Your Secret Support - and how to improve your sex life!

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We use it every day as soon as we get out of bed, and in fact many people use it when they're asleep too. It's one of the most neglected muscles in our body but when it fails to do it's job properly it can make our lives a misery!

I'm talking about the Pelvic Floor.

The pelvic floor is a sheet of muscles that support all the contents of our pelvis: which means -

• The bladder
• The rectum and it's faecal contents
• and in women, the uterus and ovaries too

When the pelvic floor lets you down then controlling your urine can be a challenge when coughing, sneezing, straining or even just standing up! For those with loose bowel motions, a weak pelvic floor means that soiling your pants can be an embarrassing problem which may lead to social isolation as well. And when the bottom literally falls out of your pelvic floor, your uterus will often fall out too leading to a utero-vaginal prolapse!

Most of these condition are preventable by good personal care. For most people this means a lifelong approach to daily pelvic floor exercises and being aware of:

• Avoiding constipation and/or straining with a bowel motion
• Avoiding persistent heavy lifting
• Treating chronic coughs and straining
• Watching your weight and losing it if you're too heavy

So how can I improve the strength of my pelvic floor?

The first thing to do is to identify which muscles they are. After all, if you haven't used them for decades it's highly unlikely you know where they are in the first place! My suggestion is that the next time you go to the toilet to pass urine, try to stop mid-stream. When you do that, you're using your pelvic floor muscles and they are th emuscles you need to focus on.

Once you've identified them, it's time to exercise them. That's simple:

Squeeze and hold for 5 seconds and then relax - don't forget to include the muscles around your back passage too! Repeat for 5 slow squeezes and try to repeat three or four times a day. It's that simple and you can literally do these exercises anywhere and no-one will know what you're doing!

If you keep this up then after a few weeks you'll be aware that control of your urine will improve. And for ladies, as your pelvic floor muscles get stronger you'll be able to squeeze your vagina as well which brings me to the bit about your sex life .....

Beating the Drum for the Country Docs

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It can be lonely out there

Rural Health - the real challenge.

As you may know, I took a few years off from clinical medicine as the emotional strain from caring for patients was hard enough, but running a practice was even harder! Now I've chosen to return to Family Medicine, but this time as a Locum GP, and I've chosen to help patients in the rural community. And it's been great!

Firstly, country people are different and have different problems. They're different in that they're more 'forgiving' and they're more thankful:  I had four 'Thank You' cards from one practice after just one three week Locum! But they face their own challenges too. Obesity is a big issue - excuse the pun - and is only compounded by the sense of inertia that occurs in small country towns. With the obesity of course comes Type II Diabetes with all it's insidious complications. 

Then there's a big issue with Chronic Pain Syndromes and the use of powerful analgesics that are being used to control them. It's a real challenge in such a short period of time to educate such patients on pain modulation, alternative treatments and the ancillary lifestyle modifications availabe. The resources needed are limited - professionals such as myself, clinical Psychologists and dieticians are nearly all FIFOs which makes continuity of care a real challenge.

And that leads to the one constant gripe of so many rural patients - with the inevitable question being asked "How long are you here for?" They feel that they are constantly having to repeat their stories to new faces (and despite computerised medical records, getting up to speed in 15 minutes in a complicated history is a tough gig even for someone with years of experience)  and many patients have literally given up trying merely limiting their consultations to requests for 'a new script'!

Our full time GP colleagues are bearing an enormous load in very isolating circumstances. I can fully understand why a female GP graduate with a young family would find it daunting to embark on a career in a remote rural practice. She would face so many professional and domestic stresses for which there are few practical answers. One may be to utilise the skills, knowledge and experience of those retired GPs who are looking for that something extra in life rather than playing bowls or embarking on another cruise, and developing an efficient, effective mentoring service!

Another would be to support groups such as the Australian Doctors Spouse Network that's been established to support Fellowship spouses in their un-ending merry-go-round of moving from hospital to hospital over their 6 to 10 year training. This group are aware of the challenges their partners face - perhaps Rural GPs Spouses can work with them to build support for their craft too.

Because at the end of the day, we're there to supply Health and Wellness information to our patients. We're there to support our patients when they're struggling. We're there to be their advocate when they have nowhere else to turn and to constantly remind them how special they are and why health is such a valuable commodity. 

At the end of the day it's all about our patients, and we can't do that properly unless we look after our Rural Doctors too.

Thoughts on long distance air travel

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Normally when we take to the air we travel from our home town of Perth in Western Australia and head West towards Dubai and Europe. This time we're going in the other direction and I'm actually typing these words, whilst I sit on the beach at Coogee NSW (and yes it's beautiful!). But tomorrow we continue our eastern adventure by taking wing to Los Angeles, a distance of 12,065 Kms or 13 hours flying time!

The biggest challenge for me is boredom. Flying tends to make one dozy anyway (and they keep turning down the lights to simulate nighttime) so actually being productive is always difficult. Once you've watched 3 movies in a row, the thrill of it beings to pall rapidly.

So I shall be taking a good book which I intend to at least open if not actually finish. I will take a notebook with me to record all those quirky things that happen when you're locked in with 350 total strangers (the good wife excluded of course)  in a metal tube at 37,000 feet, and I will get up and walk around as much as I can to stop the joints seizing up completely.

I usually start prepare for long distance travel some weeks before by working on my overall fitness and in the final week I try and do a little extra so that when I get on the plane my body will be craving sleep more than usual - despite the often cramped conditions back in "Stowage". Don't try and use alcohol as a means of getting to sleep, it will only make you feel lousy when you wake and will dehydrate you more too.

On the day of the flight I will put on my knee-length compression socks and wear them until I get into the shower at my destination. This is to reduce the risks of DVT's on such long haul flights. Because the air is drier at high altitudes I will take some lubricating drops for my eyes and some sesame seed oil to spray into my nose to keep those membranes protected to.

Once we're up, up and away then I'll drink plenty of water at regular intervals, get up and march up and down the aisles, and finally I do some stretches at the back of the aircraft - always designed to get some mystified looks from unsuspecting fellow travellers, or start up great conversations with fellow contortionists!

I also try to identify "coughers" - both in airports and on board - who may be infected with any contagious disease, by covering my face if they are near. I have also taken to wearing disposable plastic gloves when I use the communal toilet as the hygiene of others can sometimes be less than ideal.

After arrival and the obligatory shower, we go for a long walk before we go to bed and promise ourselves to be patient with each other for the next few days as the jet lag wears off.

But most of all I intend to have a ball in Seattle!

The List

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The young bride recently bought a kitchen blender which now sits proudly on our kitchen bench. It’s a wonderful machine and apparently does amazing things. I haven’t been allowed to play with it yet, but I have eaten of the fruits of the machine and they are definitely good!

Before she bought this blessed electronic gizmo, she made a list of everything she wanted from it. She then did a search of similar gizmos in order to work out which one was best for her. Finally she checked out Choice Magazine to see what they thought and where the best bargains might be found.

By now you might be thinking that I’m going to write about healthy eating. But I’m not. This is all about that strange and sometime scary event:

 “Going to see the Doctor”

From my early years when I was on the other side of the desk, to the more recent years when we've moved around to sit next to our patients, one of the 'heart sink' moments that we Docs all experience is the patient who comes in with the dreaded “List”!

Early on in life, a visit to the Doctors is usually a fairly simple  - earaches, sore throats, rashes, soft tissue injuries etc. But as we age and things start to creak and go wrong, then many people resort to “The List”. 

But beware, sometimes “The List” can end up being a double-edged sword especially if you leave your Doctor to decide which items on the list need his/her attention immediately. This is becoming more of a problem as most patients rarely get to see their own Doc these days. The reason being that most Docs are now part-timers who work in large clinics and they’ve probably never seen you before in their lives. All they have is you, your medical history and “The List”.

So my suggestion is to take a leaf out of the young brides book and do some “due diligence” yourself.

• Make a list of all the things you want to talk to the Doctor about.
• Prioritise that list with the things that you’d like to get attended to first.
• Show your prioritised list to your pharmacist or Community Nurse to get their opinion. And if you’re a little nervous about it all then take an advocate along with you - family member or friend.

Be aware that if you have more than two things on your list it is wise to make more than one appointment to deal with all your issues. Believe me, one interview will never allow enough time to properly analyse multiple problems or to allow your Doctor to explain their thoughts to you.

Finally, if you think your Doctor is not giving you adequate time or failing to treat each issue seriously, then feel free to get a second opinion. 

Ask my young bride, if you were buying a food processor you’d look around for the best deal - so why not do the same for your life!

NSAIDs - the debate that continues to inflame!

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A good friend of mine, who just happens to be a retired medical man, recently fell and broke his hip. Nothing too unusual for a man in his seventies, but when we visited him in hospital he was furtively hiding his pain medication in a tissue and tucking it under his pillow. “It’s an Anti-Inflammatory” he confided conspiratorially The look of  confusion on my face prompted him to continue “They might be OK for pain relief but they interfere with bone healing and I want to get back on my feet as quickly as possible”.

I have to admit to always being a little nervous about using NSAIDs - Non steroidal Anti-Inflammatory Drugs - having studied medicine during the period when Phenylbutazone, the first proper NSAID, was introduced. BTZ, as it was popularly called at the time, was later discovered to cause bone marrow depression in many of those who took them and swiftly removed from “The Market” . 

But first a piece of history:

The fascinating ability to treat fever and inflammation dates back about 2500 (400 B.C.) years ago to a time when the Greek physician Hippocrates prescribed an extract from willow bark and leaves. Later in the 17th century, the active ingredient of willow bark Salicin was identified in Europe. Acetylsalicyclic acid (Aspirin), a more palatable form of Salicin, was produced commercially by Bayer in 1899. However, the mechanism of action of anti-inflammatory and analgesic agents such as aspirin, and its later derivative Indomethacin, were not discovered until the early 1960’s when medical science was really beginning to find it’s feet. Things really changed in the seventies, when John Vane discovered the mechanism of action of aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) opening the door to a pandoras box of new pharmaceuticals to treat pain and inflammation.

Since then the place of NSAIDs has become embedded in our lexicon of treatments for all things that involve inflammation and pain - especially those involving our joints. But the target tissues for these medications don’t just lie in our bones and joints, they are also to be found throughout the body in our stomachs, our kidneys, our hearts and our brains too. As time has gone by, the goal of Pharmaceutical Companies has been to develop medications that produce fewer side effects whilst maintaining their anti-inflammatory effects.

So what are the possible side effects of NSAIDs

• Stomach ulcers
• Raised blood pressure
• Kidney Disease
• Liver disease
• Bleeding
• Induce asthma attacks
• Rashes, drowsiness, headaches

All of these side effects reflect the areas around the body that these medications have a collateral action upon, as well as the inflamed areas they’re principally targeted at.

A concern that I’ve had for many years is that some of these NSAIDs are now available “Over the counter” and are commonly used in children too.

WHAT I AM NOT SAYING IS THAT THESE MEDICATIONS ARE DANGEROUS AND SHOULD BE BANNED

rather

THESE ARE CHEMICALS THAT CAN HAVE SERIOUS AND SOMETIMES FATAL CONSEQUENCES IF NOT USED PROPERLY.

The vast majority of childhood inflammations and infections will settle without the use of medications. Common sense and patience are far better treatments than rushing to the Pharmacy for a magical “quick fix” - because that is exactly where those “quick fixes” should remain, in the realms of fantasy and fairy tales!

The human body has evolved brilliantly over the millennia to deal with minor injuries, minor illnesses and local inflammations. For major stuff you should always seek medical advice, because in most cases, Doctors do know more than you do.

But let me finish by saying that although Doctors know a vast amount about the human body, they are still far, far, far away from knowing everything. My medical friend with his broken hip refused his NSAIDs because he believed that NSAIDs slowed bone healing. Well, a thorough search of all the scientific papers written on the subject came to the conclusion:

“There is no robust clinical and/or scientific evidence to discard the use of NSAIDs in patients suffering from a fracture, but equal lack of evidence does not constitute proof of the absence of an effect. The majority of the available evidence is based on animal findings and these results should be interpreted with caution due to the differences in physiological mechanisms between humans and animals. ….. Till then, clinicians should treat NSAIDs as a risk factor for bone healing impairment and (they) should be avoided in high-risk patients.” 

ScientificWorldJournal. 2012; 2012: 606404.

“Do Nonsteroidal Anti-Inflammatory Drugs Affect Bone Healing? A Critical Analysis”

Ippokratis Pountos, 1 Theodora Georgouli, 1 Giorgio M. Calori, 2 and Peter V. Giannoudis 1, 3 , *

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259713/

Hospitals make you better - don't they?

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"Pyotr Petrovich admitted that he'd been a fool--but only to himself, of course.” 
― Fyodor Dostoyevsky, Crime and Punishment

There’s a good chance that you went to primary school with someone who ended up at Med School and is now a Specialist at something-or-other. You probably played together, got into trouble together or maybe you did/didn’t like him/her for any number of reasons. Then High School came along with different sports, activities, first dates, broken romances all the things that go with that decade of confusion.

The reason that I mention all this is because Docs are just like you and me - they’re human. At least I hope most of us still are! And being human we’re subject to good days and bad days, being brilliant one day and making mistakes the next. The only trouble is that when Doc’s make mistakes, it’s the rest of us who can end up in trouble!

In a  Swedish study from 2007, 12.3% of the studied population suffered an “Adverse Event” whilst staying in Hospital.  “Fifty-five percent of the preventable events led to impairment or disability, which was resolved during the admission or within 1 month from discharge, another 33% were resolved within 1 year, 9% of the preventable events led to permanent disability and 3% of the adverse events contributed to patient death. Preventable adverse events led to a mean increased length of stay of 6 days…. When extrapolated to the 1.2 million annual admissions, the results correspond to 105 000 preventable adverse events and 630 000 days of hospitalization".

Their conclusion: “This study confirms that preventable adverse events were common, and that they caused extensive human suffering and consumed a significant amount of the available hospital resources.”

Another study in Italy reviewed the case notes of 1501 patients who had been discharged from hospital. A part of their discharge summary recorded Adverse Events in 3.3% of those cases. Significantly less than the Swedish study, but still a huge number when extrapolated to the entire population of hospital patients over one year.

In Australia, the Australian Institute of Health and Welfare defines Adverse Events as “ Incidents in which harm resulted to a person receiving health care. They include infections, falls resulting in injuries, and problems with medication and medical devices. Some of these adverse events may be preventable”.

In 2011–12, 5.3% of separations (Discharge from Hospital) reported an ICD-10-AM code indicating an adverse event.

These figures are from our Health Care and Hospital systems where “Best Practice” is constantly being reviewed and updated, and where there are procedures for every conceivable situation. 

 Far from scaring people off from going into Hospitals, the message I am promoting today is:

 Never be afraid to ask questions of your Doctor or treating Medical team.

If you’re a bit overwhelmed by visiting your Doc or by being a patient in a hospital, then get someone to act as an advocate for you.

One final comment about my medical colleagues. We’ve all met those people who are arrogant and think they know everything. Or perhaps those who treat their fellow citizens with arrogant disdain. Well the bad news is that some of those went on to become Docs too! Thankfully, I’ve only met a few over my long career, but believe me, they are still out there. If you believe that your Doc has treated you badly, ignored your questions, not informed you of your treatment options or has just been plain rude - you are not powerless. Write a letter to the relevant Medical Board who are there to protect your interests. They are on your side and will not ignore your complaint.

The Caring Profession should be just that - The Caring Profession. Sometimes it doesn’t work to our advantage through no ones fault, but sometimes the Medical team can “drop the ball”. We are all part of the solution: we all need to make sure that we are responsible for our own health and that means daring to seek out information that will be beneficial to our long term health.

There should be no one on this planet more vigilant about your good health than YOU. In the case of those who need an Advocate, then take that responsibility seriously. Believe me, when Docs are patients, they are never afraid to ask questions of their treating team - because they know that things don’t always run as smoothly as the Hollywood image of Hospitals would have us believe.

95% of Medical stories have positive outcomes. But that’s not good enough. We are all a part of the solution.

Stop calling me Skinny!

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You’ll often hear it said that approximately 50% of the western world are either overweight or obese and that this can lead to serious health issues. And I agree with that. But I’m in the other 50% and am starting to get a bit fed up with being told that I’m getting skinny, or that I need a good feed to fatten me up.
Now, although I frequently write about the huge health threat that comes with obesity, what I do not do is go round telling people to their faces that they are fat and, why don’t they cut down on their eating.
The reasons behind this reversal of fortunes is that with so many people now being overweight or obese, half the population now think that their body image is normal and that the skinny ones are the abnormal ones.
As you all know, this year it’s 100 years since the start of that terrible first world war, and there have been lots of film footage of troops signing up and going to the front. So far I haven’t seen one fat person signing up in all that archival footage. Fair enough, smoking was more prevalent and cigarettes part of a soldiers rations, AND they did a great deal of marching up and down. But if they introduced conscription these days ( and heaven help they never do again) then there are going to need an awful lot of XXX large uniforms for over half of the troops.
Being overweight or obese is not the norm, but the pattern for it can so often be laid down in the first five years of life and that’s where we need to focus part of our efforts to fight the trends toward obesity related Diabetes, heart disease and cancers.



I was reminded of this after reading an article in the past on “Risk factors” for heart disease and in particular a study in the US which has been going on since 1972, and which has followed a community of people to study the incidence and causes of heart and blood vessel disease. This study, which is called the Bogalusa Heart Study and which has been an ongoing study for over 40 years now, has not provided any revolutionary results but some of the conclusions need to enter the mainstream thinking of every family, every school and every community.

But first a look at what we know, and you’ve heard it all a thousand times, but Smoking remains the No 1 bad guy when it comes to vascular disease - the type of disease that leads to heart attacks and strokes. Second comes Hypertension, or high blood pressure, which needs to be measured if you want to find out whether you have it or not. Then comes Diabetes, which if poorly controlled often leads not only to heart attacks and strokes, but also to disease of blood vessels supplying the legs, and when they get blocked gangrene and amputation may follow! And finally comes raised Cholesterol, obesity, age and being white - the Bogalusa study being run in a mixed biracial American community.

In this particular study the finding that neither obesity nor raised cholesterol rank highly as a risk will be of interest to the experts in those fields and will be the subject of intense, ongoing debate. But what we do know is that:

Since the introduction of ‘Statins there has been a 30% reduction in developing the risk for atherosclerosis - the plaque that leads to heart attacks and strokes. And that people with a Cholesterol level lower than 160mg/dL do not get heart disease irrespective of what their HDL, LDL cholesterol are or their Triglycerides are.
Obesity is linked with diabetes and diabetes is a significant risk for developing blood vessel disease. It is also linked to cancers and other medical problems and remains a real focus of necessary life style changes.

In fact one of the glaring outcomes of this 40 year old trial is that childhood nutrition and obesity should be the main focus of all preventative programs. If it’s left uncorrected then it’s linked to life long health problems that are not only physical but mental, educational and social too. So that’s why the childhood nutrition story needs to be told loud and clear and repeated in new ways year in and year out. If we give our children a healthy start in life then not only are they going to be able to make the most of their opportunities, but they are going to be healthier and get less disease. And what this means is that they are not going to need the services of our fantastic, but very expensive hospital services, which are paid for out of our taxes and our insurances. So the “price” of investing in getting our kids to eat healthy nutritious food is going to be a wonderful investment in their future and in our Nations too.

So where do we begin? Well in most places the machinery is already in place and beginning to work really well.

Smoking. Nearly every child I meet hates the smell of smoke, but sadly there are a great number of teenagers to take up the awful habit and unbelievably, cigarettes are still sold as Duty Free items in airports around the world. But in most developed countires, the good guys are wining and the percentage of smokers continues to fall, but we must never relent!
Childhood obesity requires serious, sensitive handling. Childhood obesity leads to a plethora of life long health problems. The key factors of teaching, showing, sharing better ways to eat need to be tailored to the individual and to be creative. The involvement of Chefs in school programs that allow children to try foods - and these are foods that they would normally “hate” -  prepared and presented in different ways so that the kids actually enjoy eating them, does have a huge impact. The widespread appearance of school vegetable gardens is another creative way of involving kids in making nutritious food choices and understanding how a healthy food chain operates..
Physical activity. Whilst not really impacting on weight itself, the direct benefits of physical activity in so many areas of life - heart disease, cancers, mood disorders and so on - mean that being active must always be an integral part of our education system.

Reducing risk is a lifelong health education challenge. We should not wait until mid-life to try and correct things that need not have occurred in the first place. So lets give our children the best tools available to build healthy lives, so that when their turn comes, then they will know how to build a great world for their children too.

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