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Sunday, January 27, 2013

Rumah Sakit - trans. Sick Room

Hospitals, wherever you are in the world, are not great places. Lets be honest, the three reasons to be there are; you're sick, you're visiting someone who's sick or you're involved in the treatment of someone who's sick. Whichever cateogary you fall into, it's not a great place to be.
I have never worked in a hospital (maybe I should add that to my bucket list) but I have been a patient, both in and out, and I have visited many people who've had to stay in one over the years.
I was once told doctors are in the fortunate position of being able to bury their mistakes, and laughed. My current situation has caused me to reconsider the humour.
Wait a minute, the laughter can continue for a moment as I tell you I'm currently suffering from Gout. This condition, depending on your age and global residence, will either draw head scratching perplexityand a vague recollection that you thought it was a type of Dutch cheese or you'll have a visual image of an old WWI officer, glass of port in one hand and a lump of stilton in the other, scowling due to the exasperating pain in his foot.
Let me tell you, I'm 45 years old, have a fairly healthy diet (c'mon, I live in Southeast Asia) and the opportunity to eat rich food died with my old UK salary. I liike a beer, but drink nowhere remotely close the amounts I drank when in the UK.

So what is gout and why am I devoting the best part of this blog to the condition? Let's do the science-y bit first.

This is courtesy of http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/


Gout is a kind of arthritis that occurs when uric acid builds up in blood and causes joint inflammation.
  • Acute gout is a painful condition that typically affects one joint.
  • Chronic gout is repeated episodes of pain and inflammation, which may involve more than one joint.

Causes, incidence, and risk factors

Gout is caused by having higher-than-normal levels of uric acid in your body. This may occur if:
  • Your body makes too much uric acid
  • Your body has a hard time getting rid of uric acid
If too much uric acid builds up in the fluid around the joints (synovial fluid), uric acid crystals form. These crystals cause the joint to swell up and become inflamed.
The exact cause is unknown. Gout may run in families. It is more common in men, in women after menopause, and those who drink alcohol. People who take certain medicines, such as hydrochlorothiazide and other water pills, may have higher levels of uric acid in the blood.
The condition may also develop in people with:
The condition may occur after taking medicines that interfere with the removal of uric acid from the body.

Symptoms

Symptoms of acute gout:
  • Symptoms usually involve only one or a few joints. The big toe, knee, or ankle joints are most often affected.
  • The pain starts suddenly, often during the night and is often described as throbbing, crushing, or excruciating.
  • The joint appears warm and red. It is usually very tender (it hurts to lay a sheet or blanket over it).
  • There may be a fever.
  • The attack may go away in a few days, but may return from time to time. Additional attacks often last longer.
After a first gouty attack, people will have no symptoms. Half of patients have another attack.
Some people may develop chronic gout. Those with chronic arthritis develop joint damage and loss of motion in the joints. They will have joint pain and other symptoms most of the time.
Tophi are lumps below the skin around joints or in other places. They may drain chalky material. Tophi usually develop only after a patient has had the disease for many years.

Signs and tests

Tests that may be done include:
Not everyone with high uric acid levels in the blood has gout.

Treatment

Medicines should be taken as soon as possible if you have a sudden gout attack.
  • Take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or indomethacin as soon as your symptoms begin. Talk to your health care provider about the correct dose. You will need stronger doses for a few days.
  • Your health care provider may prescribe strong painkillers such as codeine, hydrocodone, and oxycodone.
  • A prescription medicine called colchicine helps reduce pain, swelling, and inflammation.
  • Corticosteroids can also be very effective. Your doctor may inject the inflamed joint with steroids to relieve the pain.
  • The pain often goes away within 12 hours of starting treatment, and is completely relieved in 48 hours.
Daily use of allopurinol or probenecid decrease uric acid levels in your blood. Your doctor may prescribe these medicines if:
  • You have several attacks during the same year or your attacks are quite severe
  • You have damage to joints
  • You have tophi
  • You have uric acid kidney stones
Some diet and lifestyle changes may help prevent gouty attacks:
  • Avoid alcohol
  • Reduce how many purine-rich foods you eat, especially anchovies, sardines, oils, herring, organ meat (liver, kidney, and sweetbreads), legumes (dried beans and peas), gravies, mushrooms, spinach, asparagus, cauliflower, consomm√©, and baking or brewer's yeast.
  • Limit how much meat you eat at each meal.
  • Avoid fatty foods such as salad dressings, ice cream, and fried foods.
  • Eat enough carbohydrates.
  • If you are losing weight, lose it slowly. Quick weight loss may cause uric acid kidney stones to form.
See also: Kidney stones

Expectations (prognosis)

Proper treatment of acute attacks allows people to live a normal life. However, the acute form of the disease may progress to chronic gout.

Complications

Calling your health care provider

Call for an appointment with your health care provider if you have symptoms of acute gouty arthritis.

Prevention

The disorder itself may not be preventable, but you may be able to avoid things that trigger your symptoms. Limit alcohol consumption and follow a low-purine diet.

Anyway,with the words "the exact cause of gout is unknown" ringing in my ears, back to the story.

On the 6th January this year I felt such extreme pain in the big toe of my right foot that hospital was the only option. Local doctors do exist and if it were a bad cold I'd have gone to see someone like that for the traditional remedy of broad spectrum antibiotics. This required more professional advice.

The treatment suggested by A&E (the place everyone goes when first arriving at a hospital) was a blood test which confirmed high levels of uric acid in my blood, and a course of medicines consisting of anti-inflammatory drugs and pain killers. Once those were finished in 3 days, there was a further course of 10 days tablets to reduce the acid level causing the painful crystals.

Today is the 27th January and I have just completed my second course of anti-inflammatory drugs and pain killers (yes, the gout returned just vdays after completing the treatment) and a visit to the hospital, this time to see an internist. The old Chinese-Indonesian doctor was sat in a wonderfully light and airy consulting room. On arriving, Yohana and |I were led past about 30 waiting patients to see the doctor. I'm not sure that all the patients were waiting to see the same doctor as me, or even if this doctor only saw Western patients, but I couldn't help feeling guilty.

An initial conversation, in a mixture of English and Indonesian, led to me lying on the consulting bed. This itself seemed odd. I know what I've got. The doctor could see from my records what I've got. Yet my blood pressure needed to be taken again (I can only assume that lying down is the best position for this). On recording that 80 /120 is indeed normal, the doctor, with surprising speed for a man of his years, reached down and yanked both of my big toes, casually commenting "no pain there then". One day, I hope to be in a position to return this same level of patient care to this mad old sawbones.

I was ushered out of his room with a prescription for a months supply of uric acid reducing tablets and told to come again once they were finished. That's it. No advice on what other things to do. No foods to eat or not to eat. no herbal remedies to supplement the tablets. That was it.

This is why I have little faithy in Indonesian medical expertise. I apologise to anyonbe reading this who feels slighted by my descriuption, but this is first hand (foot?) experience. On another occasion I'll add the story of the Indonesian surgeon who fitted my mother with an incorrectly sized hip.