ARTICLES IN FULL CIRCLE MAGAZINE

Full Circle Magazine regularly publishes short articles by CMR’s Medical Director, Dr Alan Walters, on a range of health issues. Articles that have appeared in Full Circle since November 2008 include the following:

CHOKING

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Imagine sitting in a restaurant when a person starts thrashing about, turning blue or even pitches forwards onto the table. They may leave the room to avoid embarrassment. It could be that they have a piece of food, usually meat, stuck in their throat. In other words it has “gone down the wrong way”, or into the tube that leads to the lungs.

What do you do?

• Be aware of the possibility of choking.
• First try back blows: hard slaps in the centre of the back.
• If back blows fail, try abdominal thrusts (called Heimlich Maneuver).
• For adults, stand behind them and wrap your arms around their waist. Make a fist with your lower hand and hold it in the midline above the navel. Roll the hand so that the thumb points upwards and inwards. Grasp the fist with the other hand and then pull upwards and backwards quickly and forcibly, making a distinct thrust. You may need to do this repeatedly.
• If the patient is very obese or very pregnant, do the above procedure in the middle of the chest, rather than the abdomen. Force your hands backwards to compress the chest.
• In the case of a child or unconscious adult, lay them on their backs and kneel astride them. Put the heels of the hands, one above the other, in the midline, above the navel, interlock the fingers and thrust upwards quickly and forcibly.
• If the child is under one year, place them on your lap with the head hanging down, supported by one hand. Take an imaginary line between the infant’s nipples. Place the tip of the index finger just below this line in the middle. Let the next two fingers fall into place alongside, and lift the index finger. Push the two fingers downwards to compress the chest between 1½ and 2½ cms.
   
• As you start these procedures, you should’ve asked someone to send for help, hoping that the problem will be solved before they arrive. Remember, the emergency number for Cape Medical Response (CMR) is 082 782-4444 and we will dispatch an emergency unit. CMR respond to every call but prospective new members should ring 021 782-0606.

Puff Adder bites

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

The arrival of summer weather sees an increase in our outdoor activities, and walking in the fynbos and gardening both carry the risk of encountering snakes. Every year CMR is called to treat snakebites in this area, and records show that most bites occur in the late afternoon and early evening, usually on the foot or leg.

The two species that you are most likely to encounter in this region are the Puff Adder and the Cape Cobra.

Puff Adders are heavy-bodied snakes, up to about a metre in length, with a triangular-shaped head and a blunt rounded snout. The body colour varies from yellow to brown, with dark brown to black bands on the body. The bands may be rounded or chevron shaped.

These snakes appear sluggish and slow moving, but beware - they can move and strike with surprising speed. You may hear a hissing noise when the snake is coiled ready to strike. They hit with surprising force and the fangs may penetrate deeply.

The depth of penetration means that trying to suck out the venom or cut open the wound is a waste of time.

So, what do you do?

Immediately move away from the danger area and lie the patient down. Try to keep the victim calm and relaxed. Phone or send for medical help.

Elevate the affected limb.

Try to identify the snake but don’t attempt to kill or capture it.

The bite will be extremely painful, and there will be gradual progressive swelling moving up the limb from the bite area, at a rate of spread from 5 to 10 cms per hour.

Do NOT apply a tourniquet nor in the case of this species a pressure bandage, as serious tissue damage can occur as the swelling compresses against the tight bandage.

The patient may become progressively weaker and the bite may weep a clear blood-tinged fluid.

Call Cape Medical Response 24 hour emergency number – 082 782-4444. We respond to all calls (the office number 021 782-0606 is for prospective new members)

Mortality for puff adder bites is around 10%, but much less with prompt appropriate medical care.

Next time we will discuss Cobra bites.

Cobra bites

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Last month I talked about Puff Adder bites, and this time it’s the turn of the other common venomous snake in this area, the Cobra. These are large graceful snakes that will try to avoid confrontation and try to escape when possible - but will defend themselves boldly when required.

Most bites occur on the extremities with the lower leg and feet being most often affected.

Up to 45% of Cobra bites are “dry” bites with no venom released. It takes about three days for a cobra to refill its venom sacs so it would rather not waste it on non-edible humans. Some cobras such as the Rinkhals can squirt venom into the eyes, with a range of up to three metres.

So what does the venom do when it gets injected into a person? Often there is only a local loss of the tissue around a bite, a process we call necrosis, and this takes about 48-hours. The area of loss though can be substantial. The venom however may travel into the body and have a general effect. A process we call envenomation. One of the earliest signs of this is drooping of the eyelids. There may be generalized weakness, difficulty breathing, excess salivation, loss of blood pressure and an irregular pulse.

So what do you do? Keep everyone calm. Try to identify the snake without going near it or killing it. Lie the patient down. Do not cut open the wound or apply cooling. Do not remove clothing. If you have a bandage, or can make one from torn clothing, then wrap tightly around the bitten limb, starting from the toes or fingers. Try to wrap the whole limb. Keep the limb at the same level as the patient’s heart. Venom in the eyes will not be absorbed into the body but can do a lot of damage. Wash vigorously with water or any fluids you may have.

Deaths occur in about 5% of Cobra bites, usually between 2-6 hours after the bite. Call CMR on 082 782-4444. We respond to all calls even if you are not a member.

Diarrhoea and Vomiting

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

I can’t recall meeting an adult who hasn’t suffered with diarrhoea and vomiting at some stage in their lives. Some authorities say that four bouts per person per year is the norm.

A number of different organisms can cause these symptoms, often a virus or bacteria, usually contracted by taking in infected food or water but sometimes by direct person to person contact. Nausea, abdominal pains and a high temperature are often associated. The incubation period can vary from a few hours to several days, and the majority clear up within one to three days.

Okay, if it’s so common, what should I do to help myself, and when should I call for further medical advice?

Let’s first deal with abdominal pain. Cramping, spasmodic abdominal pain is commonly associated. If it goes when you pass wind or stools then it’s probably of no concern. However, if it becomes continuous and settles in one part of the abdomen, then get help.

The problem with diarrhoea and vomiting is that they cause dehydration. Adults are more tolerant of this than small children, particularly babies, who can run into problems very quickly. So call for help fairly quickly with tiny tots or in doubt.

Some Do’s and Don’ts:

Do’s:

• Drink only clear fluids. The ideal is a purpose-made electrolyte fluid such as Dioralyte or Rehydrat (available at pharmacies). At a push use “pop” drinks such as lemonade.
• Take little sips at a time until the nausea and vomiting subsides. Gradually build up your intake.
• You can get anti-diarrhoea medications, but I’ve never found them of much use.

• Don’ts:

• Have solid foods until things have settled down for 24-hours.
• Take milk, soups or fluids that aren’t clear.
• Try to treat the fever or headaches until the vomiting has stopped.

• Worrying signs (or red flags as we call them medically):

• Diarrhoea more than a week.
• If you think it’s due to prescribed medication.
• Bleeding from the back passage (if it’s not heavy then it can wait until daylight hours).
• Very high fever, especially if persistent.
• Persistent vomiting. If the vomit looks like coffee grounds or contains blood (rather than a few streaks) - call immediately.

CMR responds to all calls. The emergency number is 082 782-4444. Office 021 782-0606.

Blood Pressure

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Blood pressure is the pressure or force pushing against the walls of blood vessel as the blood circulates. When the heart contracts, large muscles in the heart wall squeeze blood through the system. We call the pressure on the walls at this point the Systolic pressure. As the heart refills the pressure obviously drops, and this we call the Diastolic pressure. Both are measured using a blood pressure machine to read as the heart contacts and relaxes.

If your car’s cooling system operates at too high a pressure then hoses can leak or the water pump can break and the car can boil. Similarly if your blood pressure is too high, blood vessels can leak (which in the brain causes a stroke), and the pump can break (which would is a heart attack). So it’s in your best interest to keep the pressure down. Ideally we like a reading of 120 (systolic) and 80 (diastolic) or lower. We write this as 120/80. Nowadays we consider anything over 140/90 as too high.

So how often should it be checked? If it has always been normal then annually is fine, but if you’ve had problems in the past then every six months or even three months. There are excellent medications that your GP can prescribe to control blood pressure, often with few side effects.

But what can you do to help yourself?

• Regular exercise helps keep the skeletal, muscle and circulatory systems in trim.
• Keep your weight as normal as possible - it takes more effort for the heart to push blood around a heavy system.
• Avoid smoking. It causes the blood vessels to clog up with atheroma.
• Eat a healthy diet. Fresh fruit and vegetables with a reduction in animal fats.
• Relax and enjoy life! We all know that stressful lives burn out sooner.

We prefer you to take the above advice and remain healthy. Keep CMR’s emergency number,  082 782-4444, handy. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website: www.capemedicalresponse.co.za

Malaria

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

This infectious disease kills and has killed more people than any other, with at least three million deaths worldwide. A small bug, a protozoa is responsible, and is injected into the body by the female anopheles mosquito. There are four types of parasite, the most dangerous being the falciparum strain.

The symptoms of malaria are severe fever, shivering, joint pains and vomiting; which last 6-8 hours and occur in 2-3 days cycles. 

The great news is that with sensible precautions and the correct medication it can be prevented. First let’s dispel some misconceptions:

• Medication side-effects are not worse than the disease and disappear when stopped.
• Symptoms of malaria are not masked by medication – which works to stop the disease.
• Mefloquine (larium) does not cause madness. A few people can get depressed or even disturbed when taking this, but these rare cases soon recover on stopping.

If you enter a malaria area without protection you stand a 10% chance of developing it (World Health figures). The mortality of this disease, even with expert attention is 1%.  In other words a 1-in-1000 chance of dying and a 1-in-10 chance of developing a very nasty condition. Not good odds.

Some interesting statistics. The British Army gave preventative medicines to 48000 soldiers over the past 8 years for travel to malarial areas. You would have expected 4800 cases of malaria and 48 deaths without prophylaxis, but there were only 25 cases and no deaths. Impressive figures.

It’s sensible to take general precautions such as using nets over beds; wearing long-sleeved shirts and trousers (especially in the evenings); washing clothes and nets in special insecticide solutions; and using special preparations on the skin.

See your GP before you go for a prescription for preventative drugs and advice. Remember, start this treatment before you travel and continue it for 4-6 weeks when you return.

Rigors with a high temperature on return from a malarial area can develop into a medical emergency. Our emergency number is 082 782-4444. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis.

Meningitis

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Meningitis is an inflammation of the protective covers of the brain and spinal cord.

The most common cause is a virus that causes conditions such as cold sores, chickenpox, shingles, mumps and more. Bacteria are the second most common cause. Adults are often infected by meningococcus or streptococcus pneumonia, whereas small children can be affected by more.

These infections can get into the blood stream from other parts of the body but sometimes trauma to the head (such as a blow to the nose) can open up a direct pathway.

So what are the main symptoms?  Over 90% of suffers complain of severe headache, and there is often neck stiffness with the inability to flex the neck forwards. There may be a high fever, an altered mental state such as drowsiness, and intolerance of bright light or loud noises. A good test to do is to rapidly rotate the head horizontally which can make the headache worse. Small kids will look unwell and become irritable, and in infants under six months the soft spot between the cranial bones at the top of the skull may bulge and be tender.

With meningococcal there is often a rapidly spreading rash, and this can occur first. Numerous small irregular purple or red spots may be found on the trunk, lower extremities, lining of the mouth or even hands and soles of the feet. If you press the rash with your finger, it doesn’t disappear and remains purple.

Patients may often have seizures or fits, and this will occur in about a third of all patients. Eye movements, facial movements and hearing may all be affected.

The diagnosis can be made by a combination of blood tests and by inserting a special needle into the back to tap off a sample of cerebrospinal fluid, which is normally clear but can look cloudy if infection is present.

Most viral infections will settle without any treatment but bacterial infections require rapid antibiotic therapy. Bacterial infections are usually fatal if left untreated but will usually clear with correct and prompt treatment.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis.

Croup

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Croup is an infection of the upper airways, usually in young children. It’s an acute viral infection of the upper and lower breathing tubes, and usually affects kids between three months and five years. Boys more than girls, and more common in the winter months.

Often there is a sudden onset of symptoms. Children may be well when they go to bed but wake up in the night with a croupy cough and trouble breathing. They may have a runny nose and a brassy cough, and may have been exposed to infection 2-6 days before. The cough is distinctive and sounds like a barking seal. There is a loud high pitched noise when breathing in, which gets worse when the child becomes anxious or agitated. There may be gagging and vomiting with the cough. Often there is hoarseness and a fever present. If the child becomes drowsy, drooling, and exhausted with a rapid pulse, then medical help is required.

Try to remain cool calm and reassuring to the child. Although it is very easy for parents to become extremely concerned, try not to show it. Don’t try to open the child’s mouth or to put something in the mouth so that you can see the back of the throat. A steamy atmosphere helps, so get the kitchen or bathroom full of steam, but be careful that no one gets scalded in the process. Unless this doesn’t help within about 15 minutes, ring for help.

There’s a much rarer infection which is more dangerous: a condition called acute epiglottitis, a bacterial infection at the back of the throat which causes swelling and airway obstruction. The noise the child makes is softer, with snoring or gurgling sounds when they breathe out. The cough is not very prominent. The child appears sick, drools saliva without being able to swallow, and needs to lean forwards with its mouth open to breathe. Do not lie the child down, as this may block the airway, and call for assistance.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website: www.capemedicalresponse.co.za.

Angina Pectoris

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Angina is chest pain due to insufficient blood getting to the heart. It may be discomfort rather than actual pain and is described as a heaviness, tightness, squeezing or burning, and can occur in the chest, upper abdomen, back neck or shoulders. It can radiate into the arms, especially the left upper inner arm.

It may be brought on by physical exertion or emotional stress. It can come on after meals and is worse in cold weather. Sometimes there is breathlessness, nausea and sweating. The average bout lasts 3 to 5 minutes. Usually rest will relieve the discomfort but also there is a spray (glyceryl trinitrate) that can be supplied by the pharmacy to squirt under the tongue.

Certain groups and conditions are susceptible to angina. High on the list is smoking, as well as diabetes, high blood pressure, high cholesterol, lack of exercise, and a family history of angina.

If you develop angina, it will hopefully be stable and come on with a predictable amount of exercise and go on rest. A problem can be if it becomes unstable and starts to come on with less and less exercise or even at rest. This can last up to ten minutes with a worsening of pain, and unstable angina often leads onto a heart attack.

If you think you have angina it’s important to consult your doctor for investigations. But there are certain things you can do to help yourself: Stop smoking, lose weight if too heavy, and take adequate exercise.  Brisk walking for half-an-hour, five times a week should do it.

Many doctors recommend a quarter or even a half aspirin daily, providing you can tolerate it and your doctor approves. There’s good evidence that it offers some protection and may stop or prevent the development of a heart attack.

If your cholesterol is higher than normal there are drugs available (statins) to help control it. Similarly, if your blood pressure is up, it should be controlled with appropriate medication. Treat any worsening or alteration of chest pain as a medical emergency.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website www.capemedicalresponse.co.za

Rabies

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Fortunately rabies is a rare but never-the-less dangerous viral infection. It is spread by the bite of a rabid animal, and any mammal can carry rabies. The commonest carrier in South Africa is the mongoose, but bats, foxes and dogs are often implicated. Even cattle pigs and sheep may become infected. In Natal, semi-wild dogs infect many people each year.

The behavior of rabid animals alter. Some race around in an agitated state biting everything in sight. Some become abnormally tame and it is important to stay well away from these.

Nearly everyone who develops rabies will die unless vaccinated, with only a handful of people having survived once rabies has a hold. When the virus reaches the brain the patient experiences headaches, fever, restlessness, irritability, general fatigue and anxiety. After a few days this progresses to a state of excitability with painful muscle spasms which occur when the patient tries to drink or if cold air is blown onto the face. They may become paranoid, terrified, hallucinate or even foam at the mouth. Death invariably follows within two to ten days.

The incubation period varies depending on the site of the bite. Symptoms start once the virus gets to the brain – so a bite on the face may develop into rabies in two weeks , but a bite on the foot can take six months as the virus has further to go . Once bitten the virus moves through the tissues to get into one of the body’s large nerves. It then travels up the nerve to get into the brain. Once in the nerve it is safe from attack from the body’s defences and the nerve, sitting within a tough fibrous sheath, cannot be got at.

There is an effective vaccine, but it has to be given before the virus gets into the nerve. So even though a bite on the foot will incubate for six months it is important that the vaccine is given within five days. The sooner the better. The vaccine has to be repeated at three, seven, fourteen and twenty eight days. The other important fact is that any bite should be washed with soap and water for a full five minutes (timed) as virus particles can be washed out.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website www.capemedicalresponse.co.za

Tetanus

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

There is a very nasty bacterium lurking in the soil all over the world. It is more common in moist organic soil, especially if exposed to animal droppings. In this area, with a large horse riding community, it is very prevalent. Potentially fatal, with a nasty painful death, it is never the less easily prevented with a safe vaccine. The name of the disease is Tetanus, and the bacteria that cause it are called Clostridium Tetani. Although infectious it is not contagious, in other words you cannot catch it from other people.

It lurks in the soil as spores which enter a wound and then grow into bacteria. Inside the bacteria a dangerous toxin is formed, and it’s only when the bacteria die that the toxin is then released into the body, with devastating results. The toxin is taken to the spinal cord and the brain stem where it blocks the passage of signals to and from the spinal cord.  This causes the muscles controlled by that part of the spinal cord to go into prolonged and painful spasm. We have all had cramps, usually in our calves. Imagine that intense pain in all the muscles of the body, lasting for several minutes and then going on and off for many weeks. Its incubation period is about eight days, but can be much longer, sometimes up to 2-3 months depending on how the bacteria develop and grow.

There is a belief that being injured with rusty things, such as treading on a nail will cause tetanus. The fact is that rusty objects, especially if damp make a great resting place for tetanus spores, and of course a nail will inject them directly into a nice fresh piece of tissue where they can grow undisturbed.

So it is very important that everyone is vaccinated. Most children are as a routine, but some slip through the net. I discovered that I myself was never vaccinated when young because my mother “didn’t believe in it”! For no good reason I could ever determine. The vaccine comes as a course of three injections and it is a good idea to have a booster every ten years, especially if you work with the soil, and that of course includes gardening.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website www.capemedicalresponse.co.za

Insulin

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Many years ago a young doctor sat in his clinic wondering why he felt so tired and washed out. And why were his clothes so baggy? They used to fit well. And wasn’t he drinking a lot of coffee? Had he not been getting up a lot at night to pass urine? And didn’t he want to go now? Surely he’d been just a short while ago. The penny dropped and he rushed to the toilet clutching a bottle of urine testing strips. The colour on the strips changed instantly confirming an enormous amount of sugar in the urine. He had diabetes.  Why had he refused to think about this before – before he lost fourteen kilos in weight? He diagnosed this condition every week of his life. His brother was diabetic. He’d worked in a diabetic unit in the hospital, for goodness sake. Yes, that doctor was me.

Thirty five years later, thanks to insulin which saved my life, I feel fit. I play golf, walk in the mountains, ski when I get the chance, camp in the wilderness, and generally remain busy. I have four injections a day, but with modern insulin pens and microfine needles, they’re no problem.

In 1921 Frederick Banting managed to isolate insulin from the pancreas of dogs. He worked with two medical students, Charles Best and Clarke Noble, but only one assistant was needed so they tossed a coin to decide who’d stay. Best won and went on to a life of riches and fame. Noble disappeared into obscurity. In those days, large hospitals had wards just for dying diabetic children. Up to fifty at a time. Banting took a supply of insulin and went from child to child injecting them. When he reached the ward end the first ones were waking from their diabetic comas to resounding cries of delight.

Insulin doesn’t cure diabetes but it controls it very nicely indeed. Nowadays it’s made synthetically without the need of animals. I respect the feelings of those opposed to animal experimentation, but am grateful that Banting and Best were allowed to carry out their life saving work.

Call CMR on 082 782-4444 for any medical emergency. We respond to all calls. Members have priority and non-members are billed on a fee-for-service basis. Website: www.capemedicalresponse.co.za

Tuberculosis

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

There’s evidence from the examination of Neolithic bones that tuberculosis, or TB, has preyed on man for over 7000 years. The disease is caused by a bacteria we call mycobacterium tuberculosis: a very slow growing bug which in itself makes it sometimes difficult to diagnose. TB bacteria replicate themselves only every sixteen hours compared with 20 minutes for “normal” bacteria such as E Coli.

The usual site of infection is the lungs although any organ in the body is at risk.  It’s spread when an infected person coughs, spits or sneezes. An infected sneeze contains about 40 000 droplets of bacteria and it only takes around ten to infect another person. It’s estimated that each untreated case of active disease infects another ten to fifteen people per year.

Common symptoms are a chronic cough, often with blood stained sputum, fever, weight loss and night sweats. About 90% of those infected have latent or asymptomatic TB, which means that the disease is dormant, with a one in ten chance that the TB will flare up into an active form.

Obviously if your general health is poor you are more likely to get the disease. In this country it’s estimated that 35-40% of HIV positive patients get the disease, with about 10% becoming active.

Although various antibiotic treatments are available, they generally have to be taken for six months to work, and unless the course is fully completed the disease will remain. Partially treated TB can develop resistance to the common antibiotics used, with serious consequences. We call this multi-drug resistance TB and it’s a growing problem, about 20% of cases at the present. We have second line antibiotics which we try to keep in reserve, but the same rules apply – so 2% of all cases have extreme drug resistance TB, and this is really nasty. So completing a full course of therapy is critical.

There’s an established vaccine called BCG which can give up to 80% protection – so please make absolutely sure all your family is vaccinated. BCG works better in kids than in adults, but a lot of work is being done to develop a complete vaccine program.

CMR responds to all emergency calls with priority given to members. Office number 021 782-0606. For 24-hour emergencies call 082 782-4444.

Ambulances

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

Are ambulances allowed to drive at high speed, with “bells” and lights flashing, going the wrong way around road divisions and going across red lights? Well, yes, with certain provisions. After all, if you were badly injured in an accident, or writhing in pain with a heart attack, or nursing a convulsing child, I’m sure you would want help to arrive as soon as possible. Every minute saved can be critical, and the crew might not know what to expect until they arrive on scene.

Ambulances have to be special designated vehicles, correctly equipped with proper reflective signage and conforming emergency lights and sirens. If they’re responding to a call, sirens and lights are vital to warn other road – and the crew will often alternate the warning tone to assist other road users which direction they’re approaching from. Even still, it’s amazing how many people don’t seem to notice them!

To use its lights and siren, the ambulance must be responding to a potential medical emergency, and the driver must drive with diligence and caution even though travelling at speed. Drivers are still liable to the full weight of the law if they cause an accident.

Look behind the scenes. Ambulances have to be maintained in tip-top condition at all times. Medical consumables and equipment such as drip sets, dressings, immobilization equipment, oxygen and even blankets have to be replaced as soon as they’ve been used. It also takes a number of people to run a vehicle 24-hours per day, 365 days a year, including behind-the-scenes administrative staff.

Are all ambulances the same? No. Some are Basic Life Support (BLS) vehicles performing basic medical skills and delivering patients on stretchers. Intermediate Life Support (ILS) units have more advanced life saving protocols, and Advanced Life Support units (including CMR's ambulances) have special high-tech equipment such as monitors, defibrillators, ventilators and medical drugs. ALS vehicles are usually crewed by ILS medics and “upgraded” by ALS paramedics when required.

It’s a costly business operating fully-equipped ambulances. Private services, such as CMR, get no government help or finance. CMR subscribers are covered for ambulance transportation for a small additional monthly charge, and private and medical aid patients are billed for transportation at the national tariff for the level of care given.

CMR’s emergency line, including for the ambulance unit, is 082 782-4444 and the office number is 021 782-0606.

Measles

By Dr Alan Walters, Medical Director, Cape Medical Response – and as published in Full Circle Magazine

When I was a young Doctor, in the days before measles vaccination, I saw a lot of cases of measles and it is not a pleasant disease.  Failure to vaccinate and a general drop in “herd immunity” have resulted in the re-emergence of this virus.

Measles is spread through infected droplets from lungs and noses or coughs and sneezes, and if you have no immunity then such contact makes it 90% certain you will get the disease. The incubation period is about 14 days and the person is infectious 2 to 4 days before the symptoms develop.

So what are the symptoms?

A high fever lasting around 4 days, associated with a cough, runny nose and red eyes. There may be white spots in the mouth which usually last for a day or so. A generalized rash develops usually starting on the head and spreading over the body. The rash is red with lots of spots and may be slightly raised. Itching is sometimes present. The rash changes colour from red to dark brown before it disappears.

Of course the big problems with measles occur when complications happen. Frequently the chestiness progresses to a more serious infection or even a pneumonia. If measles gets into the brain it causes a nasty inflammation or encephalitis. Brain damage, deafness, blindness or even death may result. In healthy people the mortality is about one in every 350 cases but with patients suffering from AIDS it can go as high as one in three. So, in a country like South Africa, measles can precipitate very serious problems.

There is no specific treatment for measles itself although we give antibiotics when a bacterial infection comes in on top of the virus.

So it is of vital importance that all kids are vaccinated. The vaccine is safe and two doses are usually given as part of the measles, mumps and rubella regime.

Cape Medical Response is a membership based emergency response unit. We respond to all calls but members have priority. For more information ring 021 782-0606 office hours. Emergency number 082 782-4444.

Paramedics

By Dr Alan Walters

Medical Director – Cape Medical Response

I have the greatest respect for all the ancillary medical professions such as ambulance drivers, ambulance assistants, medics, nurses or “top of the tree” Advanced Life-Support Paramedics. All do a fantastic job.

I have to say that I sometimes stand in awe of the skills of ALS Paramedics. They undergo several years of intensive training in order to handle extreme medical and traumatic emergencies, often in difficult situations, with dedication and skill. They have to be able to intubate a patient. This means using a special instrument with a curved blade to push the tongue to one side so that they can visualize the vocal cords and then push a special plastic tube through into the trachea so that oxygen can be pumped to the lungs. This procedure is difficult enough in a hospital when carried out by an anaesthetist. Can you imagine having to do it upside down in a crashed car with an unconscious person choking on a mouth full of broken teeth and blood?

What about the skill of having to put up a drip in the pouring rain on a shocked roadside victim?

Or delivering a baby on a platform of Fish Hoek Railway station (as happened last year)?

Or interpreting the complicated tracing of an electrocardiograph in a heart attack patient in order to give one of the many powerful cardiac drugs they are licensed to use?

Look also at the kit they have to take with them: a large bag or Bergen with 30 kgs of equipment and dressings, a top of the range electrocardiograph machine – complete with defibrillator attached, an oxygen cylinder, and a box of medical drugs. Their vehicles also carry stretchers, slings, harnesses, blocks, splints as well as traffic cones.

Another important skill is traffic control with safety considerations at accident sites.

So let me tell you, if ever I am unfortunate enough to suffer a heart attack or other life threatening emergency, do not call a Doctor. Send for a Paramedic.

And if you need one, ring the CMR emergency number, 082 782-4444. We respond to all emergencies although a charge is made to non-members and members have priority. Prospective new members ring 021 782-0606, office hours.

Ectopic Pregnancy

By Dr Alan Walters

Medical Director – Cape Medical Response

The clinic in which I worked in the UK was situated in a very old building. Almost two hundred years ago, in the very room I consulted in, the first recorded surgical operation for an ectopic pregnancy was carried out. The patient unfortunately died, but the surgeon said afterwards that next time he would “clamp the artery first”. His next case survived.

So what is an ectopic pregnancy? It’s a pregnancy that grows anywhere outside the womb or uterus. The pregnancy cannot survive but the local disruption it causes can be very harmful to the mother.

The usual place for an ectopic to grow is in the fallopian tubes – which are found on either side of the womb and extend almost to the ovaries. It’s down these tubes that the egg travels to get to the womb where it can safely produce a normal pregnancy. If it fails to get all the way down to the womb, then an ectopic pregnancy results.

Sometimes the egg’s journey may be blocked with an infection or perhaps old scar tissue, but often no cause is found. It is just chance.

So what are the symptoms? As the gravid tube distends there will be pain. Stabbing or cramp-like and in the lower abdomen. There can be some leakage of blood into the peritoneum (the sack that holds the abdominal contents). This will also cause pain and if the blood tracks up to the upper part of the abdomen there is often pain referred through to the shoulder.

As the egg dies, hormonal changes occur which cause a scanty brown vaginal blood loss which the patient can confuse with a normal period. In a quarter of cases, though, this does not happen. Bleeding from torn blood vessels can cause anaemia if gradual, but shock and collapse if massive.

There can be a fever and an increase in frequency of passing urine. It’s common for the diagnosis of appendicitis to be made by mistake.

Bear in mind that the ectopic can rupture before any signs of pregnancy develop. An ectopic requires very urgent medical attention.

Cape Medical Response responds to all medical emergencies. Members have priority. Our emergency number in 082 782-4444.  Membership enquiries should ring 021 782-0606 office hours.

Allergies

By Dr Alan Walters

Medical Director – Cape Medical Response

Allergic reactions are very common and many of us react against something in our environment. In fact, the number of items that can cause reaction increases each year through chemicals and additives in our foods, soaps, washing powders and general household materials. Airborne particles such as dust and pollen add to the problems.

Most parts of the body can be affected. The skin can develop rashes, itching and raised swollen areas (urticaria). The inside of the nose can become swollen and blocked and sometimes drip fluid. The eyes can become red and itchy. The breathing tubes can become constricted and wheezy. The ears can feel blocked. The abdomen can become bloated and we can experience diarrhea and vomiting.

A common cause of food allergy is peanuts, although any nut can cause problems. Many people react to dairy produce, fish, shellfish and eggs, but no food can be ruled out. Bites and stings may produce severe reactions.

Allergic reactions are much less common in the developing world and it has been shown that immigrants moving to the industrial world develop allergies in relation to time since arrival. It’s possible that antibacterial cleaning products make our environment “too clean” so that kids have less exposure to bacteria that shape their immune systems resulting in allergic reactions to relatively harmless substances later on. Children from large families have less allergic problems, presumably because they are exposed to more bacteria and viruses brought in by their siblings.

I know that many doctors, including myself, have given out too many antibiotics to young children in the past. Of course these antibiotics are often necessary and we try to do the very best for our patients – but I wonder about causing other problems later on.

A very severe allergic reaction called anaphylaxis can occur to allergy sufferers. This is an extreme hypersensitivity and can cause life-threatening swelling of the throat and face and constriction of the breathing tubes. Bee and wasp stings and peanut allergies are common examples. Very urgent medical action is called for in these cases. I recommend that suffers carry and Epi-pen which can be obtained from the pharmacy. This device injects adrenaline automatically when pressed against the skin and can be life saving.

Remember, Cape Medical Response responds to these and other emergencies on 082 782-4444. To become a member, ring 021 782-0606 office hours.