Prudence and Madness

pic from abs-cbnnews.comI’ve been watching the news less frequently this week because I was busier with my review for my upcoming exam. Unfortunately, during those less frequent times I spent watching the news, I’ve never seen or heard any worthy news at all. Instead, I suffered through a series of “sensational” and “controversial” news segment about Joey Marquez’ daughter, Jowee Ann recovering from a near-fatal case of herbal slimming pill overdose.

Read the ABS-CBN article here.

Geez, one episode of it is enough already. But almost the entire week’s night news peppered with it?!?! That’s just way, way too much!

It could have been a good setup for making the common people aware of the dangers of using “herbal” slimming/diet supplements and that not all supplements claiming to be “herbal” are good. But, as expected of Philippine “responsible” journalism, reporters have emphasized more on the feelings of Jowee (her regrets for having committed such an idiotic act perhaps) on taking the slimming pills. It would have been responsible journalism if, during the week, reporters compiled or made a series of segments regarding actual herbal slimming pills available in the country containing dangerous amounts of phentermine. It would have been responsible news reporting if someone thought of interviewing a CREDIBLE medical practitioner about the proper use of phentermine. But, no! Reporters sensationalized the news and focused on how Jowee felt like coming out of coma or how hard it was for her parents to accept that such thing could have ever happened to their daughter. Please! We’ve had enough of that from our daily dose of soap operas and telenovelas! We need hard and concrete information!

It is brave of Jowee Ann to admit her idiocy in front of millions and millions of viewers (though she, of course, will not admit directly to that). It is something that she should be given credit for. Perhaps from her mistake, many Filipinos will be brought back to reality and realize that slimming pills should not be abused. However, if Jowee Ann, really wanted to enlighten Filipinos, she should have mentioned how many pills she ingested at any one time and for how long. Or perhaps she did not want to do that because it would make her idiotic act more glaring in the public eye?

But, then why would the ordinary Filipino want that information?

It is simply because phentermine, itself, is a drug that is legally used as an anti-obesity agent. Nothing really bad in there. Except, of course, if people will use it without the supervision of a physician.

People need to understand that the adage, “everything should be taken in moderation”, holds true in the case of drug use.

Phentermine is a resin complex acting on the central nervous system to suppress appetite. It is only used for SHORT-term management of obesity, and only as an adjunct to proper diet and exercise. It is available locally as Duromine in 15-mg and 30-mg capsules. A prescription would be needed for acquisition of this drug. And it only 15-30 mg can be taken daily. That means, either you could take the 15-mg capsule once or twice daily or the 30-mg capsule only once daily. If proper dosage is exceeded, it may lead to amplified side effects such as palpitations, hypertension, agitation, restlessness, etcetera. Toxic dose varies considerably due to individual variations in tolerance of the drug so it is important not to exceed the advised dosage.

So, how many of the pills did Jowee take at any one time? I do not know how much of phentermine was in each slimming pill she used. Using common sense, I’d say she must have taken more than one pill at any one time (perhaps to speed up her weight loss), leading to toxic levels in her blood which in turn, lead her to near-fatality. Also, she may have had some contraindications to the drug like: anorexia, insomnia, psychopathic personality disorders, suicidal tendencies, Gilles de la Tourette syndrome and other disorders, hyperthyroidism, narrow angle glaucoma, diabetes mellitus and cardiovascular diseases such as angina, hypertension and arrythmias (Dollery, 1991; Reynolds, 1996)

To know more about phentermine, please read this monograph.

My point is, Jowee did not became comatose because she used a herbal slimming pill with phentermine. Jowee became comatose because she abused a slimming pill with an unknown content of phentermine. Not knowing that the pill contains phentermine is besides the point. She took for granted that the slimming pill is “herbal”. She thought that “herbal” automatically meant “natural” and “natural” meant “good for one’s health”. She left moderation out of the equation. And that is dangerous.

Moral of the story: Idiocy and Herbal supplements are a dangerous mix.

Click here to read the full INQ7 story.

As a physician, my opinion regarding this incident has been asked by my friends over and over again. However, I cannot really make a conclusion on this case simply because not much facts were revealed. If I were to study the case efficiently, I’d want to see the medical chart of the patient and the monitoring sheet used by the attending nurses. I would need to know the setup of the hospital where this incident occurred. Of course, I would have to ask statements from all the involved hospital personnel.

But, here, only the news article is available to me. And so I’m just going to draw my conclusions based on this material only. I’m afraid, though, that I’ll be raising more questions than answers in this post.

First comment I’ve to give is that the application of the diaper, in this case, is unusual. I don’t say that it is improper. However, the use of adult diapers is usually AFTER delivery of the baby. It is worn by the mother because of the bloody vaginal discharges that is expected after a vaginal delivery of a baby. What is usually used during labor is a rubber sheet or a folded linen placed underneath the pregnant woman in labor, so as not to stain the bedsheets with vaginal discharges that is to be expected during labor, too. Some may use diapers during the latent stage of labor or the early stages when the contractions were not that strong that some women may not even notice it at all. The latent stage of labor usually lasts for about 6-8 hours for primigravids and for a shorter period of time for the multiparas (women who had borne children before).

It is also important to know the status of the labor at the time that the diaper was placed. I’m sure any average, competent doctor wouldn’t place a diaper on a pregnant woman in active labor. If I understand it correctly, the mother in this case was a primigravid, a first-time pregnant woman. For a first-time pregnant woman, the early stage of labor may last to about 6-8 hours, as I’ve said. But this is difficult to asses because the woman may not even notice the weak contractions. So, I think, it is rather difficult to pinpoint the time the actual labor started. As a doctor, I would rather base my decisions on the dilatation of the cervix. If the cervix of the laboring pregnant woman is at 4 cm and the contractions are getting stronger, she is in active stage of labor already. The length of this stage may take about 4 hours to 6 hours and may be shorter for those who are multiparas. The reason for not putting a diaper on the laboring patient at this stage is that the condition may progress faster than expected. Moreso, during the second stage of labor, or the delivery of the baby, which could take only several minutes or may be close to an hour. So, when this diaper was placed on the patient in this case, I guess, the doctor was thinking that she wouldn’t be giving birth anytime soon. Perhaps the patient’s cervix was only dilated 3cm or less. But I could only speculate.

I have to make a comment on what was written on the article regarding Valium. Valium (Generic: Diazepam) belongs to a class of drug called benzodiazepines. It affects chemicals in the brain that are responsible for seizures, anxiety, and muscle spasms. And so, this drug is often used as a sedative. And the reason this drug was given to the patient in this case is for her to be able to rest while she is not still in active labor and also to avoid undue energy expenditures in her part. The patient needed to reserve her energy for the more important part of her labor: the delivery of the baby. I’d like to correct, though, that Valium will not cause anyone to lose consciousness, if given in proper dosage. It is only sedating. The article cited that the patient said she was given Valium and lost consciousness. Perhaps, it was the choice of words that was wrong. Unless, of course, she wa really given Valium at a dosage that could cause her to lose consciousness.

She may have become too sedated that she failed to noticed that she has already given birth. Thus, I can only speculate at to what time she must have delivered the baby. However, was she really that much sedated that she didn’t notice that there is already something in between her thighs, though it may not be moving or making sounds?

And then, based on this news article, there was a long interval between the last time she was checked by the doctor (midnight , when she was given Valium) and the time that the lifeless baby was discovered, which is at around 7 am. That is seven hours? Does this article tell me that no internal examinations were done during those time to check if the cervix is already fully dilated? Usually, when monitoring an actively laboring patient, IEs (internal examinations) may be done every 2 hours, or more frequent if the cervix is near to full dilatation.

As I’ve said, there are so many questions to be answered. Much as I want to be following this case as it unfolds, I’m afraid I’ll be just limited to snippets of anecdotes from grieving parents and relatives. The doctor, I presume, will keep her thoughts to herself and her lawyer. And that is, for her own good. So, don’t be surprised if the doctor involved isn’t making any press statements. She reserving all the bullets that she may gather (or appear to gather from thin air) for her defense.

May there be fair justice for everyone involved. And may the truth be uncovered, though elusive it may be.

I am from duty today so my mind is really not in a state of creative genius. I’ve been thinking of writing something about my liking for rock songs or something about a recent conversation with a close friend of mine. But I can’t gather my thoughts properly. So pardon me if everything seems incoherent. I just let everything pour out…

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And so, as I’ve said I am from duty today. I’m always on 24-hour duty every Sunday, a time when all of my friends are free to go out have coffee or just hang-out. Hahaha. But they don’t (as far as I know). Maybe because I can’t go with them? Hahaha! My friends and I used to have Saturday as a badminton night. But that changed recently because everybody seemed to become busy or unavailable the last minute. Wait, where am I? Oh yeah, the duty. I was duty yesterday. We had a drunk patient who was mauled with a baseball bat and sustained a deep laceration on the head. So deep the laceration was the periosteum need to be repaired. And an artery was hit and so the guy was literally spurting blood from his head when he was brought to the emergency room. When he was stabilized, obviously the guy seemed to be better because he was able to afford to refuse our advice to have x-ray of his skull done. Even his companions refused to have it done. The reasons they gave for their refusal were financial constraint and that the patient was better already (typical pinoy way of thinking). Despite our thorough explanation of the possible consequences of their decision, still they refused. So okay, fine. We just had them sign on the emergency room chart that they refused the xray and the anti-tetanus shots.

But the story didn’t end there.

Suddenly, the patient’s companions realized that they did not have enough money among them to pay for the emergency room bill. So, they asked permission to just leave the patient at the ER while they go home to the patient’s house to ask for money. Just imagine, they wanted to leave the poor shirtless guy with a head injury in the emergency by himself! But still, off they went. And the ER staff had to guard the patient because he might be feeling too better to run away. After several more hours, we received a call from the cousin of the patient telling us to just please take care of his cousin for him because they wouldn’t be able to return to him until morning. WTF?!?! That meant putting the patient in the observation area for about 8 hours. The hospital protocol dictates that a patient should not stay longer than 2 hours in the emergency room. If the patient needed to be observed, the patient should be admitted for, at least, 24 hours in the ward. But, no, the relatives did not want that. And then they asked if we could have someone go over to their house to pick them up because they couldn’t go out because of the heavy downpour of rain. Again, WTF?!?! What do these guys think we are? An car rental shop? One of the persons from the admin offered the ambulance to pick them up but they had to pay the ambulance fee. Of course, they vehemently refused. And so, we couldn’t really do anything but babysit the poor patient until morning.

So, morning came. And the poor guy’s relatives also came. But they don’t have money. So they came to us, doctors, begging for a discount on the fees. But we told them that if they need to arrange for delayed payment, they had to talk to the proper authorities, meaning the admin people and not us.

I don’t know what else happened after that. But I think they were not able to pay.

And this, my dear readers, happen to a lot of unfortunate folks in our country. Can anyone please tell GMA that? Or do we need to make a powerpoint presentation for her to see that?

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I was able to have a yahoo chat with my honey, Mike. I, using my cellphone signed in to yahoo mobile chat, and Mike, using his new HP laptop. He is still in Texas and he may have to stay there until October because he’s not yet done with his business there. I do miss him so much. We’ve set up an esnips account so we could easily upload our pics there and somehow, still “see” each other even we’re miles and oceans apart. I wish he’d come home soon. This must be how spouses of OFWs must feel…

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What else? Hmmm…my mind went suddenly blank again. Or rather, it got preoccupied with searching for more Rent the musical and Supernova songs on Limewire. Will post a more substantial entry next time.