lifetime and the number of partners over the past year.

If possible, it is helpful to know whether previous sexual partners were screened for sexually transmitted disease. This information provides an assessment of potential risk of disease exposure.

Part of the gynecological history includes your age when you had your first period (menarche) and the number of days between periods.

Do you have heavy or light bleeding? How long does it last?

Do you have pain with your period (dysmenorrhea)? If applicable, when did you begin menopause?

The lifestyle section of the history correlates well with the family history.

For example, if your father smoked a pack of cigarettes per day and had a heart attack at age 50, and you smoke as well, your risk just increased.

If you smoke, when did you start and how many cigarettes do you smoke per day?

Do you use other drugs such as marijuana, cocaine, LSD, amphetamines or narcotics?

On average how many glasses of wine, pints of beer or shots of liquor do you drink per week?

Do you always use your seat-belt and is it positioned properly over your lap and chest?

If you bicycle, in-line skate or skateboard, do you wear a helmet?

What is your occupation and any workplace environmental hazards (volatile chemicals, poor ventilation, hazardous materials, etc.).

Do you regularly participate in aerobic exercise? What do you do, how frequently and for how long do you exercise on each occasion?

The dietary history begins with a cursory review of eating habits. Do you eat breakfast, lunch and supper? Do you often snack between meals? How many fruits and servings of vegetables do you eat per day? Add up the slices of bread, breakfast cereals, pasta, potatoes and rice consumed per week. What other foods are eaten with them?

How about the weekly consumption of red meat (beef and pork), chicken (with or without the skin?) and fish? Vegetarians should include a list of all the legumes, beans, soya and other protein-containing foods in their diet. The dairy section includes daily milk, cheese and yogurt consumption; whether you use butter or margarine; and the number of eggs eaten per week.

Few pass the snacks, treats and extra fat section. This survey includes how frequently you visit your local fast-food haven, nibble on those cookies or indulge in your favourite chocolate bar, ice cream, salted and roasted nuts or bag of chips. These extra calories are the usual source of slow weight gain.

Your doctor may recommend tests tailored to address specific risk factors, if any, gleaned from this information. Feel free to ask questions relating to your specific concerns. Sometimes, trying to fit all this information into one visit can be frustrating and dissatisfying for both parties. Should time run out, make another appointment to have the rest of your questions answered and to review the test results.

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Originally published in The Ottawa Citizen July 2, 2003
Original Title: Sweat Shops

The effects of this current heat wave and high humidity levels are particularly dangerous for children and the elderly. Children have parents who oversee their well-being and protection from the elements. Many elderly people on the other hand do not have this level of care. They remain confined to their residences, nursing homes or apartments, some without the benefit of air conditioning.

What specific difficulties are encountered with age as it relates to heat regulation? The normal response to heat overload is a ramping-up of the body’s heat dissipation mechanisms.

Normally, heart rate increases to deliver more blood to the blood vessels on the skin surface where heat dissipates. The skin will lose heat through the processes of evaporation of sweat, air convection, heat conduction and radiation. These processes are less efficient with the current weather conditions.

The elderly have a decreased thirst response. They are at risk of not replenishing water lost through sweating. With this week’s temperatures it is not unreasonable to assume a loss of a litre of sweat every one or two hours. This rate increases with physical exertion or activity.

Many elderly people are on some type of medication that can increase the risk of heat stroke and dehydration. Diuretics such as hydrochlorothiazide and furosemide (Lasix) are commonly used to treat hypertension and congestive heart failure among other disorders. They promote salt and water loss through their affect on the kidneys.

Alcoholic and caffeinated beverages also have diuretic properties. The use of laxatives, especially the harsher agents can augment fluid loss.

They will rapidly dehydrate should they not adequately replace their fluid loss. Their blood volume will contract because of the water loss. Less blood will flow to the skin surface reducing heat transfer to the skin surface. A reduction of sweating ability compounds the problem.

With age, blood vessels do not dilate efficiently (vasodilatory response).Heart medications such as beta-blockers and certain calcium channel blockers can reduce heart rate and blood pressure reducing the capacity to circulate blood. The elderly’s maximum heart rate is much less compared to a younger adult further reducing blood flow to the skin. This also reduces the body’ ability to dissipate heat from the skin surface.

The elderly tend to be less fit and are not as mobile as younger folks. Some are bedridden or so incapacitated that they have difficultly replenishing their fluid supply. It can be difficult to get to the kitchen.

Since many of the elderly remain indoors, it is difficult to know who needs help. If you suspect someone is at risk, please check up on them. If you live in a non air-conditioned apartment complex and are uncomfortable from the heat be very aware of your risk. Knock on your elderly neighbour’s door to ensure they are safe.

This week’s temperatures and humidex will cause heat gain via heat radiation into the body. Humidity interferes with sweat evaporation. The end result can be swelling, heat cramps, fainting, heat exhaustion and heat stroke.

General recommendations for prevention include:

* Stay in air conditioning if possible.
* Drink lots of water before, during and after any outdoor activity.
* Avoid drinks with caffeine or alcohol. They are diuretics that will increase fluid loss via urination.
* Take a lot of rest breaks if you must go outdoors in hot weather.
* Avoid direct sunlight and stay in the shade when you can.
* Wear light-coloured, loose-fitting, open-weave clothes.
* Change wet clothes.
* Try to schedule activities early in the morning or late in the evening.
* Avoid heavy outdoor activity between 10 a.m. and 6 p.m., when the sun is hottest.

Source: American Family Physician

Please contact your doctor if you have questions about your medication use during this heat wave.

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Originally published in The Ottawa Citizen April 29, 2003

Original Title: The big gaping maw

As warmer weather approaches, children will be spending more time playing outdoors. So will dogs.

Although there are dog leash laws in Ottawa and the majority of dog owners are responsible, dog bites remain the most common animal bite seen in our hospitals. The Canada Safety Council estimates there are 460,000 dog bites in Canada every year, almost half of them involving children.

The Canadian Hospitals Injury Reporting and Prevention Program states animal bite injuries account for one per cent of all emergency room visits, with dogs accounting for 85 per cent of all these wounds.

Boys five to nine years old sustain the most dog bites –they account for 28.5 per cent of all bitten people. And almost one-third of the time, bites occur between 4 p.m. and 8 p.m. during summertime.

The victim usually knows the dog. Eighty-five per cent of all dog and cat bites come from the family’s or a neighbour’s pet. Thirty-four per cent of attacks occur at the victim’s home and 30 per cent at a friend’s house. Provoking the animal accounts for half of all bite attacks.

Our children are more susceptible to serious injury because they are lower to the ground. Head, face and neck bites account for 70 per cent of the cases. Forty per cent of all bites in children are facial.

Over half of all attacks were minor requiring little treatment. A third needed medical follow-up after leaving the emergency department and one in 20 required admission to hospital.

The wound care for dog and cat bites vary. Dog bites cause lacerations, punctures and crush injuries. Cat bites commonly puncture the skin. Cat bite punctures have a high risk of bacterial infection; three to 18 per cent of dog bites become infected versus 28 to 80 per cent of cat bites.

There are several initial steps to care for a dog or cat bite. First, use soap and water and gently wash the wound.

Use a clean towel when applying direct pressure to stop the bleeding of the injured part. Apply a sterile bandage to the wound.

To reduce swelling and prevent infection, try to keep the injured part raised above the level of the heart.

Consult your doctor no later than eight to twelve hours after the bite injury for an evaluation. It may require oral antibiotic therapy. Report the incident.

Cat bites (not scratches) warrant a visit to your doctor because of their high risk of infection. Deep or gaping lacerations, bites to the hand, foot or head or any signs of infection like swelling, worsening pain, a spreading area of redness, fever or oozing of pus from the wound require immediate attention. Seek medical advice and treatment if the bleeding does not stop despite 15 minutes of direct firm pressure or if you suspect nerve damage, broken bones or a severe soft tissue crush injury.

People with underlying medical conditions that compromise their body’s wound healing capability such as cancer, lung disease, diabetes, liver disease or hepatitis, AIDs or other conditions that weaken the ability to fight infection should consider every bite as serious and warranting medical attention.

Your doctor’s approach to any bite injury is to ascertain the risk of infection, clean and remove any damaged tissue (debride the wound) if necessary and to determine whether to stitch it closed or leave it open to heal. The doctor will explore the wound to determine if there is damage to deeper structure like nerves and tendons.

Deep penetrating cat bites through joint spaces, bones or tendons, bites to the face, hands, feet and genitalia and wounds requiring surgical repair usually need an oral antibiotic to prevent infection.

Antibiotic ointments like Fucidin and Bactroban work well for dog and cat bite wounds with low risk of infection. Get a tetanus vaccine booster if your last one was more than five years ago. It is best to schedule a follow-up visit one to two days after the initial assessment.

If the injury is severe, the wound fails to heal or the infection spreads despite oral antibiotics, you will likely require hospitalization. In these cases, intravenous antibiotics and an assessment from a plastic surgeon is usually in order.

Rabies shots are rarely required for dog and cat bites. The decision to vaccinate against rabies is a concern of the public health department and the medical officer of health.

Preventing animal bites continues to be an area in need of improvement. Young children need constant supervision in the presence of any pet. Animals that are eating, fighting amongst themselves or appear sick should be left alone.

When choosing a dog, pick a family-friendly dog. Veterinarians, professional dog breeders or dog trainers are an excellent resource.

© Dr. Barry Dworkin 2003

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Originally published in The Ottawa Citizen March 25, 2003
Original Title: What teens want to know: Real Questions, Real Answers

How have society’s changing attitudes about sexual activity and responsibility affected our teenage children?

The Medical Institute for Sexual Health, a U.S. non-profit group promoting sexual abstinence outside marriage, lists the devastating toll laissez-faire attitudes have had on our teens.

Its data are supported by similar reports by the U.S. Centers for Disease Control.

The medical institute raises concerns that providing sexual health information without moral context and consequence is harming our children.

The institute’s review of the data indicates that our children’s emotional and physical health is at risk.

Half of all 13- to 17-year-olds will become sexually active. Twenty-five per cent of all sexually active teens have a sexually transmitted disease.

Over 20 years, the prevalence (number of existing cases in a given population) of genital herpes in children 12 to 19 years old increased by 500 per cent. Chlamydia, a leading cause of infertility in women, occurs in one in 10 teenage girls, half of all cases in 15- to 19-year-olds. Human papilloma virus, a leading cause of cervical cancer, is reaching epidemic levels in the teen and young adult age group. Teenage girls with the virus are more susceptible to cervical cell changes that lead to cancer, compared with adult women.

Oral sex is a means for some girls to maintain they are virgins. Many do not see oral sex as being sexually active. Many teens do not even have a definition of what “sexually active” means.

As many as one in five of our teenagers are clinically depressed. Suicides have increased threefold in 30 years.

After nine years of giving health clinics at Canterbury High School, thousands of patient visits and hundreds of handwritten anonymous questions answered during classroom visits, these reports and statistics lead me to accept them for what they are: the truth.

Before writing me off as alarmist, please read what your children have had to say:

Grade 9

“What happens if when you’re having oral sex, you swallow sperm?

“If a girl swallows my sperm, will she be pregnant?”

“How is abortion performed?”

“What is the average of females being raped and beaten in the ages 14 to 16?”

“How does Viagra work?”

“As a male, if I impregnate a girl, what are my obligations?”

“Can you get pregnant without having sex?”

“My friend used to have a boyfriend who hit her and treated her like crap. He even used to use her for sex. Now he wants to get back together with her and she hasn’t made up her mind. As a best friend, what should I say to her to make the right decision without hurting our friendship?”

“Do males have to ejaculate or is it something they choose to do?”

“Can you arrange an abortion without our parents knowing?”

“Can a girl get pregnant if a guy ejaculates in a pool and she is near him?”

Grade 10

“Are there any risks for girls under 14 years other than pregnancy and STDs?”

“If you have intercourse with someone who has an STD, are you guaranteed to get the STD?”

“What is herpes? How can you get it? And how do you get rid of it?”

“My friend might be pregnant but she doesn’t want to have it. She doesn’t want to go to the doctor. She wants her friend to punch her in the stomach to kill the baby. I don’t think it’s right. What can I do to convince her to not do this?”

“Does the size of a man’s penis affect his personality?”

Grade 11

“Would it be safer to have sex now while we are younger, considering that the number of people who have AIDS is rising very quickly?”

“Is it illegal for a 15-year-old girl to be having sex with a 20-year-old guy? What if she’s 16?”

“Can you have an abortion when you are 16 without letting your parents know?”

“I just can’t handle it with the workload any more. I’ve had it trying to balance out school, homework, work, sports, friends and a boyfriend and especially parents. I’ve gotten to the point of nervous breakdown. I don’t sleep, hardly eat. I feel helpless. What can I do? P.S. What is hepatitis B and how do you catch it?”

These questions cut across all socio-economic and cultural strata. We must face this growing trend. We cannot ignore what is happening to our children. Many parents come into my office gravely concerned about their teen’s behaviour.

Teenagers, despite their protestations and efforts to act as adults, need guidance and support to become mature, caring adults.

The guidance centres on responsibility, respect, sexual behaviour and following the rules of the house.

Many parents try to be their children’s friend. The idea is the child will be more likely to accept you into their life. Parents hope they will have more influence on their child’s life decisions and actions.

This strategy, well-meaning and caring as it is, will not stand the test of time.

Friends do not tell friends when to go to bed. At some point, circumstances will dictate that parents will have to switch hats from friend to parent. Viva la revolucion!

Despite their challenges to your authority, teens do need their parents to be a foundation for morals, limits, rules, understanding and love, regardless of what the teens might say or do. Too many feel adrift in a sea of confusion. They need to know they can return safely to port.

As the questions above show, what possible benefit is it to a 15-year-old to have to worry about whether their boyfriend or girlfriend is cheating on them?

Why should they have to deal with the complications inherent in a sexual relationship on top of their educational, social and family responsibilities?

Why should they have to come into the office freaking out over whether they are pregnant or have an STD? Why are they worried about the effects of swallowing sperm? What can parents do? Quite a bit, but it is not an easy road.

Tomorrow night, Dr. Joanne Tannenbaum and I will present at the Citizen conference centre a forum for parents and teens called “What your teens want to know: Real answers to real questions.”

Sign up by e-mail at dworkinforum@thecitizen.canwest.com . Please include your name and phone number.

——————————————————————————–

Tomorrow’s column will look at teens and drugs.

Dr. Barry Dworkin is a family physician and an assistant professor of family medicine at the University of Ottawa.drbdworkin@hotmail.com

Read previous columns at members.rogers.com/barrydworkin/

Web Sites:

Medical Institute for Sexual Health: www.medinstitute.org

Centers for Disease Control: www.cdc.gov/nchstp/od/news/RevBrochure1pdf.htm

National Mental Health Association: www.nmha.org/infoctr/factsheets/24.cfm

Teen Sex: What You Need to Know

Saturday: The demise of dating: Why school kids have ‘buddysex.’

Sunday: In their own words: Students talk about hooking up.

Monday: In search of guidance: Health educators try to guide students through the morass and attempt to curb date rape by teaching the dangers of mixing alcohol and sex.

Today: Sex ed: What are they teaching our kids in elementary and high school? And Dr. Barry Dworkin on what teens really want to know about sex.

Tomorrow: High-school confidential: the Canterbury health clinic. And Dr. Barry Dworkin on kids and drugs.

Thursday: A look at what parents and teens have to say in Wednesday night’s public forum. And Dr. Barry Dworkin on the angst teens are dealing with on the subject of sex.

Friday: The consequences of the hooking-up culture: Where will society and divorce rates be in 20 years if we continue in this direction. And a reality check — teens are not the libertines they are portrayed as.

Public Forum on the Culture of Teen Sex

Parents, teens and others interested in the culture of ‘hooking up’ are invited to a Citizen-sponsored public forum held by Drs. Barry Dworkin and Joanne Tannenbaum, tomorrow at 6 p.m., at 1101 Baxter Rd. Register by e-mail at dworkinforum@thecitizen.canwest.com or by phone at 596-3664. Please include your name, phone number, and the number of people who plan to attend.

Related articles:

1. Students stressed, desperate for help
2. What teens want to know
3. Survey shows youth drug use up in past decade

Originally published in The Ottawa Citizen January 7, 2003
Original Title: Millions for Prevention: Is anyone listening?

The only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you would rather not. – Mark Twain (1835-1910)

As soon as a question of will or decision or reason or choice of action arise, human science is at a loss. – Noam Chomsky (1928- )

A recent front-page story in the Citizen remarked how a Health Canada anti-tobacco campaign using Olympic skaters Elvis Stojko and Josée Chouinard did not have much influence on reducing or quitting cigarette use. Indeed, how effective are health promotion campaigns?

A National Post article (Death: What are the odds?, December 31, 2002, page B3) reviewed the ten most common causes of death by disease in 1989 and 1999 for men and women (see inset). Some diseases are on the decline yet others such as lung cancer in women have surpassed breast cancer. Flu and pneumonia are on the rise partly due to an aging population, smoking, other chronic disease states and an aversion to flu vaccine.

Certainly, there are educational health advisory programs to combat disease. Societies and organizations do their best to inform the public about treating and preventing injuries and disease. They do an admirable job.

Yet as a physician, I continue to see many people who do not heed the sage advice of health care professionals and organizations. Perhaps it is the overwhelming nature of the health information. The mind has a tendency to turn itself off when overloaded. Ask any patient with type 2 diabetes about the plethora of diabetes health information, diets, medical tests and procedures following their diagnoses. Further, the health arena is replete with differing views and advice.

There are limits in our ability to digest (pardon the pun) the latest news about the foods and nutrients in our diet, medical studies, prevention programs and general health advice.

To wit, this is a partial list of diseases and conditions amenable to prevention, eradication or reduction of damage with early diagnosis and screening:

• Diabetes, heart disease, hypertension, congestive heart failure, stroke, kidney failure
• Emphysema, chronic obstructive lung disease, asthma
• Colon, breast, prostate, skin, cervical and lung cancer
• Depression, panic disorder, obsessive compulsive disorder, suicide, bipolar disorder, schizophrenia, eating disorders
• Liver failure, hepatitis A, B and C
• Chlamydia, gonorrhea, human immunodeficiency virus (HIV), herpes simplex, human papilloma virus (HPV)
• Tetanus, diphtheria, polio, mumps, measles, rubella, meningitis, whooping cough, influenza A and B, typhoid, chicken pox
• malaria, water-borne parasitic and bacterial diseases
• peptic ulcer disease,
• fractures, head injuries
• motor vehicle injuries

Family doctors advise their patients about all these relevant topics at the appropriate time. We have to prioritize prevention advice and screening based upon the individual’s age, lifestyle, past medical history, family history and screening tests.

“Prevention” is the buzzword heard in discussions about primary care reform (PCR). The hypothesis is that preventing these diseases would reduce human suffering and health care system expenditures. The implication of this statement is all people will cooperate and follow the recommendations of their doctor or other allied health professional. To quote Hamlet, “Ay, there’s the rub.”

What do you do when a patient refuses a treatment despite your best efforts to persuade them that it will prevent future illness? Cigarette smoking is a good example. I know a charming diabetic asthmatic father of a four-year-old girl. She asked him if he loved her. “Of course I do”, he responded. “Then stop smoking because I don’t want you to die”.

Yet he continues to smoke. He feels guilt and shame and knows very well what will befall him if he remains on his present path.

Many people know of someone in the same predicament. Despite all the education and effort to prevent disease, human nature does not fit into a predictable neat package. Throwing more money into primary prevention will not change this crucial component of health care. The very nature of human responses to disease (fear, denial, anger, and concerns about loss of independence among others) can disrupt any prevention program. Indeed, patient non-compliance to therapy is a leading cause of deteriorating medical conditions and hospitalizations in Canada.

Even with the advent of computerized records to recall patients for specific blood tests, cancer screening programs and disease-specific follow-up appointments, it remains with the patient to assume the responsibility for their own health care. Health care professionals cannot track every iota of their patients’ lives micromanaging each of their potential risk factors for disease.

The Canadian Task Force on the Periodic Health Exam provides age-specific guidelines to help physicians prioritize the relevant tests and procedures for their patient. Each person requires an individualized approach to prevention and treatment. This approach includes the person’s willingness to participate in his or her own health care.

PCR states that the present system does not encourage doctors to provide preventive care services. In fact, many physicians do provide this service. Indeed, it is a family doctor’s responsibility to prevent as well as treat disease. We can offer the appropriate tests and procedures to screen for cancer and prevent disease but rarely does any program or system ever achieve 100 per cent success.

There will always be people that require treatment despite illness prevention campaigns. Although sometimes it leads to better health, other times not, people must be free to choose for themselves.

LEADING CAUSES OF DEATH BY DISEASE AMONG MALES IN 1989 (PER 100,000)

1. Heart disease — 200.3
2. Lung cancer — 73.2
3. Stroke — 47.4
4. Chronic airway obstruction (asthma, emphysema, etc.) — 27.8
5. Flu and Pneumonia — 24.8
6. Colorectal cancer — 23.6
7. Suicide — 20.8
8. Diabetes– 14.1
9. Hereditary and degenerative nerve disease (Parkinson’s, etc.) — 12
10. Cirrhosis and liver disease — 11.7

LEADING CAUSES OF DEATH BY DISEASE AMONG MALES IN 1999 (PER 100,000)

1. Heart disease — 156.4
2. Lung cancer — 68
3. Stroke — 42.2
4. Chronic airway obstruction — 30.7
5. Flu and Pneumonia — 27.9
6. Prostate cancer — 23.8
7. Suicide — 21.3
8. Diabetes — 20.3
9. Cirrhosis and liver disease — 9.2
10. Alzheimer’s disease — 6.1

LEADING CAUSES OF DEATH BY DISEASE AMONG FEMALES IN 1989 (PER 100,000)

1. Heart disease — 147.4
2. Stroke — 62.1
3. Breast cancer — 34.5
4. Lung cancer — 29.9
5. Flu and Pneumonia — 25.9
6. Diabetes — 15.5
7. Hereditary and degenerative nerve disease — 13.5
8. Chronic airway obstruction — 13.2
9. Kidney disease — 7.4
10. Cirrhosis and liver disease — 5.4

LEADING CAUSES OF DEATH BY DISEASE AMONG FEMALES IN 1999 (PER 100,000)

1. Heart disease — 123.4
2. Stroke — 58.7
3. Lung cancer — 41.8
4. Flu and Pneumonia — 31.2
5. Breast cancer — 30.9
6. Chronic airway obstruction — 21.6
7. Diabetes — 20
8. Senile and presenile dementia — 12.9
9. Alzheimer’s disease — 12.6
10. Cirrhosis and liver disease — 4.5

Source: Statistics Canada

© Dr. Barry Dworkin 2003

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