Thursday 22 June, 2006


Posted in Michael Tam, Site News at 22:02 by Michael Tam

Do you have any suggestions, criticisms or general thoughts about this website? Or perhaps you have a “wish list” of some topics that you want to go up on this site?

If so, post a comment on this page! I’m interested to read what people have to say about “The Medicine Box”.

Best regards,
Michael Tam
(“The Medicine Box” Administrator)


  1. Peter Wu said,

    Dear Michael and May,

    I am a 6th year UNSW student who is 8.5 weeks away from our exams.
    I stumbled across your website when I was googling about perioperative
    use of anticoagulation. I was absolutely aghast when I found this page.


    I was both angry and thrilled.
    I was angry becuase I didn’t find out about this site earlier.
    I was thrilled because the articles are just amazing, as if they were
    designed for the final year studnets to pass their exams.

    I seldomly have the urge to expression my appreciation. However, I would
    really like to tell you guys how much I appreciate the articles you posted.
    You prabably hear this all the time :) but I still have to say it
    “Thank you thank you thank you~”

    I found a light house in the storm \ (^_^) /

    • Hi Michael – I am a humble patient emailing you from England, having just found your information on anticoagulation. I found it enlightening, easily understandable and also very true, having had personal experience in hospitals of anticoagulation management.

      My own story is as follows:-

      I had a replacement mitral valve in France in 2007, at the age of 60. I have since been on Previscan, which is almost always used in France, but only in France, as far as I understand.

      I have self-tested, and self-dosed for the most part, since 2008, using a Hemosense machine and strips suppled by Alere. My INR has been stable and my cardiologist enthusiastically supported my decision to self-test, which is unusual in France, as the labs make a huge amount of money out of INR testing and are successfully blocking the widespread use of portable machines.

      Having recently returned to live in England, I am in the process of switching to Marevan (known only as warfarin here, it seems).

      I am linked to the haematology unit of the local hospital here in Bristol. I go to my GP surgery once a week for a blood sample, which is sent to the hospital, who then inform me as to dosage.

      My first sample last Friday, when I was still on Previscan, gave an INR of 2.6 on my machine, and 2.4 at the hospital. Based on that, the hospital started me on 7mg of marevan.

      By Monday my INR was 3.4 – high for me, as my range is 2.5-3.5. I’ve always kept it to the bottom of the range and it has been stable for several years now.

      On Tuesday my machine gave a result of 2.7.

      Today, Wednesday, I took my machine to the surgery to do my own test alongside theirs. Horror! 4.4.

      I am expecting the hospital to phone me this evening to tell me how much to take tonight.

      This is where I am completely in agreement with you, Dr. Tam. Hospitals are far too quick to adjust the dosage, with the result that the INR fluctuates wildly.

      However, I would be the first to want my INR to be lowered in a hurry, as I have in the past suffered a major stomach haematoma caused, I have to say, by a doctor taking it on himself to adjust the dose of Previscan.

      I had a stomach ulcer for many years, finally being admitted to hospital here in England as an emergency after a catastrophic bleed. Helicobacter pylori was diagnosed and after antibiotics I have had no further problems. I now take omeprazole as a safeguard against the anticoagulants.

      That’s the story so far. No doubt the INR will settle down in due course. I only hope it does so before I get into real difficulties. My greatest fear is of being regulated by the
      hospital, as frankly I trust myself to do a better job. Fortunately, my new GP is very supportive of my self-test approach – in his words, it’s not rocket science!


  2. Mel said,

    Impressive site!

    (Note: originally posted in the “About” page – moved by Administrator)

  3. Dr P Velayutham said,

    dear doctors,

    you seem to do a wonderful and dedicated job. i am an endocrinologist trained and practising in India. i stumbled across this site incidentally. nice work. i definitely will try to contribute to the site when and where ever possible. all the best.

    Dr p Velayutham

  4. gabriel said,

    This is a wondeful and most helpful website. I can imagine the enormous amount of energey and effort you put in to develop this web site but this will be an invaluable tool for many doctors to come.
    thank you so much

  5. Deb Kendall said,

    Thanks for the wonderful info on metabolic syndrome. I hope to do lots of self study for the clinical diabetes educator exam. I was home sick this week and googled right into you. You are my favorite favorite right now!

    Deb K RN

  6. mtcl82 said,

    Hi Michael and May,

    I followed the link from Paging Dr. forums to your site.

    I find your articles very helpful in a practical sense, and the work you put in to creating this site deserves to be commended.

    However, I was somewhat puzzled by the fact that your blog entries (Medical Rants) were on sale, in PRINT, as well as the ‘creation of the medicine box’. With all due respect, who in their right minds would purchase a book containing blog entries that can be accessed free on the web? Your blog and this website are good, but not THAT good.. if you understand what I mean..

    Keep up the good work though..


  7. Michael Tam said,


    I fail to see your point entirely, unless you are complaining about getting free stuff. The websites are free as are the compiled PDF e-books. If you want a printed copy, obviously you are going to have to pay the printer of which the books are basically at cost.

    With all due respects, who complains about being able to access free information? Thank you for suggesting that I am perhaps wasting my time. :-?


  8. B said,

    G’day purveyors of scholarly tidbits!

    This website has just been meritoriously added to my stringently selected bookmark tab on the Mozilla browser. Although I am not among the typical target audience of medical practitioners and doctors-to-be (regretfully), this site will serve me well as a satiating source of my topical information diet (keep up the rantings!), and form part of my “continuing professional education” resource sites, although I lament that the nature of my current work will thwart the retention of most of the information due to lack of use and practical application! (Have the found genetic association to a photographic memory yet?? Hook me up with some gene therapy!)

    I was very suprised to find that both of you worked at 407 Doctors! Just a stones throw away from where I work.

    If I may humbly seek your advice on an issue; given the current skyrocketing intake of graduate entry medical students and the foreseeable downstream burden it will place on the availability of quality junior training positions and posts, what measures are being, or should be taken to account for this? I am considering an attempt at GEM but fear it may be a fruitless endeavour if I graduate to find a black hole of substantial work opportunities!

    Cheers :)

  9. Michael Tam said,

    Thank you for your comments!

    With regards to post-graduation training, there is at present a substantial unanswered question of where and how positions will be made available to the “tsunami” of medical graduates in the coming decade. It is estimated that the number of medical graduates will close to double by 2012.

    As published in a recent edition of the Medical Journal of Australia (1):

    One of the most immediate concerns is the number of places and the resources available at the prevocational training stage. This is looming as a potential bottleneck in the system as more students than ever compete for junior medical officer positions. Although the states and territories have agreed, as part of the Council of Australian Governments (COAG) Health Workforce initiative, to provide sufficient intern-level positions, this does not address the need for similar increases in resources for the subsequent postgraduate training years (PGY2 and PGY3). Urgent attention is required to ensure that availability of clinical teachers, teaching time, access to patients, and necessary infrastructure is sufficient for the increased trainee numbers throughout this critical period of training.

    What is unstated here is that COAG has only guaranteed intern positions for Commonwealth funded medical students. Potential students looking at full-fee paying positions must think carefully!

    That being said, medicine is a fulfilling career and even with workforce bottlenecks in Australia, there are plentiful international opportunities.

    (1) Joyce C., Stoelwinder J., McNeil J., Piterman L. Riding the wave: current and emerging trends in graduates from Australian university medical schools. MJA 2007; 186 (6): 309-312 [Link]

  10. Subterranean said,

    Howdy Michael and May,

    I just wanted to say a huge thankyou for putting the time and effort into making this site – as a medical student it is an invaluable resource and incredibly helpful to get such practical and useful advice in which I can apply into my growing knowledge base.
    Keep up the amazing work – it is hugely appreciated!


    • Allan Harrison said,

      I also agree… and its a good site and I’m grateful to you . Thank you.

  11. Rex said,

    Regarding the South Park article on God.

    God will get you for calling him vengeful!

  12. Someone has already asked this question, but I did not see the respond answer. Can you write on an IV bag with a mark? Will it leak throught? I would like to know…Betty Stewart RN

  13. Michael Tam said,

    Dear Betty,

    See the follow up comments here.

  14. Tammie said,

    Dear Tammie,

    I empathise with your loss but the content of your comment was not appropriate for the feedback thread.

    Yours sincerely,
    Michael Tam

  15. [edit]
    Dear Antonia,

    The content of your comment was not appropriate for the feedback thread.

    Yours sincerely,
    Michael Tam

  16. mor_maew said,

    Dear Michael and May
    Thank you for this wonderful site . This blog not only provide medical knowledge but also show your generous mind to all of us .
    Thnak you very much

  17. Sam said,


    Your comment has no relevance in the website feedback page.

    Michael Tam

  18. drhassan said,

    Hi ,i was really impressed in the way you present the fluid management , which is really confusing, as it is presented in different ways , and no simple international standard formula , i think the best people who can help in solving this issue are the anesthetists and nephrologist as they are the best to understand fluid physiology , and body reaction to dehydration or over hydration , i refer you to a very good website which helps a lot in understanding this subject(up to date)

    Drhassan GYN ONCOLOGY

  19. JustPaige. said,


    Unfortunately, the comments of this page is not the appropriate venue for your questions. Please consider discussing the issues you raised with a general practitioner or clinical psychologist.

  20. Eire said,

    I was very surprised after reading the article on “don’t prescribe pain medication and benzo’s to new patients.” My surprise came with the example that was given. It was a pretty major assumption to suppose that the elderly woman was an opiate seeking addict. I would not want a GP that jumped to such conclusions without any factual evidence of such. The elderly rarely run to their Doctor when an issue arises because of the expense, same goes for prescriptions. Regardless of the other issues she may have, financially she may not be able to cover the costs they will bring. Perhaps the pain relief she was given was, in her mind, enough. Just because she didn’t come back does not mean she is addicted to opiates or you were duped. Also factoring in the nationality differences, it is unclear if she even understands the true nature of her issues. Being from another country, and being elderly…makes her economic mindset even more of an issue. There could be a number of reasons for the prior Doctor issue. I realize there is a large issue of abuse ongoing but GP’s still have to recognize that not everyone is out to dupe them, and sometimes they are explanations for not following up as requested, especially with the elderly, or even those with issues that overwhelm their lives, yet still suffer from chronic pain.

    • Michael Tam said,

      Thank you for your comments Eire but may I suggest that you read the continuing discussion in the comments of that article. On investigation after her non-attendance she had in fact received a huge quantity of opiates from numerous prescribers in a pattern that can only be explained by diversion.

      As per that article, the best stance to take is to not prescribe strong opioid analgesics or benzodiazepines to new patients to the practice if they are specifically requested. Patients who are on either agents long term will already have an arrangement with one prescriber. The onus is on the patient to demonstrate that their regular prescriber is happy for you, the new treating physician, to supply their regular prescription. If their regular prescriber is going on leave or is otherwise unavailable, the continuing management of their chronic pain will almost certainly be planned.

      It should also be noted the requirements under NSW law. It is illegal to prescribe drugs of addiction (specifically S8 drugs like strong opiates) to people with drug dependence without the prior approval of NSW Health.

      Chronic pain is difficult to manage and yes, many patients are under-treated. Nevertheless, acknowledgement must be made to the serious problem of diversion of prescription medications as well as the risk of medication dependence. No one likes the idea that we are potentially leaving patients in pain but this must be balanced by the reality that strong opioid analgesics in themselves are not effective therapy for chronic pain and prescribing opiates to people with drug dependence is harmful. The requirements for patients to receive regular strong opiates and benzodiazepines in the Australian system is that they must engage with a single prescriber.

    • LouLou said,

      Can I add: basic antibiotic advice for week 1 internship, to the wish list?

      Thanks for your site, the fluids section is brilliant!


    • Allan Harrison said,

      No one really knows maybe the patient died , without evidence it’s so easy to judge people… its sad that its that way. Its the real people that suffer Chronic disabling pain that pay for the cheats. Thank you.

  21. Marcia Burtt said,

    As a non-health professional, after spending some time online trying to understand coumadin-heparin bridging, I was thrilled and grateful to read your clear explanations.

    What is still not clear to me is the difference between how coumadin prevents clotting as opposed to how heparin prevents it. I gather they function differently.

    If coumadin takes 4 days or so to take effect, why can’t it be restarted the day before surgery?

    • Michael Tam said,

      Dear Marcia,

      The summary on coagulation in Wikipedia is actually pretty good:

      The coagulation cascade is a rather complicated system. Heparin and warfarin affect different parts of that system.

      With regards to warfarin and surgery, remember that not all surgery goes to plan and bleeding complications are not uncommon. Furthermore, it isn’t that warfarin takes “4 or so days to take effect” but rather, it takes that time before you reach near its full effect for the dose. For any major surgery, it would be safer to use a quick/short acting and easily reversible anticoagulant during the period of surgery.

  22. Michael Tam said,

    Dear tim D.,

    I moved your comment here.

  23. Jun Camero said,


    I am a great fan of your work. Do you have any articles on how to work out the different types of insulin (basically diabetes management) in the ward? Been searching your site and could not find one.

    Thanks in advance.

  24. Jeremy Edwards said,

    Hi Mr Tam.
    I was researching something for a friend and I came across your article ” How to change antidepressants” I need to ask you a question. My friend has been on prescription Paxil for chronic major depression. The medication is being supplied by pharmacies throughout the country (Trinidad & Tobago) via a program initiated by the Government called Chronic Disease Assistance Program (CDAP) whereby free medication is prescribed and given to chronic patients requiring such assistance. As such you literally have to take what you get. For the period that my friend has been a participant in this program, the suppliers have changed the brand/type of drug given on numerous times for various reasons (cost, availability etc.) What I was researching is whether or not this constant change of brand can have some negative physical effect or otherwise on the patient. Your article states that change in brand must allow for washout periods etc. Does this mean that while the patient is going through this period and he/she is not on any type of antidepressant that they may have some sort of withdrawal symptom or relapse into depression? If yes then is it therefore inadvisable to have to change prescription antidepressants on such a regular basis? Is there any serious psychological/mental threat from such activity?
    What would you therefore advise not only to the patient but to the Regional Health Authorities and Ministry of Health and all persons responsible in the implementation and maintenance of this program?
    Looking forward to a swift reply.
    Yours sincerely,
    Jeremy Edwards.

    • Michael Tam said,

      If the changes in medication brand are due to use of generic medications (of the same drug) from different companies, then there shouldn’t be an issue.

      If the changes in medications are resulting in completely different antidepressants (or changes in doses), then yes, there is a problem. It would be inadvisable to regularly change medications in this fashion as you are exposing someone to all the potential side-effects of the different agents with no benefit.

      With regards to advice from a health policy perspective, it would be prudent to limit the pharmacopoeia to just a small number of older and cheaper agents (e.g., fluoxetine and sertraline) but for the supply of these agents to be reliable.


      • Jeremy Edwards said,

        Thanks for your prompt response Mr. Tam.
        She has been switched from Cipramil to Effexor and now Paxil because the drugs are either late or being discontinued by distributors. She chose to change from Effexor because it was not “agreeable” to her. Does this then qualify not as changing generic forms of the same drug but switching antidepressants completely? (I would think so.)
        Warmest Regards.

  25. Michael Tam said,

    Yes, it would appear that in your description that the antidepressants have been changed completely. This would not be recommended practice.

  26. Dr. ABBAS Adeel said,

    Thank you M.Tam for very good knowledge. I am appearing in exam and needed to know about management of patient pre-op who is on warfarin therapy…. Thanks again…

  27. Wei Shi said,

    Hi Michael,

    I am an intern with Family Planning NSW and have been tasked with updating google search items. I chanced upon one of the factsheets you placed on your website (on chlamydia)

    Click to access fpa-chlamydia.pdf

    Just to let you know, FPA Health has since been renamed Family Planning NSW.

    Do have a look, there are many useful and informative resources that you may want to use.

    Wei Shi

  28. boz brooks said,

    Excellent information. Simpley and clearly presented.
    Does a person served with a NSW Community Counselling Order by the Tribunal have the right to make legally binding contracts. My son, 30, and his partner were about to borrow money to purchase a cottage. My son has had a recurrance of mental illness, is in hospital. We think a CCO to encourage him to visit case worker/counsellor regularly will help keep him well. He always takes his medication. How would a CCT affect his right to enter into a contract?
    Thank you

  29. Claire said,

    I read your article on oral rehydration protocol and you mentioned a study in the hospital in canterbury 2002-2003 , I was wondering if you could provide the full reference for me please. I am designing a trial of oral fluids protocol for my dissertation
    Thanks claire

  30. Dr. Smriti Shakya said,

    I am a doctor working as a medical officer in Kathmandu, Nepal. I went through your articles and found them to be very effective and productive as well. I found them very useful. So, I would like to request you to please kindly post the articles relating to the fluid management in hospital admitted non-operated patients eg. I mean. patients kept in ventilators because of critical illness, critical patients not being able to feed. How to manage the fluid according to replenishment of deficit and then maintenance? Hope to see your next article very soon.
    Dr. Smriti Shakya

  31. Dr. Barta Adrienn said,

    Dear Dr. Tam,
    I am a dentist from Hungary, teaching at the Medical University of Budapest, Faculty of dentistry, Department of Orthodontics and Pediatric dentistry. I have read your article about “Physical examination begins with the hands” and I like it very much. Now we are writing a book for the hungarian students and one of my topic is the “anamnesis and clinical general and dental examination of a child” You have a very good picture in your article about the cyanotic nails and club finger and I would like to ask you to allow me to use this picture in our new book.
    Thank you for you answer in advance and I wish you all the best! I like Medicine Box although I am a dentist.
    Dr. Adrienn Barta DMD, PhD, assoc prof

  32. Ravindra said,

    I am 1st year general surgery postgraduate, Please suggest me
    some books regarding
    *post operative fluid management
    *suturing skills
    *standard general surgery book for postgraduates

  33. Ravindra said,

    sir, can i get live general surgeries anywhere(not laparoscopic)

  34. Who do I contact to get the proper dosage of coumadin…that is, if it’s dangerous to take 5 days consecutively of 5mg and then the 6tth with 2.5; then starting back the 7th with 5mg again?

  35. Would like an answer to my question above as soon as posible since I was told that it could be wrong to use the dosage above. Thank you

  36. MW said,

    how about using half normal saline instead of rotating NS and 1/4 NS?

  37. Wedad Salem said,

    Great website and great resources, thank you very much

  38. QueenOf6Hearts said,

    Hi, im in my second semester of PA school and we recently finished pulmonary section. I used your site to learn about the steps in treating asthma. It’s so organized! it saved me a lot of time. thank you so much for your time and effort. I totally appreciate you!!

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