Monthly Archives: April 2013

Alone in Open Water

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Darwin's Arch

“Only two people have died this year,” the dive master tells me, sipping her coffee in a café close to the scuba diving shop I’ve just stepped out of… Becky Wicks,Galapagos 2012.

Short clip on what you see diving at Darwin’s Arch, Galapagos.

Nobody expects to die on holiday. Nor does anyone plan to be lost at sea, yet that is exactly what happened while diving in Galapagos. One of the members of our party prematurely surfaced after failing to locate his dive buddy underwater. His flotation marker and horn were not seen or heard by our diving zodiac. For 90 minutes, the muscular pull of the Humboldt Current swept him further away from the site. He was one small neoprene head bobbing in open water 926 km off the coast of Ecuador, and thousands of kilometers from westerly New Guinea. As are all Galapagos divers, he was equipped with a GPS device to mark his location. Linked to the ship, it allows a diver’s location to be pinpointed in case of emergency (if you lift it out of the water). And so, for the duration of his solitary float, accompanied by hundreds of hammerhead sharks, he was not unduly upset. Only after a tense visual grid search was he was found, kilometers away. It was then, he discovered, his GPS wasn’t working after all. If we had not searched the open ocean, he would now be gone. It was a harrowing crisis with a fortunate happy ending. By coincidence; much funnier now than it was then, the lost diver’s name was Bob.

Several divers die in Galapagos every year. The exact mortality statistics are maddeningly hard to get. Drowning, currents, cold water, equipment malfunction, previous medical conditions (or being unfit), inexperience and diver errors are the common causes. Yet diving Galapagos is the best in the world, and so, many go. My suggestion is to leave the Galapagos to the expert divers, as there are many other excellent dive destinations.

Despite the Galapagos experience, diving is a fantastic hobby. It is a safe, tropical holiday for most people. It is something that couples of differing physical ability can do together. If you have bad knees or hips, the lack of gravity makes it a sport you can enjoy. It is great to share with friends, relatives, kids and spouses. If you are a photographer, you will be in underwater Nirvana. The golden rule of diving, however, is that you are responsible for yourself. It is not a sport for slackers who cannot be bothered to be properly trained, check their own equipment, and then check yours. PADI, NAUI, SSI and SDI, unlike resort dive courses,are excellent programs with 8 hours of classroom and 3 to 5 open water dives. Then you need to start diving. Pick safe sites and go with more experienced people than yourself. You are inexperienced, in my opinion, till you have had a minimum of 60 dives. Upgrade your skills at your local dive shop with courses such as Stress and Rescue, Advanced Open Water or Navigation where you will meet new friends and add more skill. Experienced divers are generous partners and their knowledge keeps you safe.

Find out about the safety record of dive operators before you choose one. Go to http://www.scubaboard.com/forums/forum.php to pick up the dirt from other divers. Hints on the best places to go, best prices, gear tips, training courses and much more are available online. Have a good diving buddy, preferably someone who loves you (or, at least, likes you). Practice your new skills with dive holidays in the tranquil waters of Mexico, Hawaii, Palau, Bonaire, Australia, etc. If you are fit, conscientious, don’t overestimate your ability and dive safely, you will never become a statistic.

Melanoma – Dying for the Sun

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Excellent video about prevention and treatment of melanoma.

 “Illness is the night-side of life, a more onerous citizenship. Everyone who is born holds a dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”

-Susan Sontag

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Melanoma land is a place you don’t want to visit. It is the fast lane to cancer at a young age when you have better things to do, like live. The diagnosis smacks you on the side of the head. You walk into the doctor’s office a healthy person and you leave as a cancer patient. Just like that.

How did it happen? If you are red headed, blonde, blue eyed, have lots of moles or freckles, have spent hours in the sun or in tanning booths, you get fast tracked. Some are unlucky and have melanoma in their family. In melanoma risk, genes do matter.

Here is the good news. Doctors are much better at diagnosing melanoma. Tools like dermoscopy enable the doctor to see a mole’s architecture better than the naked eye. Although the incidence of melanoma has risen, 70% of melanomas are now diagnosed at a treatable stage. When this occurs, removal can be a cure. The concerning melanoma is the thicker one. If a melanoma is more than 4 millimeter’s thick when first seen, only 40% of patients will make it to five year survival.

How do you prevent melanoma? Most people know this information, but many ignore it some or much of the time.  For a summary of preventative measures, visit this site: http://www.cancer.org/cancer/skincancermelanoma/detailedguide/melanoma-skin-cancer-prevention

I am going to assume that you are already at risk and tell you what to look for. If you are a white female, melanoma often appears on the lower legs or the back. I estimate 70% of the melanomas I see on women are on the lower legs including the feet. For white males, it’s the back and the trunk. (I do see facial melanoma but it is more common in older people). An individual with 100 common moles or five abnormal (but noncancerous) moles is at a seven fold increased risk for melanoma.

Have a regular skin checkup by your doctor, especially if you have a lot of moles or freckles. New moles, especially at 50 years of age, could be a concern. Mention to your doctor any moles on your soles, between the toes or in the nail beds. Be aware of the ABCDE of melanoma. If this term is new to you, look at one of the following websites to learn about the ABCDE’s of melanoma diagnosis, and remember, the key to survival is early diagnosis.

For more info on the topic of prevention and early diagnosis go to:

http://www.bccancer.bc.ca/PPI/TypesofCancer/Melanoma/default.htm http://www.cancer.org/cancer/skincancer-melanoma/detailedguide/melanoma- http://www.patient.co.uk/health/Cancer-of-the-Skin-Melanoma.htmskin-cancer-diagnosed

Melanoma- The Social Perspective

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“The idea of preventative medicine is faintly un-American. It means, first, recognizing that the enemy is us.”

– Chicago Tribune, 1975.

“Growth for the sake of growth is the ideology of the cancer cell.”

– Edward Abbey

No one should ever die of skin cancer. You can see it and touch it. It is not lurking deep in the dark moist recesses of your body waiting to declare itself as your silent angel of death. The exception, of course, is melanoma and melanoma is increasing at a rate faster than any other cancer. In the last 60 years melanoma has increased 10 fold in countries such as Australia, South Africa and New Zealand. The USA is not exempt from this statistic, nor is Canada. One in 100 Canadians will get a melanoma.

I grew up in the generation of the burn. Sunscreen was unknown, and we knew that a good burn led to a tan anyway. As a kid in Australia, my sisters would compete to see who could peel the blistered skin from my back in one complete layer. At the beach, my mother told me to stay in the water so I would not get a burn. As teenagers in Vancouver B.C., we drove to Mt Baker in Washington State to dig a snow pit, slather on baby oil and spend the day seeing how much we could cook our bodies. In spring, it was the best way to start your tan early. You can see where this is going. The next generation has more information, but they are just as foolish. The risk of melanoma increases 75% when sun beds are used before 30 years of age and the number of young people I see coming into my medical office with a permanent tan has increased dramatically. My office staff (who help me cut out skin cancer all day) are tanned all year round because they look better. In society, the denial and disconnect between cause and effect is astounding.

I live in Canada, not exactly the tropics. Despite this, I diagnose a large number of melanomas every year. Many are in the over 50-age group, but not all. The youngest patient I have seen in my career was 15 years old. I have looked after patients who have died of melanoma. I have friends who have died of melanoma, in some cases as late as 20 years after the original diagnosis. Bob Marley and Burgess Meredith (The Penguin from Batman) succumbed to melanoma. Celebrities such as Anderson Cooper, Cybil Shepherd, Ewan McGregor and even John McCain have survived melanoma.

So what gives? Melanoma comes from intense UV exposure. UV radiation is a carcinogen. All of the UV radiation from childhood is saved in your UV bank account and accrues interest. Each year, in daily life, you make additional deposits. Driving your car (professional truck drivers have more skin cancer on their left face), shopping, sitting in the back yard, going on holiday to lower latitudes or higher altitudes, adds to the principle deposit. Depending on how diligently you invest over a lifetime the carcinogenic effect accumulates and starts to manifest as skin cancer, usually in the 40’s to 60’s. Add to the UV exposure the physical characteristics of being white skinned, red or blonde haired, blue eyed, freckled, having had a previous skin cancer or a large number of moles, a family history of melanoma or a higher income and you are set to visit melanoma land.

Melanoma is a social issue. Before 1920 purposeful tanning did not occur. The working classes were tanned because they had to labor. For them there was no status involved, only poverty and hard work. Now, older people tan because they have the disposable income to afford leisure in warm places. Tanning signals to others that one has free time and is less bound to the daily grind of employment. Youth tans because current fashion shows more skin, and tanned skin is synonymous with sex.  Women tan because unsightly cellulite, veins and imperfections are said to appear less obvious. Men tan because they feel they look more “cut” or muscular. Tanning is a social signal, plain and simple, and because it is I predict melanoma incidence will continue to rise.

” What is not brought to us as consciousness comes to us as fate“

-Karl Jung

AMREF (African Medical and Research Foundation) Flying Doctors

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Two hands in prayer could represent the job of a physician, working in the third world. One hand represents the challenges the job entails while the other hand represents the rewards the work brings. Together the hands are the silent prayer that such a doctor may recite while working in areas where conflict, disaster, poverty and few first world resources are part of the job. Many physicians and nurses in Vernon, British Columbia, Canada do such work and it is on a volunteer basis. They do this because they can.

Recently I visited Dr. HS my friend, colleague and former emergency physician at Vernon Jubilee Hospital. He had recently completed a month in Africa as an AMREF flying doctor. AMREF, based in Nairobi, Kenya provides pro bono air evacuation in medical emergencies to people in many African countries. The service is provided 365 days per year. Flying doctors volunteer for a month of service and provide 24 hours of availability during that time. Other than being 15 lbs. lighter and sleep deprived, HS was in good health, if somewhat subdued in spirit. I could tell from his face that he was a different person than the one who had left a month earlier.

HS arrived in Nairobi on New Year’s Eve and within hours was taken to the airport for his first patient transport. He had enough time to introduce himself to the nursing staff and review the medical equipment on board the plane before being whisked to Tanzania to stabilize and transport a tourist who had broken her pelvis falling out of a land rover. Hours later in his Nairobi accommodation, he was again called to fly back to Tanzania to stabilize and transport a politician who had suffered a cerebral hemorrhage. Each trip comprises many hours and as tired, stressed and hungry as he was, after midnight he was back to the airport on his way to Somalia. It was only later that he was informed that the area was a hot bed for al- Shebaab, the Somali based cell of the militant Islamist group al-Qaeda.

Sadly, a large majority of the trauma HS had to treat and transport was the result of motor vehicle accidents. Dangerous roads with few rules, no seat belts, crowded vehicles, and remote locations create the perfect conditions for vehicle disasters. HS recalled one such case involving a family of ten individuals. After hours in the air to reach them and hours in a land rover to get to the village, he found himself on site after dark. One child had died, seven family members had head injuries and many had internal injuries, lacerations and broken bones. Treating the injured was carried out in the dark dirty corridors of a makeshift hospital, surrounded by most of the village; all of Africa’s mosquitoes ‘and little help beyond several excellent transport nurses. With failing weather, the surviving patients needed to be quickly stabilized before the window of opportunity to fly back to Nairobi passed. Individuals were stacked like cord wood in the belly of the plane only to have one child die before takeoff. As a result injured patients needed to be removed and repositioned complete with intravenous lines, ventilators and monitoring equipment so that the little one could be given to the remaining family for burial. During the long trip back, another family member was lost. Many hours later, HS delivered the surviving patients to the Nairobi hospital. Visiting 2 days later, he was shocked to see several of his patients still sitting in the hospital corridor where he had left them several days before. In Africa, with limited resources, life, by necessity, is cheap.

Our Canadian physicians do excellent work in many poor countries.  They are well trained and like HS are generous with their time and skills. All volunteer organizations, and AMREF is no exception, need cash.  The organization helps Africans on a volunteer basis but also, for a minimal fee, provides excellent medical insurance for tourists. Recently when travelling in Africa I felt confident knowing that if I got into trouble, HS would be flying in to pick me up.  That is what I call service.

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Check out AMREF at http://www.amref.org/about-us/

Vein or Vain? Looking at Varicose Vein Disease

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Ever felt embarrassed to wear shorts because of unsightly purple or blue varicose leg veins? It’s not unusual for me to see a patient, usually (actually almost always) a woman, complaining of unsightly or uncomfortable leg veins expressing guilt for coming to the doctor with their problem. Why is this? Perhaps it’s the perception that problem veins are trivial and therefore not worthy of a “real” medical visit, or maybe it’s the fact vein problems are so commonplace that they are deemed, by some, to be a normal variant of the human condition. Sometimes it’s a simple failure to understand the significance of abnormal veins and how they can negatively impact health. Some patients are under the impression their problem can’t be fixed. Whatever the reason, it seems the poor little vein, and those who carry an abundance of them on their legs, don’t get the respect they deserve.

The term varicose means abnormally swollen or dilated and is used almost exclusively to describe veins. Varicose veins usually occur because one or more of the valves inside the vein, whose job it is to direct blood toward the heart, have failed. In the case of leg veins, a “blown valve” usually results in the abnormal flow of venous blood back towards the feet.

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 (schematic of vein valves)

As a result, the veins swell, become tortuous and are often uncomfortable. If small veins are involved they are termed spider veins, if larger veins are involved, they achieve the designation varicose veins. The cut-off between a spider vein and a varicose vein is arbitrary however, and both can cause problems with the legs, not to mention the embarrassing appearance.

Apart from the cosmetic appearance, varicose veins (and sometimes even spider veins) can cause swelling, aching, burning, itching, throbbing and restless legs. Varicose and spider veins can also lead to leg ulceration. Fully 80% of all leg ulcers are caused by vein disease.

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(varicose vein disease examples of patients seen, 2012)

In most cases, it is the larger varicose veins that result in severe symptoms and ulceration, but smaller varicose veins and spider veins can cause their fair share of grief as well. On more than one occasion, I have seen patients who have had repeated and frightening bleeding occur from small veins around the ankle after they are bumped or nicked. Varicose veins also predispose to phlebitis (where a superficial vein becomes inflamed, red and painful) and, in some cases, even blood clots.

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Honduras 2010 (venous ulcer that had been present for 20 years)

A physician experienced in vein diagnosis and treatment should assess vein disease. The assessment should include a detailed history of the condition and examination that includes an ultrasound assessment of the involved veins. Only then can the root cause of the problem be determined and an appropriate treatment plan developed.

When it comes to treating abnormal veins there are usually four treatment options: no treatment (OK, that’s not really a treatment, but sometimes it is the best route to take), injection sclerotherapy (this involves injecting veins with a medication and is appropriate for smaller veins), endovenous laser ablation (this involves inserting a catheter and laser fiber inside a vein) and surgery. Often, a combination of these treatments will give the best results. In most cases a compression stocking or sock will provide significant benefits as well.

Having abnormal leg veins properly diagnosed and treated is important to maintaining the health of your legs and circulation. Even if you suffer with “just” spider veins, it is reasonable to have them properly assessed and treated. There is no reason to feel guilty or reluctant to do so.

Getting High in Africa

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In spite of their advancing age, the Boomers are up for a challenge. Over my adult life millions of middle aged Canadians have run a marathon, competed in a triathlon, joined a local boot camp, climbed a mountain or in the more recent years, signed up for an endurance race. Last year at Whistler, my 50 yr. old sister in law, a corporate executive not known to get too dirty in a day, dragged her gel nails through mud, rain and freezing pools of water to complete in the Tough Mudder. Today, these events are not the exclusive domain of the gloriously athletic, but instead are populated by ordinary citizens out for a challenge.

Personally I prefer the challenges found in the mountains. If they are covered in rock, snow, ice, glaciers or just high, count me in. For a long time getting into the mountains was challenge enough and then in my fifties with no kids at home the new challenge became;” How high can I climb”? My kids vetoed Everest so, as a consolation trip I climbed Mt Rainier. I tried to cajole a solo trip to Denali out of the family but that was another ”NO” from the smarter ones. (Everyone excluding me). I then started a campaign for Aconcagua in Argentina. This is a smaller hill at 22,837 ft. (6,962m) and does not involve technical skills. My husband, Bill the Wise, suggested Kilimanjaro instead. After all, it is lower at 19,341 ft. (5,895m) and he would consent to come as well.

Kilimanjaro is the highest peak on the continent of Africa. Thousands of Mzungu kichaa (crazy white people) climb it every year. You need to be in good physical shape, have good rain and cold gear and 5 to 7 days to reach the top. Succeeding is based on the interplay of three components- physical fitness, mental toughness and how your body responds to altitude. The first 2 are up to you. The third is the unknown variable. Adjusting to altitude is partially genetic. Being very fit and stubborn does not guarantee that” thin air “(very low oxygen) at high altitude will agree with you. For example, several years ago, the world-class tennis player, Martina Navratilova, succumbed to life threatening acute mountain sickness (AMS) and required evacuation from Kilimanjaro.

The real cure for AMS is, of course, not to get it. It is avoided by not climbing too high or too fast. Proper hydration and caloric intake are essential as is descent to lower altitude at its first signs. The deadly effects of altitude are real and every year several people die on Kilimanjaro because they did not descend in time. It is wise to purchase medical evacuation insurance if you plan to go to altitude.

Mild AMS can occur above 8,000 ft. (2,400m) and manifests as a sledgehammer headache that does not respond to analgesics. No one will die from AMS, but they can if it advances. Two medical conditions that can result from AMS and that can kill climbers are HACE (high altitude cerebral edema or brain swelling.) and HAPE (high altitude pulmonary edema or fluid on the lungs). HAPE is the condition most commonly associated with death at altitude. Early HAPE manifests as a persistent cough, shortness of breath even at rest, fever and/or bronchitis while early HACE can be diagnosed by loss of balance, headache, nausea, vomiting or reduced mental acuity. In advanced HAPE persistent cough produces pink sputum as a bloody fluid collects in the lungs while in advanced HACE brain swelling can lead to paralysis, coma and death.

Today most climbers take Diamox, a type of water pill, in an effort to ward off or at least postpone AMS. Sometimes a steroid is also needed. The downside of this medication is, of course, frequent urination.  Other drugs are used to ward off HAPE and these include Nifedipine (Adalat) and Viagra (Yes, that one). Aspirin helps as well to stop clots in the legs and lungs. There is certainly irony in the fact that so-called healthy climbers must stuff themselves with pills to ward off altitude sickness,

So did we make it to the top of Kilimanjaro? Yes. Did I like very high altitude? Not so much. Would I do it again? The answer is definitely maybe. Perhaps I would try Aconcagua, on a few more medications.  Firstly, I suspect, this will require intense negotiation at home.

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First World Problems

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The best part of travelling is coming home. No matter where I go I am always grateful to return to my home town. Travel makes me thankful for things that I have taken for granted my whole life. Yesterday I was grateful for indoor plumbing. Today it’s the clean drinking water in my house that has my attention. Tomorrow when I return to work, I will be grateful to live in a country that has healthcare.

Through travel to, and work in, other countries, I have discovered how much I have simply because I am Canadian.

Coming home always requires an adjustment period and I think this time, coming home from Africa, it will take longer to readjust to my first world problems. The Internet is down, my Mac won’t sync with the iPhone, and the stove isn’t working. I get the flare of anger that frustration brings and then I feel embarrassed I have felt this way at all.  It is not easy to forget that I have just been a guest in a country where the average citizen has few of these worries and may walk 10 km to get their water.

When I return from poor countries, my toughest readjustment occurs at work. In Canada we want and expect our health care to take care of us and for the most part it does. Everyone can see a doctor at a family practice or a Walk in Clinic. If we are ill out of hours we can go to the emergency department. If we need to be, we are hospitalized and have operations, cancer care, extended care and hospice care. Moreover, we can access these services for a small medical services fee or for nothing at all. And yet, we are unhappy with the wait times, the lack of direct access to some drugs and tests, that some services are not covered by MSP and that sometimes we have to travel to see a specialist. This is all a part of our Canadian system and I have done my share of complaining about it as a practitioner, a politician and as a consumer. When I travel to other countries and realize that the vast majority of the world does not have any of these things to complain about simply because they have no healthcare at all, I go through a period of frustration both with patient’s expectations and with my own as a doctor.

Over the years my husband and I have done medical work in Honduras. This Central American country is the second poorest in the Western Hemisphere after Haiti. I have learned many lessons from my patients but one very pleasant Honduran woman provided me with the kind of lesson I still apparently need. She was in her fifties and had come 6 hours by bus to attend the clinic. She stood outside for hours to be seen, dressed in her very best. She had a non-healing ulcer on her leg the size of my hand and had had it for many years. She had had 17 pregnancies and 15 living children. Sometimes such an ulcer is made more complex by underlying diabetes and diabetes is very common in Central America. I therefore asked her if she had diabetes. She became very worried by my suggestion. Her response to me was “ I have come to have my ulcer treated but you will need to tell me if I am diabetic. I have never had the opportunity to see a doctor before”. Her response was beyond my understanding. I assumed that she, at 50 years of age, with her complex medical history, must have had some medical intervention.   I was a first world doctor working in a third world country and it was up to this Honduran woman to deliver the reality check.

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Being 60

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One rainy afternoon, wanting distraction, I leafed through a typical women’s magazine. You know the kind. Fluff about fashion where the models are 15 yrs. old (and 98 lbs.) and a pair of shoes is an entire week’s salary. I was attracted to an article entitled, “Makeovers: 2013”. On the glossy photo spread there were 5 tired women set to be remade into modern beauties. Paired “before and after” photos represented a woman of each decade; the ingénue at 20, the office worker at 30, the supervisor at 40, and the professional at 50. Having just turned 60, I looked for the rest of the article but that was all that there was. I was just too old for this magazine to be interested in me, and, by extension, whole generations of women were thus rendered redundant, invisible.

The fifties, the sixties and beyond are the age in life when, in my experience, women come into their own. It is a time when they are free of the constraints of raising a family. It is the time when they have mastered their job. Often, they have settled with a partner that they can live with and at some future time, die with. Often, for the first time they look in the mirror and ask themselves, what do I want to do with the rest of my life?” or, “what do I need that is just for me?” It is a sad reality that just when women feel they have arrived, society feels their time is up.

We still live in a world where a woman’s power is influenced by her appearance. I recall a supermarket tabloid with the lurid headline, “Hilary Clinton without makeup”. The most powerful woman in the world was being panned for her missing mascara while negotiating a deal for peace in the war torn world. Whether it is Michelle Obama’s guns or the late Margaret Thatcher’s purses women are reduced or lauded based on their appearance in spite of their economic independence, self-determination, brains, education, bravery, leadership and accomplishments.

Prejudice against women goes back to the foundations of western democracy. The end of the Middle Ages divided democracy into two spheres. The public sphere was defined by the rules of liberal democracy, universality, equality and reason. This was the exclusive territory of men. The private sphere was governed by inequality, subjection and emotion. This was the realm of women. For centuries women’s place was in the home where they were governed by the rule of “the man in his castle”. Women are no longer the property of their husband and since 1914 we have even be granted the vote, but we are still judged subjectively, and part of that is how we look and by extension, how old we are.

Is it any wonder that women seek cosmetic enhancement? As women age the power attached to their youthful appearance dwindles and they are judged harshly for it. I see many women my age and older who are wondering what they can do to regain their youthful appearance. They do not want to be someone else; they want their power back in a society that does not consider them worthy of a magazine make over. They want to move from the world of ghosts into the world of the relevant.

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