Death by Fugu

Few days ago, a colleague of mine asked my help to asses a case of a young patient with no history of asthma nor heart condition in the past who was admitted due to sudden onset of difficulty of breathing. When I saw the patient, he was restless and dyspneic. History revealed that the condition started few hours after eating a puffer fish. According to the family of the patient, there were 12 of them who ate the fish and two died before reaching the hospital.

Despite of the risk, we Filipinos still love to eat puffer fish or butete as we commonly call it in tagalog. In fact, I have one friend whose family likes to eats puffer fish. According to her, it taste like chicken and it is delicious.

Actually, this is the first time I encountered a patient poisoned by eating a puffer fish as far as my medical practice is concern. I never expected that puffer fish poisoning could cause instant death even if taken in small amount.

According to the NATGEO WILD, there are more than 120 species of puffer fish worldwide. Mostly are found in tropical and subtropical ocean waters, but some specie live in brackish and even in fresh water. They have long tapered bodies with bulbous head. Some wear wild marking sand colors to advertise their toxicity, while others have more muted or cryptic coloring to blend with the environment.

They range in size from the 1-inch-long dwarf or pygmy puffer to the freshwater giant puffer, which can grow to more than 2 feet in length. They are scaleless fish and usually have rough to spiky skin.

The diet of the puffer includes mostly invertebrates and algae. Poisonous puffers are believed to synthesize their deadly toxin from the bacteria in the animal they eat. Almost all puffer fish contains tetrodotoxin, a substance that makes them foul tasting and often lethal. Tetrodotoxin is deadly, up to 1,200 times more poisonous than cyanide.

The tetrodotoxin kills by paralyzing the nerves. Victims can't move or breath but they are fully conscious until their lungs fail. The only way to save victims is to use a respirator to breath for them until the toxin ware off.

Amazingly the meat of the puffer fish is considered a delicacy in Japan. They call it fugu and it is extremely expensive and only prepared by trained, licensed chefs who know that one bad cut means almost death for a customer. Indeed this is an ultimate food taboo.

Frequently Asked Questions on A(H1N1) Vaccine

Last June 16, 2010, I had myself vaccinated with A(H1N1) together with other health personnel of our City Health Office. This is in accordance to the Implementing Guidelines For Vaccine Deployment by the World Health Organization (WHO) and the Department of Health (DOH) wherein the Health Care Workers/Frontline Responder are the number one priority for vaccination followed by pregnant women, persons 6 months and less than 5 years old and those more than 60 years of age and persons above 5 years old and less than 60 years old with underlying chronic medical conditions.

I would like to share with you some of the frequently asked questions on A(H1N1) vaccine.

What is an A(H1N1) Influenza Vaccine?

This is a vaccine that will protect humans against the A(H1N1) influenza. Immunization experts have recommended this vaccine to be safe and effective for A(H1N1) influenza but emphasize that it will not prevent "flu-like" illnesses caused by other influenza virus.

How is the vaccine given ?

The vaccine is given by injection into the upper arm for most people. In infants and younger children, however, it is the thigh that is the recommended site for the vaccine shot.

Do people need more than a single dose of the vaccine ?

Immunization experts recommend only a single dose in persons over the age of 6 months.

If I already had A(H1N1), will I still need to receive vaccination?

Yes, because getting previously infected with A(H1N1) virus will not provide lifetime protection against the disease.

How long will the vaccine provide protection ?

The vaccine has proven to be effective but studies are now being conducted to further determine the duration of its protection against A(H1N1).

How safe is the vaccine for pregnant women ?

Recent studies do not show harmful effects with respect to pregnancy, a developing fetus, birthing, or post-natal development. However, pregnant women with complicated pregnancies are advised not to receive the vaccination. The US Food and Drug Administration has approved the use of one dose of vaccine for full protection for pregnant women. The flu shot is given to pregnant women after the first trimester of pregnancy.

Can a breastfeeding mother receive the flu shot?

Yes. Breastfeeding is fully compatible with flu vaccination; and preventing the flu in mothers can reduce the risk of the infant getting the flu.

What are the possible side effects from the vaccine ?

Soreness, redness, tenderness, or swelling where the shot was given; fainting (mostly young people); head and muscle aches; fever; and nausea. These are generally mild, will not need medical attention and will last for just a day or two.

Why do some people who have been vaccinated still get influenza ?

People can still get the influenza because no vaccine can provide 100 % protection against the disease; however, they will greatly reduce the risk of getting sick. Experts said that the vaccines only become effective about 14 days after vaccination. vaccinated individuals can also get influenza by different starin of the virus for which the A(H1N1) vaccine does not provide protection.

Can people who have allergy to eggs receive the vaccine ?

People who are allergic to eggs might be at risk for allergic reactions from the vaccine. In 2009, experts from the Center for Disaease Control (CDC) said that the people who have egg allergies should consult with a doctor or other medical professionals before considering any influenza vaccination.

Can the A(H1N1) vaccine be administered simultaneously with seasonal flu and other vaccines ?

It can be given at the same time as other injectable influenza and non-influenza vaccines provided that it will be administered at different injection sites under the supervision of professional health workers.

Who should not be vaccinated without a doctor's advise ?

Some people should not get vaccinated without consulting a physician first and these individuals include: (1) those who have severe allergy to chicken eggs, (2) those who have had a severe reaction to influenza vaccine, (3) those who have developed Guillain-Barre Syndrome, a severe paralytic illness, after getting a flu vaccination in the past, (4) children younger than six months of age, and (5) those who have moderate-to-severe illness with a fever.

Sources: Recommendation on Pandemic (H1N1) 2009 Vaccines WHO's Strategic Advisory Group Experts (SAGE) on Immunization; 2009 (H1N1) Inactivated Influenza Vaccine FAQs Center for Disease Control and Prevention; Deployment Plan for the Distribution of Pandemic Influenza Vaccine WHO Geneva; DOH Interim Guidelines for Deployment and Use of Pandemic Vaccines

Six In The Beach

My friends prepare your swim wears because summer is just around the corner. By this time, I am sure all of us are already thinking where to go this coming holy week. No doubt, Bora would be one of our top choices.

Since most of us will be going to the beaches this time of the year and for sure we will be eating and partying a lot in those places, allow me to give you some lessons on how to prevent or stop medical conditions that could spoil our summer getaway.

Lesson I: Motion Sickness

Motion sickness is a very common disturbance of the inner ear that is caused by repeated motion such as from the swell of the sea, the movement of a car, the motion of a plane in turbulent air, etc. In the inner ear (which is also called the labyrinth), motion sickness affects the sense of balance and equilibrium and, hence, the sense of spatial orientation.

There is no difference between motion sickness and sea sickness. Some people experience nausea and even vomiting when riding in an airplane, automobile, or amusement park ride. This condition is generally called motion sickness. Many people experience motion sickness when riding on a boat or ship. This is commonly referred to as sea sickness (mal de mer), even though it is the same disorder. They are one and the same phenomenon and will subsequently be referred to as motion sickness.

The most common signs and symptoms of motion sickness include: nausea, paleness of the skin, cold sweats, vomiting, dizziness, headache, increased salivation and fatigue.

Here are some tips in order to avoid motion sickness. Eat lightly before embarking on your trip. Take your position near the front of the vehicle whether it’s a car or a boat. Face the direction you're headed to keep eye and body sensations in sync with each other. Keep your eye trained on the horizon or on a fixed spot ahead of you. Keep the window open and fresh air accessible at all times.

Taking medicine like Meclizine HCL (Bonamine) 12.5 mg/ tab for children between 5 to 10 years old and 25-50 mg/tab for adults and children more than 11 years old to be taken 1 hour before travel is also very helpful.

Lesson II: Food Allergy

Food allergy is an abnormal response to a food triggered by your body's immune system. Allergic reactions to food can sometimes cause serious illness and death. Tree nuts and peanuts are the leading causes of deadly allergic reactions called anaphylaxis.

According to the National Institute of Allergy and Infectious Diseases, the most common foods that could trigger allergic reactions for adults include: fish and shellfish such as shrimps, lobsters and crabs, peanuts, tree nuts such as walnuts and eggs. For children, it includes eggs, milk and peanuts.

The most common signs and symptoms of food allergy include: itchiness of the skin, nausea, vomiting, diarrhea and abdominal pain. In severe cases, patients can develop eczema, hives, asthma attacks and anaphylactic shock.

I strongly advised that you bring antihistamines with you like Loratadine (Claritin) 10 mg/tab to be taken during allergic reactions once a day for adults and children more than 12 years old and Loaratadine (Claritin) 5 mg/5 ml one teaspoon for children between 2-12 years old weighing below 30 kg and two teaspoon weighing more than 30 kg .

In cases where in allergic reaction is already severe, visit the nearest clinic or hospital for proper management.

Lesson III: Indigestion

Indigestion, also known as dyspepsia, is a term used to describe one or more symptoms including a feeling of fullness during a meal, uncomfortable fullness after a meal, and burning or pain in the upper abdomen. Indigestion is common in adults and can occur due to over eating.

The following are some tips that could help in treating indigestions: eating several small, low fat meals throughout the day at a slow pace, refraining from smoking, abstaining from consuming coffee, carbonated drinks and alcohol, by stopping the use of medications that could irritate the stomach lining like aspirin and anti-inflammatory drugs and getting enough rest.

Antacids, such as Aluminum Hydroxide 200mg / Magnesium Hydroxide 200 mg (Maalox) chewable tablets are usually the first drugs recommended to relieve symptoms of indigestion. You can chew 2 tabs every 6 hours to relieve the above condition. For children, you can give them Maalox suspension 2 teaspoon every 6 hours for hyperacidity.

Lesson IV: Food Poisoning

Food poisoning and diarrhea can seem even worse when you are traveling. Try to restrict travel to areas with high standards of hygiene.

Food poisoning is a common problem that can be easily treated. Each year, an estimated 76 million people in the United States become ill from the food they eat, and about 5,000 of them die according to the CDCP, Centers for Disease Control and Prevention.

Beef and poultry are generally the main causes of food-borne illness, but a number of other foods also pose a risk. . A recent study shows the top 10 riskiest poisoning foods based on the number of outbreaks and cases.

Surprisingly, some healthy foods are considered high-risk for poisoning outbreaks. Leafy greens are on the top of list, most likely due to poor handling practices and contaminated washing equipment. Eggs have the second highest number of outbreaks, with most of them caused by salmonella. Half of all cases of egg-related illness are in restaurants. Tuna rounds up the top three as fresh fish can decay soon after being caught, leading to poisoning. Oysters, potatoes, cheese, ice cream, tomatoes, sprouts and berries complete the top 10 list.

Food poisoning is cause by harmful bacteria, with symptoms ranging from upset stomach to fever and severe vomiting and diarrhea.

For diarrhea, you can take Loperamide HCl (Imodium) 2 mg two capsules initially then 1 capsule after every diarrhea. I also advised you to drink plenty of water and energy drinks like Gatorade to prevent dehydration. However, if symptoms persist, go to the nearest hospital for further management.

Lesson V: Sunburn

Most of us aren’t really keen on using sunblock yet, but it’s never too late to start protecting our skin from sun damage.

Pick a sunblock whose Sun Protection Factor (SPF) fits your purpose. If you’re going to be out in the sun briefly, you may go for sunblock with SPF 15. This means that the sunblock is formulated to protect your skin from the sun for 150 minutes. SPF 30, on the other hand, promises to give you 300 minutes of sun protection. The ideal sunblock should contain titanium dioxide or zinc oxide, which keep dangerous ultraviolet rays from hurting your skin. It should also have helioplex, which helps preserve the sunblock’s SPF. Moreover, it helps if your sunblock is enriched with vitamin E.

Remember to put sunblock on early. It takes time for sunblock to be absorbed by your skin, so apply it 15 to 30 minutes before you go out into the sun. Some dermatologists recommend that you reapply every hour, while others urge you to do so every two hours. The best thing for you to do would be to reapply as often as you see fit or depending on the sensitivity of your skin. Don’t forget to apply sunblock on often-forgotten spots like your nape, ears, and eyelids. Harsh sunlight spares no part of your skin.

Lesson VI: Heat Stroke

Heat stroke is a form of hyperthermia, an abnormally elevated body temperature with accompanying physical and neurological symptoms. Unlike heat cramps and heat exhaustion, two forms of hyperthermia that are less severe, heat stroke is a true medical emergency that can be fatal if not properly and promptly treated.

Symptoms of heat stroke can sometimes mimic those of heart attack or other conditions. Sometimes a person experiences symptoms of heat exhaustion before progressing to heat strokes.

Different people may have different symptoms and signs of heat stroke. But common symptoms and signs of heat stroke include: high body temperature, absence of sweating with hot red or flushed dry skin, rapid pulse, difficulty of breathing, strange behavior, hallucinations, confusion, agitation, disorientation, seizure and coma.

Victims of heat stroke must receive immediate treatment to avoid permanent organ damage. First and foremost, cool the victim. Get the victim to a shady area, remove clothing, apply cool or tepid water to the skin (for example you may spray the victim with cool water from a garden hose), fan the victim to promote sweating and evaporation, and place ice packs under armpits and groins. Monitor body temperature with a thermometer and continue cooling efforts until the body temperature drops to 101-102°F (38.3-38.8°C). Always notify emergency services immediately.

The most important measures to prevent heat strokes are to avoid becoming dehydrated and to avoid vigorous physical activities in hot and humid weather. Take frequent breaks to hydrate yourself. Wear hats and light-colored, lightweight, loose clothes. Avoid alcohol, caffeine, and tea which may lead to dehydration.

Last but not the least, if you are taking medications like anti-hypertensive as your maintenance, don't forget to take it with you before leaving for your summer vacation. Happy trip my friend!

M3 Turns 1

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Last Friday, M3 Bacolod celebrated its first year anniversary. The celebration opened with a holy mass which started at about two in the afternoon and was held at the lobby of the dialysis center. It was officiated by Rev. Fr. Lazaro Ervite HRD Director of Colegio San Agustin- Bacolod.

After the holy mass, Dr. Victor de Guzman, Medical Director of M3 Dialysis Center, Inc. Bacolod Branch, welcomed the patients and their family, the staff of the center and most importantly the guest of honor of that day, Dr. Ramesh Vemuri, the owner of M3 Group of Companies, who came all the way from Chicago.

Dr. Ramesh Vemuri gave a very short inspirational message but a reassuring one. He also thanked the patients and the staff for their trust and support for M3.

As I was listening to Dr. Ramesh Vemuri’s speech, I soon realized that despite the problems encountered by this center, I am still proud to be part of it, not only because of the hope that M3 brought to our patients but also because of our efficient staff, especially the nurses, who work professionally and tirelessly to meet the needs of our patients. Keep it up!

We also celebrated the birthdays of Dr. Vemuri and Dr. de Guzman on that afternoon. We were all treated with a merienda cena. I really loved the assorted local food delicacies from Quan especially the “toron”. Thanks Ma'am Jay for the tips.


For me, anniversaries and birthdays are celebrated in order for us to reflect on our mistakes in the past, to be humble on what we achieved in the present and to be hopeful for our dreams in the future.

Who Let The Dogs Out?

Indeed El Nino took its toll by not only affecting our water and agricultural products but also increasing the incidence of dog bites. Since last week, I have at least one consultation of dog bite a day. Majority of the dogs that bit our patients was either owned by their friends or by their neighbors. Unfortunately, most of the dogs had no rabies vaccination and as expected the most common site of injury is the legs. So far, there is no sex or age preponderance based on our data.

Rabies has the highest case-fatality rate of any infectious disease. The rabies virus, which causes inflammation of the brain leading to paralysis, is transmitted through animal’s saliva. It enters the human body through animal bites or when a pet infected with rabies licks a person’s skin with wounds or breaks.

Good thing that our city and municipal health offices and our government hospitals right now have enough supply of rabies vaccines. But for me, as a physician, prevention is still better than cure thus I would like to remind everyone that we should have our dogs vaccinated especially El Nino is getting worst.

Actually, there is a correlation between cases of dog bites and rising temperature according to a research published in the March 2009 issue of Otolaryngology-Head and Neck Surgery. In fact, the author suggests that it may be due to a general increase in the irritability of dogs during the warmer months. Furthermore, the author adds that families should be made aware of the increased likelihood of dog bite injuries during summer months.

Since we are expecting a long summer this year because of El Nino, I would like to share to you some simple tips that I believed could help our dogs to cool down during this very hot season. First, we should always make sure that our dogs have available water to drink inside their cage all the time. Second, we should bathe our dogs as often as possible. And third, we should not allow our dogs to roam around without leash.

Finally my dear friends, always remember that our responsibility doesn’t only end to our dogs but also to the people around us. According to R.A. 9482 Anti-Rabies Act of 2007, in case our dog bit somebody, it is our responsibility to assist the dog bite victim immediately and shoulder the medical expenses incurred and other incidental expenses relative to the victims injury. So in order to avoid this accident to happen, be a responsible pet owner.