I saw him a few times for the last few weeks and a few days ago cleared him from workcover for soft tissue injury to his left arm and a sprained neck, after he rolled his truck.  He was very grateful as I gave him 2 weeks off for rehabilitation with the help of competent physiotherapist to manage his injury.

I am usually very quick to respond when dealing with acute pain.  I jumped the queue, and called his name. 

Ben had resumed truck-driving. Unfortunately, the left tip of his 4th finger had been amputated three days ago in a mishap. He was unloading animal feed from the truck and the gate accidentally shut with his finger caught in the slit. 

He was surgically cleaned and sutured under digital block by a doctor in a small hospital.  However, his finger was throbbing in tremendous pain, and he was unable to sleep at night, causing his wife to stay awake all night looking after him.  He was holding his left hand and I could see his eyes were full of tears.  “Did you have any oral painkiller last night and this morning?”, “Yes, panadeine forte not doing anything at all.  I had been taking 12 tablets since last night, it seems like I was swallowing lollies.”

He looked genuine, and I know him well (I have to be careful of drug seeking patients).  I drew up 15mg morphine with 10mg maxolon (=metoclopramide hydrochloride), and given intramuscularly to his left buttock.  I sent him home with 50mg tramal (=tramadol hydrochloride), instruction to take every 6 hours, but could be topped up with panadeine forte (paracetamol 500mg+codeine phosphate 30mg/tablet) 2 tablets in between if needed, with only maximum of panadeine forte of 8 tablets/24 hours.  However, I had to warn him of main side effects of nightmares from tramadol, drowsiness with tramadol or codeine. 

He returned next day for wound check, but this time his pain was well under control with regular oral analgesia, more happily he and his wife able to sleep through the night.   Unfortunately, his wound closure was almost about 30% necrotic and with partly wound dehiscence.  I decided to sent him to hand surgeon for further surgical intervention.

Morphine sulfate : Morphine is the principal alkaloid of opium.  The most common adverse effects are constipation, lightheadedness, dizziness, sedation, nausea, vomiting, sweating, dysphoria and euphoria. 

Metoclopramide hydrochloride : It has a few usages.  In this context, it was used to control nausea and vomting (to prevent nausea and vomiting secondary to morphine).  The most frequent adverse reactions are restlessness, drowsiness, fatigue and lassitude.

Tramadol hydrochloride : It is a centrally acting synthetic analgesic of the aminocyclohexanol group with opioid like effects.  It is not derived from natural sources, nor is it chemically related to opiates.  The possible adverse effects are fits, anaphylactic reactions, gastrointestinal upset, dizziness, sedation, sweating, tolerance, nightmares. 

Panadeine forte : It is an analgesic and antipyretic.   The common adverse effects of codeine phosphate are nausea and vomiting, constipation, dizziness and drowsiness, rarely skin rashes may occur. 

He lived in Egypt,aged 78,  had a sudden massive heart attack while walking up stairs.   He did complain of general unwellness while she spoken to her father last over the long distance phone.  “So are you going to fly back to Eypt for his funeral and show him respect.”  She could not, and I know deep down, both of us have schedule booked for next few weeks.  In Egyptian culture, the dead has to be buried on the same day.  However, on day 40, there is a special ceremony.  She is planning to fly back to attend it.

Apparently, she only had 2-3 hours of sleep overnight after hearing the bad news.  She took stilnox (sleeping pill), without much effect.  She turned up to workplace at 7am, and had been sitting inside her room since then.  “I am feeling the guilt of not being there for him”.  “May be things would be different if I was there”.  “I think mum will have trouble to cope being alone suddenly”……..

Bereavement refers to the feelings of sadness and depression following the loss or death of a significant other.  A wide range of emotional and physical problems may be associated with bereavement including grief, anxiety, and the associated physical symptoms of insomnia and anorexia. 

Intense emotional reactions are common in the first weeks following bereavement and include:

• crying
• irritability
• worry
• anger
• guilt
• insomnia
• loss of interest in usual activities
• somatic manifestations of depression or anxiety

During the first month or so, such reactions would be acknowledged as being “usual”, but these symptoms may become disabling.  The time taken for complete recovery will vary from one individual to the next.  Some individuals may recover rapidly from acute distress in a few weeks while others can show residual impairment in functioning for 4-5 years after their loss. 

How have you coped?

She was very agitated, crying easily, but very aggressive in her behaviour,  in language especially.  She wanted help, yet she did not have the willpower to do it.  She wanted quick fix, yet she was angry with me as I could not recommended her the quick solution.  She ended storming out and kicked the door on her way out and screaming on the corridor.  She turned back and told my receptionist,”She is the nastiest, and worst person I have ever seen.” 

I felt annoyed with her behaviour, yet disappointed about what she said.  Interestingly, on the same day, a middle aged bearded but well kempt and well dressed male turned up at the end of the day.  He was the one I helped about 6 months ago to quit his long term marijuana used.  Now he has not touched a smoke, including tabacco since I last saw him months ago.  I was very proud of him when I saw him, furthermore more proud about myself of able to help a soul to pick up his life.  At the end of the consultation, I softly asked his permission to let the previous lady to talk to him as her mentor to give up marijuana.  I thought this might be the gateway for her to start.  Initially he was reluctant, then he said, “OK”.  He consoled me most likely she was ran out of money to buy more marijuana, and she would like to get some medications eg diazepam to calm her down to help her to sleep.  I thanked him for not blaming me as a “bad person”.

drug type (Cannabis)=common names(marijuana, grass, pot, dope, hashish, oil, buddha sticks)

Marijuana can be a stimulant or sedative/hypnotic depending on the herb types.

Stimulant withdrawal syndrome: The withdrawal state that results from either stopping or reducing the use of stimulants includes lethargy, fatigue, psychomotor retardation or agitation, craving, increased appetite, insomnia or hypersomnia, and bizarre or unpleasant dreams.

Sedative or hypnotic withdrawal syndrome: Sedative or hypnotic withdrawal states are characterised by tremor of the tongue, eyelids or outstretched hands, nausea or vomiting, tachycardia, postural hypotension, psychomotor agitation, headache, insomnia, malaise or weakness, transient visual tactile, or auditory hallucinations or illusions, paranoid ideation, and grand mal convulsions. 

Symptoms include:

1) Insomnia during the major sleep period, or

2) excessive sleepiness during the major waking period (when working nightshift or frequently changing shiftwork).

These problems tend to be worse when work schedules are poorly organised. 

Work schedules that rotate in a clockwise fashion (morning followed by by afternoon followed by night shift) and allow sufficient days off between shifts for recovery is the least worst of all shiftwork patterns.

In sleep deprived shiftworkers, the main period of sleep is often greatly reduced. Strategically timed naps can be helpful to ameliorate the situation. 

Workers coming off nightshift should wear sunglasses, particularly if they drive home to sleep in the morning. This helps minimise the effects of bright light on the circadian clock.

Nocturnal enuresis impacts the daily life of 61% of children. 1.5% of 13-year-olds and  adolescents rate nocturnal enuresis as significant event in their life. This can persist into adulthood, with 0.5% of adults with nocturnal enuresis, which can be associated with a high incidence of depression, lower self-esteem and sleep disturbances.

It is interesting to note genetic factors play a role in 2/3 of children with nocturnal enuresis.  However, older children may have more severe nocturnal enuresis and are more likely to have daytime urinary incontinence as well.  Not all children will “outgrow” their nocturnal enuresis.

It is therefore important to identify the causes of nocturnal enuresis (eg.arousal/sleep problems-obstructive sleep apnoea; nocturnal polyuria;bladder dysfunction and reduced functional bladder capacity), risk factors (eg. constipation; bladder infection; type I diabetes;  spinal bifida; psychological factors; ADHD) and genetic factors, and treating appropriately with correct diagnosis of the problem, management strategies are likely to be highly effective for both children and adolescents. 

In a study conducted by University of Melbourne, Australia discovered a significant relationship between unsupportive fathers and postnatal depression.  Mothers were found to do about three-quarters of the domestic tasks, while men had more than double the women’s leisure hours. 

Therefore, the findings suggested treatment of postnatal depression should include the father as well as the mother. 

Wheezing is an extremely common symptom in children, with up  to 40% of children reported as having at least one episode of wheezing during childhood.  Although wheezing can be caused by many things, the most common one is asthma. 

If your child has the symptoms of cough, wheezing chest, disturbed sleep, especially with early morning and exercise-induced cough/wheezing. there is a high possibility your child could have asthma.  A prompt visit to a doctor is essential for diagnosis and early treatment. 

Farmers are encouraged to identify the warning signs of depression, anxiety, sleep disturbances, anger problems, disturbing and suicidal thoughts. They should get help early with their doctors.

A US study found that people who experienced migraine headaches had more sex drive than those with tension-type headaches.  The migraineurs rated themselves on average as having a higher sex drive than their peers with no migraine. 

The logic is, researchers said both migraine headaches and sexual desire were partially modulated by systemic levels of serotonin (5-HT), a chemical that was chronically low in migraine patients.

Therefore, serotonin levels may be partially responsible for migraine and sex drive, but more research is needed to find out the serotogenic phenomena. 

Having migraine is not totally bad for your sexual relationship afterall.  “I think I have migraine tonight, darling”, if your partner mention this to you, you should have a better guess what it means. 

[Source: Headache 2006;46:983-90]

The prevalence of OSA was nearly three times as high in men with type II diabetes as in general population, ie 56% of men at high risk of OSA and 38% at low risk, 4% already diagnosed with OSA (3% of them receiving continuous positive airway pressure treatment)— research done by sleep specialists in UK (Thorax 2006;61:945-950).

 Therefore, people with type II diabetes who presented with symptoms of insomnia and OSA should seek help from their clinicians early.