Medical Bytes Thailand no 116: ‘A good day’.
The following is a guest opinion article from Doc Martyn.
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Medical Bytes Thailand no 116: ‘A good day’.
The following is a guest opinion article from Doc Martyn. His opinions and advice are entirely his own and may not necessarily be those of The Pattaya News Company Limited. His contact information can be found at the end of the article.
1. On 16/7/24 ‘Herman the German’ called me about his heart. The history; about 2 years ago he suffered persistent bradycardia (slow heart rate) of <40beats/minute, for which he required and was given a cardiac pacemaker. In the last two months his heart had deteriorated into Atrial Fibrillation, AF, see photo 1. This is not an uncommon problem in the elderly. Hermann is 85 years old.
2. When I reviewed his case, he told me that a local cardiologist had offered him a choice of medical management or cardiac catheterisation with ablation, which involves burning the inside of the heart, see photo 2. I recommended medical management. Hermann asked me to organise this treatment for him, which I did. My recommendations; he continues his blood thinner, Xarelto, and starts Tambocor (drug name flecainide), a Class 1 antiarrhythmic drug, which blocks the sodium channels of the heart. This causes the heartbeat to slow down.
The side effects of Tambocor include nausea, fatigue, dizziness, and headache.
Within 6 days Hermann was suffering all these side effects and, despite the Tambocor treatment, he remained in AF.
3. I referred him to a local hospital for Pulmonary Vein Isolation, PVI, aka cardiac catheterisation with ablation. This was performed on 28/7/24 at a cost of THB 400,000.
I reviewed Hermann on 5/8/24, eight days post PVI. The ablation procedure had failed. Hermann’s AF was worse and his heart was failing. He was seriously ill.
Further, and to my surprise, the cardiologist had prescribed Cordarone, a drug similar to Tambocor, with all the same side effects. Except, Cordarone is far more toxic than Tambocor. It causes serious side effects including, but not limited to; liver damage, pulmonary fibrosis, loss of vision, erythema multiforme and peripheral neuropathy. This drug is far more hazardous than Tambocor. The cardiologist was aware that Hermann was unable to tolerate Tambocor. Nevertheless, he prescribed Cordarone 200mg I tablet 3x/day, a considerable dose.
I treated and stabilised Hurman’s heart failure. As expected, within a week Hermann could no longer tolerate the side effects caused by the Cordarone. The treatment was stopped.
4. In the late 1990s PVI was championed in Quebec, East Canada, where many cardiologists received training in the nascent discipline of PVI. It is very clear that the outcome of PVI is directly proportional to the facility, expertise and experience of the cardiologist performing the procedure. Little experience; poor outcome, substantial experience; good outcome. Hermann’s PVI was a complete failure, indeed the procedure pushed him into heart failure and possible death.
5. As I have stated in previous MBTs, compared to medical education in the West, the Thai medical school education system is deemed to be inadequate. A fully qualified Thai doctor is unable to work in the West without additional training in Western Hospital(s) and examination. ‘Home grown’ Thai doctors are only able to work in Thailand, Cambodia, Myanmar, Laos etc.
Of concern: I was recently informed that over 50% of the doctors working in the Pattaya Private Hospital system are ‘home grown’ medics, without overseas experience or training. Therefore, by extrapolation, there is a greater than 50% chance that those professing to be specialists would not be recognised in the West as specialists in their discipline. Indeed, these doctors would require additional training before being accepted as GPs, never mind becoming specialists.
Returning to the capacity of the cardiologist who managed Hermann: There is a greater than 50% chance that he was `home grown`. Such a doctor would not be accepted into specialist training for cardiology in the West, never mind the sub-speciality of ablation therapy. Hermann’s treatment was a complete disaster: Little experience; poor outcome.
6. Once Hermann’s heart failure had resolved, I considered how to manage him going forward. On August 19th I prescribed the old-fashioned treatment known as Digoxin, starting with a loading dose of 750microgm daily for 1 week. He was to continue the Xarelto, his blood thinner. I was in Jomtien when Hermann called me on August 23rd. He complained about non-specific abdominal pain. I explained that I was going to be late home because I was interviewing a Russian neurologist who wished to join my team of doctors who were prepared to help Thais living in remote areas. Hermann was happy to wait. The Russian doctor was a delightful man who spoke good English and ‘my language’; `medicine is my true vocation`, `the patient comes first` and `as medics we have a duty of care`. I invited him to join the team.
7. As I drove home, I mused about Hermann’s abdominal pain. Did he have an ischaemic bowel? Did he have an abdominal aortic aneurysm? Were his kidneys failing? Was he bleeding into his abdomen from the Xarelto? Did he have obstructive bowel disease? And the list went on. When I arrived home Hermann was there. I examined his abdomen; it was soft and non-tender. His bowel sounds, borborygmi, were active, suggesting an overactive large bowel. His rectal examination was normal. There was nothing seriously wrong. I took his hand and felt his pulse. I smiled and then I laughed. I was delighted. His heart was back in sinus, normal, rhythm after only 5 days of treatment. He was going to live.
8. Friday 23rd August: Another doctor asking to be included in my program and a life saved. It was indeed “a good day”.
Addendum: Over the past 6 years, as a retired medic living in Buriram I offered second opinions on any medical issue. I recently moved to Pattaya. As in this case, if you reside outside of Pattaya, telephone consultations are provided. For assistance; please contact me, Doc Martyn, on Facebook or call Dao on 095 414 8145.