Medicine during Natural Disaster

Nine years ago today, 26th December 2004, the Indian Ocean Tsunami brought serious damage and health disasters to fourteen countries boarding the Indian ocean. Natural disasters such as the Tsunami cause a huge number casualties, but further health issues are generated from starvation, lack of shelter and the quick spread of infectious diseases. It was expected that there would be a huge rise in waterborne diseases, for example cholera and malaria. However the major issue affected the people  swept by the tsunami, which caused high levels of 'tsunami lung.'

Tsunami Lung is caused due to inhalation of mud and polluted water, containing several infecting microbes, it is thought that B. pseudomallei is one which is found within asian soil and water, however it is not certain as no laboratory was available to investigate the culture causing the illness. The symptoms of tsunami lung include bacterial lung infection, similar to pneumonia. Therefore it can treated by a strict course of antibiotics, however due to the lack of preparedness and slow response, the medical infrastructure was overwhelmed and there were lack of antibiotics available. This meant that many 'victims' could not be treated, and further neurological problems were created, leading to problems such as paralysis. These neurological problems are a result of infection spreading into the brain via the blood stream, resulting in abscesses. The brain swells in response to abscesses which can result in pressure on delicate brain tissue, or cutting off blood vessels supplying the brain. This is considered a medical emergency, as high pressure in the brain can be life threatening.

The lack of equipment available needed to diagnose tsunami lung, caused an increase in problems developed. A chest radiograph is required to identify lung infection and further computed tomography scan of the brain to confirm abscesses. The amount of trauma patients means there is a lack of staff and time to examine patients suspected with chest infections, furthermore many of the fourteen landmasses boarding the Indian ocean had little or no access at all to this type of equipment, therefore most was supplied by international relief, such as the US navy hospital ship which was docked off the coast of Banda Aceh, Sumatra. 

Resources:
http://en.wikipedia.org/wiki/2004_Indian_Ocean_earthquake_and_tsunami 
http://rense.com/general66/tsu.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1310941/
http://www.nlm.nih.gov/medlineplus/ency/article/000783.htm

Scotland phases out Liverpool care pathway

The Liverpool care pathway was established at the Royal Liverpool University Hospital in conjunction with the Marie Curie Palliative Care Institute. Palliative care is a medical treatment designed to make people with terminal illness feel as comfortable as possible- both physically and emotionally. It can be used to relieve symptoms but not cure the conditions. The LCP was recommended as a model of best practise by the department of health, and was therefore been adopted by many UK hospitals and other health care settings. However there have been many controversial issues with the pathway, and so Scotland have decided to phase out this type of treatment.

When used correctly the LCP was very successful in Scotland and had supported good quality of care in the last hours and days of life. However it has been recognised that inappropriate use of the pathway, such as patients being denied rights of food and water. Furthermore another example is, when patients are not being removed from the pathway if signs of improvement were shown. Therefore there were high levels of complaints from relatives, and the high proportion of misuse has led to the phasing out of the Liverpool Care Pathway in Scotland within the next 12 months.

The review of the LCP pathway earlier this year recognised this misuse and so the report published on the use and experiences of the Liverpool care pathway recommends phasing out of the LCP to be replaced with individual end of life care plans for each patient.  The report also provides methods of improving the care pathway:

1.     A general principle that a patient should only be placed on the LCP or a similar approach by a senior responsible clinician in consultation with the healthcare team.

2.     Unless there is a very good reason, a decision to withdraw or not to start a life-prolonging treatment should not be taken during any ‘out of hours’ period.

3.     An urgent call for the Nursing and Midwifery Council to issue guidance on end of life care

4.     An end to incentive payments for use of the LCP and similar approaches

5.     A new system-wide approach to improving the quality of care for the dying

Reference:

https://www.gov.uk/government/publications/review-of-liverpool-care-pathway-for-dying-patients

http://www.bbc.co.uk/news/uk-scotland-25464265

http://en.wikipedia.org/wiki/Liverpool_Care_Pathway_for_the_Dying_Patient

Obesity: social choice or a disease?

Obesity is defined as someone who is overweight with a high proportion of body fat; the body mass index of an obese person would be between 30 and40 and above 40 would be classified as morbidly obese. A disease is a disorder of structure or function and produces specific signs or symptoms or that affects a specific location and is not simply a direct result of physical injury.

Therefore the symptoms of obesity are weigh gain, with combined increase risk of other illnesses such as type 2 diabetes, colon cancer and heart disease, as well as further social issues such as depression. These symptoms can arise due to an underactive thyroid gland, also known as hypothyroidism, where a lack of thyroxine means the patient has a lower metabolic rate, therefore more food is stored as fat. Furthermore weight gain can be a secondary impact of reduces physical exercise due to fatigue which is also a symptom of hypothyroidism. Another example of obesity not being a social choice is due to excess levels of cortisol secreted from the adrenal cortex, diagnosed as Cushing’s syndrome. There is a build-up of fat stores on the abdomen, face, neck and upper back, because the excess cortisol does not increase the metabolism of protein and carbohydrates. Instead it slows down or disables metabolic reactions inside the body.

However on the other hand, the majority of the obese patients, have a high proportion of fat, and a high BMI due to eating more calories than are burnt, and the excess is stored as fat. This would be described as a social choice, although there are many influencing factors such as access to cheap, high energy foods, the increased use of cars or public transport and also less active jobs. Nevertheless it is a social choice on the food consumed, and the lack of exercise and individual does.
Although obesity is considered a social choice, on the other end of the spectrum, anorexia nervosa is a condition when someone is severely underweight with a BMI of less than 17.5. Unlike obesity anorexia is a mental health condition, and therefore not defined as a social choice. This gives the perception that obesity is easily curable through change in lifestyle, whereas anorexia is harder to cure and needs medical intervention. However should obesity not need medical intervention when it causes increased health risks?

Finally recently on the news, was a story of a five year old girl who was ten stone and taken in to care. Although this is due to excessive consumption of food and lack of physical exercise, it cannot be considered a social choice. Parents have primary control on raising a child, therefore the type and amount of food consumption is provided by parents or guardians and at a young age there is vulnerable knowledge to the need of exercise. There are many social and medical problems associated especially with childhood obesity. The medical condition consists of type 2 diabetes; high blood pressure, high cholesterol and asthma, but the more concerning are the social impacts of depression, teasing, discrimination and low self-esteem. For both the medical and social reasons lowering the quality of life for the child, it can be defined as a type of child abuse.

References:

http://www.nhs.uk/conditions/Obesity/Pages/Introduction.aspx
http://www.nhs.uk/conditions/Anorexia-nervosa/Pages/Introduction.aspx
http://www.medscape.com/viewarticle/778000_1

Epidermolysis bullosa (EB)

Epidermolysis bullosa is a group of inherited skin conditions; researchers have classified 27 variants of the condition however there are 3 main types of EB:

·       Epidermolysis bullosa simplex is a dominantly inherited condition therefore a child has a 1 in 2 chance of inheriting it if one of the parents is affected. EBS can also be a result of a ‘new mutation’ within cell division. This is the most common t type of EB, accounting for 70% of cases. There are three types of EBS:

1.     Weber Cockayne EBS- which is the most common type of EBS and the blistering symptoms are localised on hands and feet and often do not become obvious until the child begins to walk. Other friction such as riding a bike can cause blisters to develop on the inner thighs or the buttocks. Generally blisters are made worse by excessive sweating.

2.     Kobner EBS- Symptoms are similar to EBS however within hot conditions they usually become more affected. There may be mild blistering of the mucus membranes such as inside the nose, mouth or throat. Scarring and milia may occur on the skin, but this is uncommon.

3.     Dowling Meara EBS – very severe case, where in some circumstances children develop over 200 blisters a day. The widespread blistering can make the skin vulnerable to infection and affect an infant’s normal feeding pattern which means they may not develop at expected rate.  Blisters may also develop inside the mouth and throat making eating and speaking  painful.

 

·       Dystrophic epidermolysis bullosa can exist in two forms, recessive dystrophic EB (RDEB) therefore unless both defective genes, the patient is just a carrier of the disorder and doesn’t show any symptoms. However on the other hand Dystrophic EB (DDEB) causes fragile skin and blistering inherited by a dominant gene.

·       Junctional Empidermolysis bullosa (JEB) although only 5% of cases are infected, its considered the most severe form. Blistering occurs at the junction between the epidermis and dermis within the basement membrane. Hair loss is a common symptom due to blistering of the scalp. Further problems arise because tooth enamel is not properly formed which means teeth may be discoloured, fragile, and prone to tooth decay. Regular review by a dermatologist is needed, as severe issues can arise such as cancer.

The defected genes affect protein production in the upmost layer of the skin, there is a tendency for the skin and mucous membranes to blister and break down in response to minimal friction and trauma because the layers of skin do not ‘stick’ to each other.

The treatment available is to relive symptoms but no cure the condition, by avoiding skin damage, improve quality of life, and improve quality of life and preventing complications occurring such as infected blisters or malnutrition.

References:

http://www.gosh.nhs.uk/medical-conditions/search-for-medical-conditions/epidermolysis-bullosa/epidermolysis-bullosa-information/

http://www.bbc.co.uk/news/health-24902658

http://www.nhs.uk/conditions/Epidermolysis-bullosa/pages/introduction.aspx