Coleman’s guide to poisoning and the dark arts

After listening to my most recent podcast on toxicology an anaesthetist friend reflected that his job essentially involves poisoning people with potent toxins.

He could have made a fine living as a Royal Poisoner in the Middle Ages, except for his soft spot for administering antidotes towards the end of the operation.

Scheming royals traditionally considered that sort of thing a character flaw.

The ancients liked their poisons irreversible. Anyone who accidentally woke up in the recovery room was given a pillow, but not in the modern sense. Let’s call it airway management.

When Therapeutic Guidelines: Toxicology approached me to do a podcast I jumped at the chance.

I had always been fascinated by those Russian spies who could drink enough vodka to kill a bear yet die soon after sipping a cup of tea.

So, imagine my disappointment once I discovered the book was all about managing accidental poisonings rather than being a Soviet instruction manual.

Useful as a GP reference, but as a bedtime read? Very putdownable.

Ancient druids used to take years to learn how to craft a decent poison, but these days multinational companies pump out thousands of ampoules a day. They are called medicines, not poisons of course; but there’s quite an overlap.

My anaesthetist friend probably dishes out more ‘nerve agent’ per year than the KGB. Happily, he is also considerably more likely to follow the product’s safety leaflet instructions.

Getting your hands on a neurotoxin may be easy these days, but imagine all the trouble Socrates’ assassins had to go to 3000 years ago, to bump him off with hemlock.

A full day gathering the white flowers then picking out enough seeds to kill a Greek philosopher (around half the Russian dose).

Hemlock – philosopher’s bane

Grind the seeds, boil them, sieve the sludge with your toga cloth, and remember not to lick your fingers.

No ampoules back then, so the use-by dates were probably rubbish, too.

If you couldn’t slip it into their wine by Sunday drinks at the agora, you’d have to spend all Monday out in the meadows starting again.

By the time of Shakespeare, toxicology had advanced to the point where it started to intersect with Therapeutic Guidelines.

Ophelia’s “long purples” were her foxglove flowers, later described as “dead men’s fingers”, on the riverbank where she died.

Dead men’s fingers – foxglove

Digitalis poisoning didn’t kill Ophelia — she drowned.

And oddly enough, digoxin’s first medicinal use was to stop people ‘drowning’ from massive heart failure.

Coincidence, I ask you?

Well, yes, obviously. Shakespeare was a poet, not an oracle. Not unless someone discovers a missing, rather tedious scene where Hamlet spends all Monday collecting purple flowers and distilling their toxin.

No, he was too busy bumping off Polonius. Possibly with polonium.

The Bard’s most famous poisonous brew was burned and bubbled (twice, apparently) in a witch’s cauldron at the start of Macbeth.

Hemlock makes it into the ingredients list, as does salt-sea shark — a prescient reference to those cartilage-based arthritis products that have proved so lucrative and useless ever since.

None of the other cauldron additives ever made it onto an anaesthetic trolley, at least once the pharmaceutical companies abandoned their phase II trials for eye-of-newt.

Too hard to catch the slippery little blighters. They’d see you coming before you could enucleate them.

Newt, with eye still in-situ

The modern toxicology text outlines the management of evenomations from eight-legged spiders to no-legged snakes.

Yet it turns out that by far the most dangerous creature is the two-legged doctor: All drugs are poisons; the devil is in the dosage.

Half of the toxicology information is about therapeutics gone rogue: accidental or deliberate overdosage, pharmaceutical miscalculations or simply the human body doing what we GPs know it does so reliably — buggering up for no apparent reason.

One of my female patients recently clocked an INR of eight, and I have no idea why.

She could have killed a rat by sneezing on it.

My working theory is that someone distilled ‘dicoumarol’ from sweet clover flowers and slipped it into her tea.

The coroner, more pragmatically, might have questioned my warfarin order.

Toxicology guidelines are about trying to mop up the mess. (A quiet vitamin K infusion to get you out of a tight spot).

I like to imagine the mess is created by redback spiders, bluebottle jellyfish and grey-suited Israeli assassins.

But nope…it’s mainly just us.

Plain old doctors, doing our thing, playing with dangerous toys.

This article was first published in Medical Observer, Oct 2020

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Bad Habits

Serenity

The wellness industry sells good habits to those who can afford them but don’t need them. Superfoods for super dudes.

Turmeric, quinoa and curecumin; so easy to sell, even if hard to spell. Actually, it might be curcumin. Or cumcurin?

Not cucumber, which isn’t considered a superfood, despite those sandwiches having kept our Queen alive for longer than any other celebrity.

And I bet you Ma’am doesn’t take rhodiola root powder in her Earl Grey.

Regardless of spelling, modern society gives the worried-well ample opportunity to get even weller, for a price.

Happily for marketers, the wellness scale has no upper reference limit, which means no one can ever reach peak health, at least while there’s a coin in their purse.

COVID-19, touted by conspiracy theorists as an infectious disease (that’s the unwellness talking) is instead a gift to wellness promoters. Because if you don’t have it you are, by definition, well.

That’s almost everybody — a market of very well people who won’t stay that way without help.

They will be kept well by the purveyors of hydroxychloroquine, organic house sprays and celebrity chef BioChargers ($25k and there’s not even a Thermomix setting.)

Living a natural lifestyle never cost so much. Continue reading

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Avoiding doctors like the plague

Tojetti_bee_sting

“The bee sting” Virgilio Tojetti 1898

Unlike many colleagues, I have no tales of being inspired to study medicine by my childhood family doctor, mainly due the fact that I didn’t have one.

Logic tells me those vaccine syringes didn’t plunge themselves, but I honestly have no memory of ever visiting a doctor. My parents opted for the set-and-forget method for the health care of their many children, recklessly ignoring the danger posed to GP income streams.

I’ve met a couple of colleagues who share my doctorless upbringing, but they both had a father who was a GP. Being treated by a parent is frowned upon, but at least they own a script pad.

My mum must have cottoned on that the medical board had no jurisdiction over part-time librarians, because whatever couldn’t be put right with aspirin and poultice would be managed by me lying down in a corner and reading—quietly—until it healed.

Dad was no better. He was a barrister, back in the days when that was a more appreciated skill than being a barista.

He almost took me to a doctor in the summer of ‘78, after I was stung by a bee in our front yard. Instead, mum talked him into a trial of placebo—a trip to the Kew pool.

As I walked barefoot across the hot grass to the pool edge, a second bee flew at me (technically, made a beeline) and stung my other leg! Dad suspected I was crying wolf until I pointed out the golden assassin writhing in its death throes. No, I was merely crying.

My swelling leg finally tipped dad into definitive action—at the pool shop he bought me a Paddle Pop instead of the usual Icypole.

Nope, no doctor for grazes, gastro or gluten tests. I suspect if I’d lost a fingertip they would have sent me out looking for it. “And bring us back the superglue with your good hand.”

Skip forward four decades, and I have become the very thing I had been trying to avoid all my childhood: a GP (no, not a third bee, obviously).

In one of life’s remarkable coincidences, it seems that my children also turned out to be the type whose parents rarely sent them to doctors.

To be fair on their mother, this neglect was paternal in origin. She often raised her eyebrow at my recalcitrance and even, when occasion demanded, raised her ire—this involved two eyebrows, plus sharp movements of the tongue.

I occasionally gave in. I did take one of the kids to the doctor when he lacerated his face under my watch (“The swing was an unpredictable torsional pendulum, yer honour.”)

The only available doctor was my junior registrar, so I oversaw the suturing, but his name was most definitely on the invoice, so it still counts.

Probably the most pressure brought to bear was when our youngest son hadn’t started walking by 21 months. My hand-drawn normal distribution curve had become less reassuring over the months—though I’m still chuffed my wife never spotted my distortion of the horizontal axis.

She started collecting opinions from friends who were teachers and physios and other sensible people, dropping these into dinner table conversation. Get him to a paediatrician. It seemed the whole, slightly underqualified world was against me. If Facebook was a thing, she would have recruited the trolls.

My explanation that my lad was merely a skilled negotiator—convincing his older brothers to ‘fetch’—started to look thin as his second birthday approached.

Then one day he just upped and walked. Attaboy! A month later he ran. Maybe he just didn’t require anything out of reach before then.

I hope my kids don’t have the same neglectful attitude to their own children, not least because we GPs need all the customers we can get these days. It’s fine to avoid doctors like the plague, until there is one.

The new telehealth items are the way to go: the perfect solution for the reluctant parent. On your precious day of carer’s leave, why let the Weet Bix go soggy while seeking a medical opinion?

Pour the milk, Skype the GP and hold your baby up to the camera.

Are they pixelations or a rash? Ah whatever—she’ll be right.

 

This article was first published in Medical Observer, June 2020

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Podcast 14: Alcohol-related harm in general practice

REACH_alcohol

(43 mins)

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GP team Liz Sturgiss and Justin Coleman bring the GP Sceptics podcast back to life, and this time it’s all about alcohol…but not in a good way.

Liz leads a Monash University project called REACH — for you, that’s “Reducing alcohol-related harm in General Practice”. As usual, I’m just the guy who asks the dumb questions on your behalf, as you while away your time during coronavirus lockdown.

This podcast is all about encouraging behaviour change.

The experts in the podcast are Liz herself (you’ll recognise her distinctive voice and smart questions) and two of our favourite GP-experts (see below) who have built their careers on maximising the chances of someone reducing their alcohol intake as a result of an ordinary consultation with their GP.

Nothing fancy, but if every GP got 10 per cent better at it, the effect on Australia’s physical and mental health would be formidable.

Dr Paul Grinzi is a GP in North Melbourne who educates about alcohol and other drugs for the RACGP. We ask him about his tricks of the trade when it comes to taking an accurate history of alcohol consumption, and he describes how to subtly prompt patients to come up with their own ideas of what might motivate them to change.

I loved his concept of GPs being ‘actively curious’ in what makes the patient tick. Listen in to find out how to become a ‘travel agent of change’.

Dr Hester Wilson is a Sydney GP, a lead clinician in the GLAD (GP Liaison in Alcohol and other Drug) Project, and Chair of the RACGP Addiction Medicine Network. She discusses the new Australian Guidelines on reducing health risks from drinking alcohol (2020).

Although you may have never thought of yourself as a cheerleader, Hester describes how GPs should cheer people on towards healthier behaviours.

Finally, Liz takes me to task with a ‘What would Justin do?’ dilemma, which quite frankly was my easiest yet. I blitzed it!

Happy listening to your 43 minutes of GP education. Soundcloud and Apple links will be added soon.

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Managing diabetes is not all about expensive medication

After 2 1/2 years, Dr Justin Coleman finishes as Editor of the Diabetes Management Journal. He will continue to remain involved with the DMJ, as a member of its Editorial Advisory Board. This is his final editorial.

Around 100 articles have hit this editor’s desk over the past 2½ years, journeying us through a hundred different aspects of managing diabetes.

The desk itself has gone on a journey too, when last year I transported it from Brisbane in the southern half of Australia (yes, check the map) to almost as far north as you can go. The Tiwi Islands just cling on to the nation, counterbalancing Australia’s only larger island—Tasmania—on the opposite edge.

In terms of diabetes issues, the people walking into my general practice have considerably more in common with East Timor to the north than with most Australians to the south. Here, type 2 diabetes (T2D) is so common that it is a general expectation.

My small community of 1600 includes 22 people on haemodialysis, with almost as many again waiting in the big city to ‘return to Island’ when a haemodialysis bed becomes free. Where I live, ‘new bed available’ has become a sad euphemism to mark the ultimate end-point of our diabetes and renal management.

So when an article lands on my desk discussing cutting-edge technology around the artificial pancreas, or a drug research breakthrough, I have to remind myself that most Australians live in surroundings where these advances will improve lives. This progress heralds an exciting future for those who are already effectively accessing what we have now, and many readers of the DMJ will soon be delivering it. Exciting stuff!

Yet in my time at the helm, I have also made sure to commission plenty of articles that go back to the basics, to ensure we do them well. After all, it is at the ‘blunt edge’ of medicine—far from the news headlines—that most health gains are made.

Primary health care, rather than the specialist diabetes clinic, is the health home of most Australians who have T2D. A few dip in and out of tertiary clinics and private hospitals offering advanced complex care, but it is the daily work of general practitioners, diabetes educators, dietitians and exercise physiologists—often generously supported by endocrinologists—that meets the bulk of the care needs for Australians with diabetes.

If asked to list the things that really matter, I’d note that diet, physical activity, weight loss and simple, cheap pharmaceuticals (hypoglycaemics and cardiovascular preventatives) carry the load. Management of these basic factors does not require much advanced technical knowledge, but absolutely requires skills around ‘what is likely to work’ for the individual with diabetes sitting in front of us.

Take something as simple, cheap and basic as physical activity. By any measure we know it is beneficial for people with diabetes; let’s not limit the claim—it is beneficial for life as a human!

For a sedentary person, the end-goal of ‘more activity’ is backed by more research than a health professional could possibly need, and has greater health benefit than any front-page medical advance this century.

Yes, the goal is obvious, but not so the solution.

After all, that same goal would equally apply to a Brisbane business executive attending a corporate health check and to a Tiwi man I opportunistically pluck from my waiting room. The real skill—the subtle art—is in finding the ‘solution’: an approach to management tailored to that individual.

The  exec may benefit from their GP having read DMJ articles about High Intensity Interval Training, tai chi (see p23) and barriers to exercise, while my clinic staff might take more note of DMJ features on poverty and diabetes, free community exercise programs and exercise with diabetes complications.

A sedentary lifestyle, a poor diet, and an obesity issue are all wicked problems that demand that the health professional has access to a kit full of evidence-based, low-tech tools. Selecting the right tool requires communication, trust and an ongoing relationship nurtured over time.

Sometimes the intervention will involve something new, exciting and shiny—wearable technology or a novel drug class—but don’t confuse the ‘thing’ with the ‘process’.

Diabetes management is no sprint race.

The Feb 2020 edition of the DMJ is available here.

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My perfect medical statistics day

I don’t know how others celebrated International Statistics Day, but I decided to dedicate an entire morning clinic to the cause.

If I’m honest, I usually drift into the old habit of seeing each patient as an individual, but for once I made a concerted effort to treat everyone as a statistic.

I didn’t want any atypical patients ruining my outcomes, so I worded up my receptionist Joan about who to book in.

“Please exclude anyone who has heart failure, doesn’t speak English or is on two or more medications.” She raised a dubious eyebrow. “Oh, and I want them allocated randomly.”

Joan’s eyebrow went decidedly bell-curve. “Randomly how?”, she protested. I gave her a coin to toss and a friendly wink. She means well.

The first patient on my list was “Baby 4136 (gender blinded)”. Joan had received my memo about de-identification.

Continue reading
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GP Sceptics podcast 13: Nurses’ conflicts-of-interest

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Few ever talk about it, but it’s not just doctors who are courted by the medical industry. Nurses are also frequently targeted when it comes to promoting pharmaceuticals and medical devices.

Barely anyone except Quinn Grundy talks about it, in fact, so Liz Sturgiss and Justin Coleman point the microphone at this registered nurse who did her PhD on that very topic.

The extent of what Quinn reveals will surprise you…it most certainly surprised all the nurse managers who were sure she would find nothing when she started digging.

From surgical devices to wound dressings and pharmaceutical purchasing committees, it turns out nurses have far more influence on where money gets spent than most people assume, not least the nurses themselves.

The only ones not surprised are the companies who have been pouring substantial resources into reps educating nurses, thereby ensuring their brand features prominently when it comes to spending taxpayers or patients’ money. Unlike marketing to doctors, there are no legal restrictions to marketing to most nurses, and few health services have even considered the issue.

I know nurses at my general practice continue to see ‘educational’ reps who promote expensive wound dressings, glucometers and other devices, a full 10 years after our GPs stopped seeing reps altogether.

The discussions around the ethics of this seem to be a decade behind, within a nursing profession which is otherwise such a champion at the forefront of promoting best practice.

Dr Quinn Grundy is a postdoctoral research assistant at the Charles Perkins Centre at the University of Sydney, soon to assume a faculty position at the University of Toronto.

She has just launched her wonderfully titled book Infiltrating Healthcare: How Marketers Work Underground to Influence Nurses   [The code DNB290818 gives a 15% discount]

Quinn mentions the dataset Pharmaceutical industry payments to healthcare professionals which is my go-to database for discovering the degree of links between doctors quoted in media articles and the pharmaceutical industry. That dataset was almost going to sit on my website here, actually, after a friend of mine collated all the reports mandated under the Medicines Australia transparency arrangements. However, I figured the University of Sydney had better lawyers and thicker skin, so I facilitated its publication there.

Also in the podcast, Liz delves into the Therapeutic Guidelines series and finds they come up clean as a whistle when it comes to independent expertise. Such a fantastic evidence-based resource for prescribers! Justin interviewed Susan Phillips, the CEO of eTG, at the recent GP18 conference.

In the final segment we look at the latest controversy from wonderful troublemaker John Ioannidis who has dreamed up a world where professional associations don’t get to author their own guidelines.

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A textbook case walked into the room

Pityriasis

Textbook rash with a ponytail, by Ben Sanders

Four days ago, a textbook case of pityriasis rosea walked into my room. Well, technically it was the girl who walk in…the rash was just a hanger-on. But to me, the rash was everything.

The more I looked, the more textbook it became. It was as if a Murtagh’s patient education handout had grown legs and a ponytail.

The lesions weren’t just red—they were salmon-pink. Salmon-pink, I tell you.

If an Atlantic salmon had leapt into her T-shirt and flopped around in a “Christmas tree” pattern for a few minutes before being sustainably released back into the ocean, those lesions could not have looked more classic.

“And I don’t suppose that oval patch on her back appeared 7-14 days ago did it, Dad? Goodness, see how the scales attach to the outer border of this herald patch like a collaret? Your daughter has become a thing of rare beauty Mr Smith! A textbook case.”

Note to self: it is more exciting to diagnose a textbook case than to father one. Beauty, as it turns out, is only skin deep.

Addendum: the modern man neither knows nor cares what a collaret is, which is somewhat of a shame. The dapper legacy of the early dermatologists has been supplanted by the drab business tie.

Back to textbook cases, however. Have you noticed how few there are about, these days?

Not just rashes, but all the classics seem to present rather half-heartedly. Continue reading

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Vitamins: mostly harmless, mostly profitable

VitaminsVitamin D is mostly harmless. Sure, it can cause toxicity (mainly hypercalcaemia), but usually at megadose levels of around 60 capsules per day.

Vitamin C is also mostly harmless. My parents, advised by the medical zeitgeist when I was a child, gave us one citrus-flavoured tablet every day during winter.

And extracted fish oils are mostly harmless, except of course to the extractees: the fish.

Another thing these three supplements have in common is that they are all wildly successful products of health marketing. Marketing that uses ordinary doctors to amplify the message…doctors like you and me.

Arthur Dent (upon reading the description of planet Earth in The Hitchhiker’s Guide to the Galaxy): “Is that all it’s got to say? Harmless! One word?”

Ford Prefect: “I managed to transmit a new entry off to the editor. He had to trim it a bit, but it’s still an improvement.”

Arthur: “And what does it say now?”

Ford: “Mostly harmless.”

Douglas Adams

As highlighted recently the US has seen almost a tenfold increase of vitamin D sales in the last decade compared to the previous. Yet a recent meta-analysis  of 33 randomised trials showed that vitamin D or calcium supplementation has no effect on the incidence of fractures.

After years of venerating the “D”, it seems the vitamin is more often a marker associated with an illness rather than its cure. Continue reading

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Post-truth therapy: alternative medicine with alternative facts

 

broom

Sweeping out the dirt

 

Being a medical sceptic is a hard gig, these days. Our negativity cops bad press; we lack the faith of traditional healers, the chutzpah of health bloggers and perhaps even the imagination of Donald Trump.

Lift the carpet to scrutinise the evidence for surgical procedures or pharmaceuticals, and detractors will point out that at least western medicine eventually responds to scrutiny – so how about first sweeping out the badlands of alternative medical practices?

But, take a broom to the dust at the foundation of so many complementary medical claims, and devotees will tell you to first get your own house in order.

We critics get used to sweeping criticism.

So, when the RACGP approached me last month to write their official submission to the Senate Report on the TGA reforms, I keenly obliged.

Over the last couple of years I had written the RACGP Choosing Wisely recommendations, aimed at reducing unnecessary procedures and treatments. Or, if some staunch traditionalists are to be believed, conspiratorially aimed at undermining the very basis of our rights as doctors to order whatever we want.

Having disturbed the peace at home, the TGA submission was a chance to kick up some dust over at Alternative House.

“More than a thousand claims…the majority are unscientific”

The issue is the bill before the senate that will allow manufacturers of complementary and alternative medicines to make therapeutic claims for their products without pre-approval. Marketers will be allowed to choose a claim from a selective list. Continue reading

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