Welcome to my blog

Dear Colleagues,

I have been working as a Palliative Care physician over a decade (in the UK and now, in rural NW-Tasmania).

I have been working with the small community based palliative care team to cover 25,000 square km area!  Working in the rural palliative care is a ‘challenge’ and a new experience!

  • There are unmet palliative care needs in terms of access to the widely dispersed population in NW Tasmania.
  • This rural population is mostly supported by GPs & Community nurses.

This Blog is created to support my rural primary health care colleagues !



  1. To develop a strong palliative care understanding / foundation, through education to rural NW Tasmania.
  2. To disseminate / share my understandings & experiences with rest of the world.




6 thoughts on “Welcome to my blog

  1. Dear Dr. Thiru’s,
    I was doing search on the net looking for presentations about MBO, I am really impressed by the nice presentation that you posted on the net.
    I have a kind of symposium where I will give lecture obout MBO, to a group of GP’s and Nurses, can you kindly give me a permission to use your nice slides about MBO in my lecture.
    Please advice.
    Best Regards.
    Dr. Mahmoud Anbarserri
    Riyadh , Sausdi Arabia
    mobile: +966504593922
    emaill: anbarserri@hotmail.com

    • Dear Dr Mohamoud Anbarserri,

      Thank you for your mail. Please use it for your lecture
      Let me know if you need my original power point slides
      Dr Thiru

  2. I have spent many hours reading your blogs Dr Thiru, great reading and a big learning curve for me as an early career nurse. Thankyou for the time you have spent putting this information together. Regards luke

  3. Hello Dr Thiru Thirukkumaran,
    I am a patient of yours.
    Vascular Degenerative Disease factor 5 liaden
    The Methadone you have recently prescribed to me for control of pain. Is making me sick and constipated . I have stopped taking it.
    I was wondering would or could it be worth looking into medical marijuana for the pain, as a lot if other medication does the same. Or look into something else that may work for me.
    I don’t mind this being public but I couldn’t find your private email.
    Thanks for your time

    • Dear Michelle,
      I can’t talk about my patient’s history & examination findings in public. (Even though, you don’t mind). But this is a good topic to discuss in general for all…
      First of all, I don’t mind trying anything for my patients to improve their comfort; but the medication should be safe to use… I practice evidence-based medicine…

      When we prescribe pain medications, we consider many factors. Because every individual is different….. with the combination of their associated medical conditions, allergies & hypersensitivities, their oral medication absorption….. and so on!

      I look at the followings, before suggesting any medications:
       Other ongoing medical problems & the severity of those conditions
       Their drug allergies & hypersensitivities
       Particular group medications’ side effects in the past/present
       Drug tolerability if he/she has been using it / used it before
       Oral routine absorption issues
       Medication cost

      In my experience, ischemic pain is difficult to manage. This pain is due to poor blood supply (blood vessel narrowing or block) example: Heart attack

      You have to look at this problem carefully…..… Due to the poor blood supply, part of the body (live) cells/tissues developed Hypoxia (poor oxygen consumption). What happens if you not giving water and nutrient to a plant….?

      In human body, when we get a complete block in a blood vessel, whatever the part supplied by that blood vessel will die after some time ( example: when someone get heart attack and not treated within the time, depending on the place of block (main coronary artery or small branch) either patient may die or may suffer permanent damage in his/her heart.

      On the other hand, if the blood vessels are narrowed due to certain on-going vascular disease or previous surgery, the live cells (supplied by that particular blood vessel) will experience constant ischemic pain… with the lack of oxygen…!

      There is no “one magic pain medication” (including medical marijuana) will cure the ischemia fully (due to the nature of ischemic pain) except anaesthesia – In other words, switching off the brain..! Remember…. Pain is a feeling (like hungry); pain experienced by the brain, not by the affected part

      In my evidence-based experience….., I find that trying a few types of medications together can reduce the ischemic pain intensity from ‘severe’ to ‘bearable’ state…….
       Neuropathic agent (Lyrica / TCAs / Ketamine) + NSAID + Opioid +/- Topical anaesthetic patch or cream

      Again, these regimes may vary to every individual –
       If… one has significant Gut Bleeding risk, I may avoid NSAID  may cause further bleeding
       If someone has inflammatory bowel disease ( Crohn’s disease or Ulcerative Colitis), I will be cautious with any opioids  titration of opioids may lead to narcotic bowel syndrome
       Sometimes different route (subcutaneous than oral) may help to improve the pain

      I don’t want to talk about your case in this open page. If you have any questions… please ask me in our next review

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