All facets of the great profession of medicine are fascinating and that is basically the reason why I pursued a career in General Practice. It provides the opportunity to diagnose and manage diseases from A-Z (acne to zoonoses). Practising in a rural community, with the luxury of managing the local hospital, was the ideal environment for my interests and consequently I entered rural practice in partnership with my wife, Dr Jill Rosenblatt in 1969. As the only practitioners in the community of Neerim South we enjoyed considerable responsibility especially with the management of emergencies. The discipline of General Practice, however, is one of the most difficult and challenging of all the healing arts. General Practitioners are at the front line of patient care and have to manage presenting problems as they appear at any time and place.
We all want to be remembered for something – a major contribution to science, or a political triumph bringing peace to a beleaguered world, or perhaps you would like to be honoured with an eponymous syndrome? Or, more modestly, as one committed housewife said, “I would like simply to be remembered for making good gravy.” She held on to this humble desire until it was pointed out to her by some wit, that such a wish was really taking cannibalism too far. So what do we boil down to? If not exactly gravy, then perhaps a juicy bundle of conflicting desires encased in a will for pleasure. No philosopher, artist or scientist has been able to come up with a better reason for doing something than pleasure (giving it, and receiving it).
A world without pleasure is pointless. We may sense this pointlessness on a bad day as we go out to work, fighting stolidly to save impossible lives. But if we accord taking pleasure in our patients as a primary aim, all may not be lost. Of course we know that patients’ welfare and the relief of suffering should be our first concern. But this wears thin after a decade or two (or a week or two) at unpromising bedsides. Pleasure is the only motivator that lasts a professional lifetime. Like it or not, there is no alternative to pleasure. Just as the sex therapist must “give permission” to inhibited clients to enable them to partake of the full range of sexual pleasures, so medical authors have to give permission to fellow doctors to sample clinical pleasures. We are so conditioned by our objective scientific training that we tend to put pleasure last in the list of tasks we must accomplish – if it ever gets onto the list at all.
So what are the pleasures we are talking about? I was once told by a connoisseur, who happens to be a judge, that all pleasures are sensory (as he refilled my glass with a sumptuous wine). So “enjoying our patients” does sound rather cannibalistic in this context. While we do not exactly endorse this approach, it reminds us that swallowing is the vital precursor of many pleasures. And in the clinical context, this means swallowing the whole patient – hook, line and sinker. For those who do not fish, it may be necessary to point out that the sinker is…
In 2009, a woman pleaded guilty to reckless homicide and faces up to five years in prison for exercising her husband to death in a swimming pool. He suffered a ‘heart attack.’ [1] We cannot know, however, whether this was an ischaemic event or an arrhythmia. Exercise is promoted and encouraged in society; it is considered a healthy pursuit with benefits to the heart and mind. We know that certain heart diseases make exercising dangerous, but what risk is exercise to a healthy person without known heart disease?
Ancient history records the death of the Greek messenger Phidippides who ran 26 miles from Marathon to Athens to deliver the news of the victory over Persian invaders, only to collapse and die soon after his arrival.
In the past few years we have heard of professional athletes collapsing during soccer and basketball games and on the athletics track. These are graphically represented and frequently viewed on YouTube. In September last year, Evander Sno, a midfielder for Dutch soccer giants, Ajax, suffered a cardiac arrest during a match. He was successfully resuscitated after four shocks from an external defibrillator – an outcome unfortunately not shared by several athletes in recent years.
Can these deaths be prevented?
Not so long ago, there was evidence to suggest that marathon runners were immune to coronary artery disease, [2] and this idea has pervaded public perception. If someone can compete in countless marathons and triathlons, how could they possibly be at risk of dying from a heart attack? This has been debunked however, with the finding that coronary disease is the major cause of exercise related deaths in the over 35 age group; a phenomenon also seen in younger individuals. [3] To confuse matters more, there is evidence that strenuous activity kills patients with known heart disease but the risk is reduced if they exercise on a regular basis compared with those who are sedentary. [4] To top it off, recent Australian research shows evidence of damage to the right ventricle detected by MRI following a triathlon in normal hearts. [5]
One of the problems in identifying athletes at risk is the similar appearances of the athletic heart to abnormal pathological hearts. Physiologic changes can occur which mimic the appearance of these conditions (so-called ‘athlete’s heart’). They can manifest as morphologic changes (such as wall thickening mimicking hypertrophic cardiomyopathy), ECG changes (usually voltage changes, non-specific…
