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.

According to a research conducted by Professor Leon Lack, psychologist of Flinders University of Adelaide, “The feelings of sleepiness and fatigue the next couple of days were significant in comparison with people who maintained their regular wakeup times on Saturday and Sunday mornings.”

Delayed waking was associated with a 42-minute delay in dim light melatonin onset and an eight-minute increase in time to fall asleep compared to keeping habitual wake-up times.  This is because sleeping in on the weekend people delay the body clock by about 45 minutes.  It is recommended only sleeping in for half and hour on weekends.

PTSD is characterised by the development of a long-lasting anxiety response following a traumatic or catastrophic event.  Typically individual experiences or witnesses a traumatic event such as actual or threatened death, serious injury to oneself or another person, or a threat to the personal intergrity of oneself or others.  The individual’s response involves helplessness, intense fear, or horror. 

PTSD usually develops within 3-6 months of the traumatic events and involves:

• nightmares and disturbed sleep
• images, dreams, or flashbacks of the traumatic event
• avoidance of cues which act as reminders of the traumatic event
• amnesia about important aspects of the traumatic event
• intense arousal and anxiety on exposure to trauma cues
• depressed or irritable mood
• social withdrawal
• concentration and memory difficulties
• being easily startled

The typical traumatic events include: violent assault (eg.  sexual or physical assault or mugging); torture, being taken hostage, kidnapped, or held as a prisoner or war; terrorist attacks; severe car accidents; being victims of natural or man-made disasters; being diagnosed (or having a loved one diagnosed) with life-threatening illness; witnessing or learning about the unexpected death or injury of another person.

The National Center for PTSD has more information for sufferers.

Nicotine replacement therapy in the forms of nicotine patches, chewing gum and inhalers are available for the purpose of smoking cessation.  However, how much is the safety maximum amount of nicotine in our body?

Combining different forms of nicotine replacement therapy such as patches and chewing gum can boost quit rates to above 50% and still poses no risk to patients, according to a smoking cessation expert.  It has been shown we cannot overdose on nicotine and there was no reported case or symptoms of toxicity. 

An Australian survey found that one in four smokers used patches and smoked indicated the dose was “too weak”.  The smokers needed to “top up” nicotine levels to avoid cravings and withdrawal.  The expert suggests to try nicotine patch first, if still smoking, to add more nicotine replacement therapy until they do not feel like smoking.  This approach has 60% abstinent beyond three months.

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. 

• Children By Choice
• Family Planning Queensland

Depression is a common accompaniment of chronic pain syndrome as in shingle sufferers, both need to be treated.  After 10 days of being confined to bed, older people lose 44% of their functional muscle strength and 9% of their muscle mass.