CARPAL TUNNEL SYNDROME

There are times in my career that I hesitated in the operating room; whether to do further surgery or be conservative. And this is one of them.
A patient who drifted in the high seas for 3 days after their boat capsized during the HURRICANE PABLO which devastated Mindanao sustained contusion of his left hand. This became swollen and the fingertips darkened. He was in pain while drifting holding on to a small wooden flank. He was picked up by another boat barely surviving with other multiple body injuries. When he was brought to the shores of General Santos, attention of the doctors were focused  in reviving him by placing him in the ICU. His hand was misdiagnosed as an ordinary swelling. He was always severely in pain and complained about his hand. Nothing was done to it. The family decided to transfer him to Davao for further treatment.
When I received him, his index-middle-ring and small digits were black on the tips with severely swollen phalanges. The swelling also involved the palm and the dorsum of the hand.
He was in a late stage of CARPAL TUNNEL SYNDROME; severe constriction of the middle nerve and venous system of the hand.
The patient wanted me to cut the tips of the fingers. I explained to him that that is not the main problem right now. He was losing the whole hand. I wanted to do FASCIOTOMY; cutting the fascia of the hand to relieve the compartmentalization. But in the back of my mind, I wanted to do what the patient wanted me to do.
After doing FASCIOTOMY, I argued with myself whether to proceed with the finger amputations or not. But I was sure, the amputation stumps will not heal because the phalanges were so swollen. Despite the wish of the patient, I did not amputate. I went out of the operating room and came back several times not knowing whether my decision was right or not.
The next day was a cliff hanger for me. I made my rounds and the first thing that I asked the patient was: is it still painful. The patient was smiling and told me he had a good night sleep the only one since the HURRICANE.  

RESULT OF SELF MEDICATING

 I have been vocal against self medicating and the use of herbal medicines since 2004 especially those being applied on wounds. This is the result of MX3 placed directly on the wound. This was once a small scratch but because the patient listened to the radio and her neighbors, this resulted to a large gaping wound nonhealing for more than 2 months now. The wound does not epithelialized ( form new skin) because the MX3 killed and burned the new skin being produced by the body every day. A scub is forming on the rim of the wound preventing further migration of the new skin into the center the wound. Wounds heal by forming subcutaneous tissue inside the wound and it is covered by new skin from the periphery. If something is preventing the skin's migration, the wound does not heal. Nothing stimulates fast growth/migration of the skin. Absolutely nothing. Take it from me and my 31 years of experience as a surgeon. Facilitate the skin formation and you will have wound healing. 

FRACTURE OF THE PUBIC RAMUS

An 11 yr old boy was hit by a van and thrown 4 meters away hitting his right side. The only physical signs of trauma were multiple abrasions on the face and right shoulder and a contusion-hematoma ( bruise) on the right flank. On xray, there was fracture on the right ramus of the pelvis similar to this xray picture from the Department of Health Gov of Australia

Sorry, guys, I forgot to upload the xrays of this boy. But, this is just to show how trauma may affect everything in a human person's body. The trauma was on the right but the fracture was found on the left rami of the pelvis. I could not find any reason why.
The moral lesson is, if your doctor examining you suspects something, urge him to suspect everything.

POVIDONE IODINE

Time and again I have proven that povidone iodine placed on a wound will delay healing. It forms a hardened scab over the wound accumulating pus, preventing proliferation and growth of new tissue and even killing it and forming a big crater of a non-healing wound.
I have stopped using povidone iodine solution on wound dressing since 1986 right after I noticed that it takes time for the wound to dry up even ordinary abrasions sustained by patients who figured in a vehicular accident.
I have seen with my own eyes under a microscope how povidone iodine dehydrates skin cells and kills them the way it kills bacteria.It is good for preoperative skin preparation but not for fresh wounds and dressing.
But until now nobody seems to know about it. IN all emergency rooms in any hospital here in the Philippines, povidone iodine is the routine dressing solution. Soap and water are forgotten; the right solutions for wounds.

PROFESSIONAL FEES

In these years of medical insurance coverage and MEDICARE (PHIC here in the Phil), medical professional fees are pegged on value units and whatever coverage these insurances pay ( on what protocol I don't know). But we always feel that these payments are not enough for the risk of our decisions when we treat patients. IN fact, we feel that our decision making is priceless.
     IN the years before these value units were instituted, we charged patients based on how much risk our profession was exposed in the  treatment decision making. I am talking about surgical cases. Most people find these professional fees exorbitant. I have never encountered a patient who said that the professional fees of other surgeons were just enough. My professional fees were often gratis and if ever they pay, the money is just enough for my daily needs.
   How much really is the risk of our profession when we do surgery? Foremost we are subject to the satisfaction of the patient. The less we explain, the more likely the patient will sue. And if people around the patient starts to bile the work of the surgeon because somebody they know had this and that though not a single patient is exactly the same as another, the patient will likely to question the work of  his surgeon. Even if the outcome is perfect ( to me as a surgeon), the patient will likely find the reason to ridicule the handiwork of his/her surgeon.Not fair of course but not all patients are like this. I had a lot of patients who go home with a mile of smile

74 yr old with a breast mass

A very active 74 yr old woman developed breast masses on both  sides.She had a history of excision of a breast mass 10 years ago and turned out to be fibrocystic. This time, she wanted them removed though I suggested a fine needle aspiration biopsy; less trauma, clinic procedure, less expense. But she rather would have them gone instead of thinking about them for the rest of her life if they turn out to be benign. But cardiopulmonary clearance prevented the procedure to be done under general anesthesia. I opted for local anesthesia which she dreaded because of the trauma she experienced in the previous surgery. My anesthesiologist would not like to use neurolept anesthesia because of her age. So, I have to be contented with diazepam plus lidocaine.
Everything turned out to be uneventful and finished the surgery on both sides of the breast in 40 minutes; 20 minutes on each side.
This always reminds me of the show :NAME THAT TUNE"......I can guest it in 2 notes.

HINDU GODDESS

In my role as a personal-family physician, I sometimes take the role of a Hindu goddess with multiple hands and arms and multiple faces.
Some patients would not like me to divulge whatever my medical findings are to the patient. I face the relatives with grim face in serious cases while I smile to the patient while discussing the case. Though I always insist of letting the patient know, some relatives fear that divulging his real situation would aggravate and lead to early death which is not often the case.
Some people expect us to perform surgery in different locations at the same time or to finish pronto in a wink. We haven't finished injecting anesthesia and they would ask:" Are you done?"
During surgical residency, some consultants expect us to hold the retractors steady while suctioning the blood and holding their sutures tout. . In other times, they would expect us to answer  all questions right while retracting the liver away,; the intestines to the left and below and the gall bladder up.
Oh! How we wished to have all the arms and hands of the Hindu Goddess.

DC HERALD

I am starting to write a column in a local newspaper DC HERALD; a Catholic weekly newspaper circulated among church goers every Sunday. It is a compulsory reading for Catholics here in Davao City. With a circulation of about 2000, this could be a good spring board for my marketing.
Ever since I became a doctor I have been marketing myself with the use of leaflets, radio, writing a news column, television and Internet.  I was involved with so many free clinics and free surgical programs just to market my practice. This was because I read Steven Covey's books and was convinced that even medical practice need marketing to survive. He was right. If not for my marketing, I could not have survived with so many doctors in our city.
My computer had been busy the past two weeks making marketing letters. All marketing gurus I have known including Suzi Orman have been saying not to sit on our laurels. We have to be on our feet most of the time innovating ourselves following the trend of the time. That is what I have been doing to this day until I drop dead.

TUBERCULOSIS OF THE SPINE

In this age of enlightenment ( think  Google, Ipad, cable), we should not have any tuberculosis of the bone much more tb of the spine. The last time I diagnosed one was 5 years ago. But lo and behold, I saw one yesterday with a partial destruction of his spinal vertebra at the thoracic level. And he has no symptoms except marked lost of weight. He claims he really does not know where the disease came from since he never knew of anybody having the disease coming near him. The sad fact is most of these people are resistant to anti-tb drugs. I started him on regular medicines plus an injection and cross my finger.

SEQUELA OF steroid injection for scorpion bite

Just as I have foreseen, the patient who was injected with steroids for scorpion bite developed facial edema and generalized mild bloating in the upper and lower extremities. The hand where incision and drainage was done drained out pus up to yesterday. But the hand has markedly diminished in size except the fingers.  I have seen scorpion bites where the whole surrounding skin sloughed off. What remained was bare ligaments and tissues. This entailed skin grafting and more expenses to the patient. Good that this patient did not have that. They had difficulty in going home because they paid a lot for the hospitalization including medicines.
While managing this patient, I came up with the idea why not develop a RETAINERSHIP PROGRAM where at Php50 per employee per month, the employees of the company could have free consultation together with their first degree relatives. I would charge PHIC coverage only (medicare ion the States) and no extra in the professional fees including surgical procedures. Most health insurance in the Philippines charge each member hand and foot ( about 1/8 of their take home salaries). And they block any coverage on preexisting diseases which are most often the complain of these people. They seldom get sick and if ever, what they spend in the hospital for medicines and daily room rates do not consume the usual annual fees of these HMO'S. The Philippines Health Insurance Corp covers room and 1/3 of surgical procedures with a minimal fee to the physician/surgeon which is good enough if we don't change our cars yearly. PHIC covers a very minimal amount on medicines. That is why, this is the main  problem of employees when they get admitted. I was thinking what if I facilitate credit account for them in accredited pharmacies where they can charge their medicines and pay for them in small amounts ( monthly salary deductions for instance). A pharmacy I know would readily agree with this arrangement because it is a captured market and they would be assured of payment because the companies where these employees work will see to that.  What do you think?

BOUNDARIES OF SPECIALTY

Whose specialty is this? Plastic surgeon, ophthalmologist, dermatologists, general surgeon? Some people would even claim that this is  for oncologist or radiologist not to mention the HEAD AND NECK SPCIALIST and the ENT. Confused? So am I. What did I do?
I cauterized it and excised the base of the wart. Yes, it is only wart and if you go to a doctor who do not think of expense for your sake, he will do biopsy first. Wait for the result. And then, do z-plasty excision if he is a plastic surgeon. Or for ENT man, he will do V-EXCISION. Or if he is opthalmologist, I don't know what he will do with it.
IN this era of specialists and subspecialists, we get confused where to go or to refer and this adds expense to the patient. For me, if I can do it and if I believe that I can do better, I will do it for the sake of the patient.

SCORPION BITE SEQUELA

5 days after bitten with a scorpion on the hand, the patient's hand swelled despite the steroids given intravenous and subcutaneous direct to the site of the bite. The fingertips became pale signifying ischemia due  to the pressure created by the swelling. On examination, the dorsum of his hand was fluctuant signifying accumulation of fluid. This prompted me to aspirate the hand with a 10cc syringe. Lo and behold, the aspirate was pus. The patient confessed that he punctured his hand on his own using a needle thinking that he could be a surgeon on his own body. The scorpion bite became infected. In my past cases, scorpion bites produce a fluid filled vesicle which were clear and non-turbid. Definitely he needed incision and drainage. I did it this morning and extracted about a 100 cc of pus.
Moral lesson: let us surgeons do the management. You can never treat yourself.

QUESTIONING DOCTORS ADVICE

Have you ever thought of contradicting doctors' prescription and advice? Dangerous but there are some things we say that are not rational. For instance not eating meat for those who are hypertensive. But you were eating meat ever since you were born. Why would it be dangerous to eat them now? If you read medical and fad books on diet, meat is the only major source of protein. It could never be substituted by any other form. Besides, is there a study showing that meat aggravates HYPERTENSION? Yes it increases cholesterol; the cholesterol that is floating in your arteries and veins. But the meat you ate this morning could not increase your blood pressure because the cholesterol responsible for it was taken 20-25 years ago. It will affect your blood pressure 5 to 10 years from now when it deposits in your vascular system. If you take it from your diet, there is no way the body could replenish the fat based vitamins and the cholesterol necessary to produce hormones.  

SCORPION BITE FOLLOW UP

I saw the patient this morning. He received 2 injections of SOLU-CORTEF yesterday afternoon; 1 intravenous and the other given subcutaneous near the bite wound. I was horrified when I saw him. The hand was darker; more bloated. The fingers are more pale than yesterday. In other words, the steroid was not working. But the patient insisted that the swelling has diminished in size. The pain has subsided and there was no numbness on the tips of the fingers signifying CARPAL TUNNEL SYNDROME or the impingement of  the nerve passing thru the wrist. The treatment was working but the doctor cannot see the difference or the effect of his management.
In here, you can see the importance of communication and rapport between the patient and the doctor. If I did not believe my patient, I would insist surgery; open up the hand to release the pressure. But I believed him and he believed in what I was doing. 

SCORPION BITE

If you have watched SKYFALL where Bond is playing with a scorpion, you would think it was cool . Wait till you will have a bite too. The pain is so excruciating very difficult to relieve with ordinary pain relievers. There is a burning sensation inside the tissues and the pain shoots into other parts of the body. Then, the bite site swells double the size of the affected area and starts to darken.  A vesicle forms and in 24 hours, this bursts and leaves a large raw weeping area. It does not heal until the venom disappears  and will need skin grafting to cover the wound. If the affected area is the upper extremity, amputation is more likely.
Anti venom injections are not available in many third world countries where the incidence of scorpion bite is more prevalent.  What we do is to inject steroids to mask the effect of the venom. It is the only medical armamentarium we have. 

MULTIPLE SURGERIES

In my 31 years of practice, I have encountered a lot of patients who have had  multiple surgeries: breast, gall bladder, thyroid, appendectomy. And the most often questioned asked is would they survive another surgery. Of course, Most people who undergo the first surgery find the experience  nerve wracking. But the next surgeries these patients breezed thru without question. They found the procedure a necessity and a must for survival. Some patients leave their destiny to fate; que sera, sera; what will be will be as the song goes.
But others would resist the surgery and would come back late for it. They cannot survive the procedure if done. No matter how uneventful the first surgery was, they still find the new procedure nerve wracking again.

PROBLEMATIC PATIENT

 I have this patient who had been coming to the clinic for the last 10 years. She lost her husband at the age 35 and never married again. She started to become a hypochondriac soon after becoming a widow. She had no outlet nor a single friend to talk to, Her children live in different locations but occasionally visits her. She cannot go along with her mother nor anybody else. She developed Colloid GOITER 3 years ago and after several laboratory tests, I started her on goiter medicines. After 2 years of treatment, the goiter persistently enlarged and she opted to have surgery.
She became more problematic after surgery. She became psychologically unstable bordering schizo and depression.  And she does not take the medications I am prescribing her. I urged her to see a psychiatrist, endocrinologist and whatever doctor she could find. What do you do with a patient like this?

GOT SOME FRIENDS TOO

After a long tenure in a foreign country, a husband came home and found his wife pregnant
" I am sure you didn't have a virgin birth since no one followed Jesus Christ. You never wanted artificial insemination because you said you cannot be sure who the father would be and you would like to enjoy making the baby. Who among my friends got you pregnant, Frank, Cris, Harry?"

The wife retorted: " I've got some friends, too."

FARTING IS SUCH A GREAT SORROW

You try to keep it to yourself but it comes out on its own no matter who you are with. It does not follow decorum nor does it have any diplomatic protocol. Once it is out, it announce its presence to everybody no matter what. If the FBI and the CIA  have secrets, the fart is exactly their opposite. It does not have any secret at all.
You cannot prevent its formation just as we cannot do anything with the weather. Yes we know there are signs of its coming. Not written in the Bible of course, but what we have eaten previously is the de facto precursors and the messenger of its coming like John the Baptist.
When it comes, it comes no matter who you are. Deodorants,  anal plugs, sanitizers and atomic bombs do not prevent its coming. Some may come with silencers but otherwise they come with bravura exhaust pipes and Lamborgini howitzers.
Some jokers employ or mask its coming with hits like "this ugly rats" and "damn dog farting ". They don't make any. Well, Eddie Murphy made a killing on farting.
So, what do you do when you accidentally release a fart? Pretend its not yours? Prevent yourself tilting on one side to allow its escape undetected? Or you just simply smile and make yourself the subject of the joke. hahahahaha

SPARE SOME FOR SEX

A patient was being wheeled into the operating room suite with the doctor on her side. She was to undergo MODIFIED RADICAL MASTECTOMY or the removal of her entire breast for cancer. Before the team could enter the sterile room, her Chinese husband came rushing breathless and pulled the doctor over the side and murmured:
"Please, Doc, can I ask a favor before you do the surgery?"
" What is it, retorted the doctor, " I am in a hurry."
"Can you spare some of her breast for sex?

WARTS

Whose specialty is wart removal? If they are small as a pin head, the dermatologist takes care of them.When they grow more than 1 mm, they are referred to the surgeon for excision. If they are more than 2 cm and darkens in color, they are seen by the plastic surgeon. If they are more than 5cm, they are referred to reconstructive surgery. If one specialty rules over all sizes, he/she will be questioned of unethical practice. What does the patient do? She goes to a non-medical cosmetologist. hahahahaha

TAIL OF SPENCE

What carabao is this? This is a part of the breast that extends up to the armpit in some women. During lactation and in some cases during pregnancy, this enlarges and will show as a mass below the axilla. Oftentimes, this is mistaken for  a tumor and monkeyed for a biopsy. If your doctor is not aware of this, a total excision will be done for no reason. As a patient, you will be worried if you are not oriented about this. 

ACUTE ABDOMEN

Before the advent of subspecialties in the 80's, our main concern in evaluating patients was whether the patient needs surgery or not. We do not worry whether it is general surgeon's case, a gynecolgist's, a urologist,, a neurosurgeon's problem or biliary surgeon's expertise.  As a surgeon, we determine whether it is an acute abdomen or not; whether we need to do surgery or not. Today, we are given the task and a narrow path to thread whether it is ours or not. As often the case, we general surgeons open the abdomen and peep inside. And if it is in our field of expertise, we finish the job to be done. If it is not ours, the patient is referred to another specialty and the let the patient wait for several hours under anesthesia. We know how to do it. But we do not like to be confronted in the conference room for doing a job not under our field of responsibility.

MOTORCYCLE DEATHS

 The incidents of motorcycle deaths in the Philippines  are rising. So, it is too in countries where it is the major mode of transmission. Affordable and easy credit for low income people. The problem lies not on the motorcycle but the people who use them. They become kings of the road and lord it over bigger vehicles. They think they are invincible with the helmet on. Most vehicular accidents are due to reckless driving and alcohol.  Good if they die instantly. They don't. They consume all the finances of the family and the government institutions where they go.  Is there any solution out there?

CONTRACEPTIVE METHOD

I was in a free clinic program where I had to face a lot of patients not my especialty. One woman who had 7 children one after the other was assigned  to me for breast examination.  After several questions pertaining to her breast mass like how old was the youngest; when was the last menstruation and so on, we came to the questions why she had a lot of children. Didn't she used contraceptive methods like pills, IUD, depot injectons. Her response was:
" Well, to be frank with you doc, I only use the penis of my husband."

HIGH CREATININE

Many people think that renal/kidney failure  is an acute disease or the effect is immediate. Most people do not know that symptoms like body malaise and weakness are signs of kidney failure. If you are diabetic or suffering from a serious condition like HYPERTENSION, the most likely end point is kidney failure.
Now, this does not come in where the patient collapses or would show facial edema right away. The first symptom he/she would feel is the inability to climb stairs or to walk a distance he usually is capable of. I have seen this in so many patients that it is the first question I wold ask if a patient has DIABETES OR HYPERTENSION  in line with the surgical procedure I would do later on.
I once was forced to do an operation on a uremic patient  ( kidney failure patient) and it was really frightening because the bleeding was uncontrollable. The wound was oozing all over  and I had to remove a tumor the size of a baby's hand with the blood covering the operative site.

PATIENT OVERLOAD

There are days when there are so many patients to see and little time to relax. And this would cause me to wish for more breaks. I even have days when I wish I could refuse to go to the clinic. But this is not so. Yesterday was the worst time of my professional life. I started to have flu with colds and fever with body malaise. Everybody gets sick of flu including us doctors. I played golf in the early morning thinking that I could bear the disease. But after playing, I was starting to get weak. I thought I won't have so much patients to see in the clinic and could relax for the day. I was mistaken. The clinic was full of people and most of them were surgical. I had to do a very extensive dressing on a diabetic patient. The minute I finished everyone, I was so exhausted to drive home. I did not like to eat but the wife insisted to take my meal. I hit the sack like a falling timber.

HYPOCHONDRIACS

I had my share of patients who were hypochondriacs. They usually start by pin pointing  a lot of pains and aches on their bodies . I usually don't know where to start. If a patient does not follow the protocol that we learned in medical school, we will be at a lost.  For example, a patient complains of headache that radiates to the foot, it does not follow any disease algorithm. Either he has a problem in the head or he has a problem in the foot. Two diseases are plaguing the patient. If he adds another symptom, for instance, pain the neck, this will add to the confusion. What if there are 10 pain areas that he is complaining, we will get crazy and this makes us think that the patient is a hypochondriac and he ills a lot.  Because we are not in the position to argue and tell the patient to follow the protocol ( of course), we ask him to undergo a lot of diagnostics. When the results come in and they are all normal, most the time, this will add more to the paranoia of the patient. The question they usually post is why are all his lab results normal when he can feel a lot of pains. When we start telling the patient that he never had any problem, this will lead to a severe exchange of words leading to quarrels and confusion.
I have not fallen to this problem again after I decided to face a hypochondriac patient head on. The moment I can sense that his history is going nowhere, I usually deliver my cards face-up and tell him that nothing is wrong with him.

X-RAY FAILURES

If your doctor completely relies on diagnostic and laboratory exams to make a diagnosis and fails to examine you thoroughly, he is bound to make mistakes. There are so many diseases that could never be detected by these doctor's tools.  Appendicitis is one. It is diagnosed by the physical examination of your doctor and complete blood count is a mere 20% of his decision making. Ultrasound can not confirm Acute appendicitis nor an x-ray for that matter.
Fractures of the ribs especially those that occur in the COSTOPHRENIC ANGLE cannot be seen by x-ray. If your doctor did not examine you very well by palpation and auscultation and rely only by the x-ray film, he will miss it. You feeling the pain cannot accept that there is nothing wrong with you. The doctor will always say that there is nothing wrong with you because he cannot see it on xray. You end up disappointed and angry because modern medicine has failed you. No, not modern medicine but your doctor was relying so much on technology. If your doctor did his job as he studied, you won't spend so much for an xray and may be dispensed from spending for it. If your doctor does not do a thorough exam on you, change him.

KNOWS ME BUT CAN'T SAY MY NAME

My friend of 20 years was admitted to the hospital yesterday. He is 50 years old but as if we knew each other all our lives. We are close on a first name basis. But yesterday, he cannot say my name. He just stares at me and would mumble that he is good; he can take this and many other words people who do not know each other say when they meet after a nod and a hello. On CATSCAN, nothing was wrong with his brain nor did he have any sign of paralysis signifying that he had a stroke. His family was so worried that he cannot even say the names of his children and wife. But if you keep pestering him to recognize you, he gets angry meaning he knows us but cannot just say our names. APHASIA is the term for this.
Together with a neurologist  we started brain medications. 6 hours after, he cannot move his right  arm and right leg. STROKE. I saw him at an earlier stage. Well, we cannot do anything else but physiotherapy. He was a chain smoker, fat and always stressed out.

PERSONAL PROTOCOL

In my 31 years of medical practice, I learned not to force an issue. If the patient is not willing to compromise whether it be in his treatment mode ; the period of convalescence; or the financial aspect of the surgical procedure, I let go and ask him/her for a second opinion ( euphemism to go find another doctor). Medical science is not an exact science. There are things we cannot control and the variables are so numerous. They can turn against the patient or against the doctor and most often it will be the seed for misunderstanding between the two parties. I am a patient man and am very meticulous in explaining the situation. I do not leave anything for granted. Sometimes the explanation is longer than the procedure. That is why some patients become disgruntled when they go to other doctors because they do not find this kind of service. I am a talker and I love to say everything I need to say. The success of my radio program for 5 years attest to that. 

CAN YOU TELL THE DIFFERENCE

As a layman, can you see the difference between this two xrays? If you can, anybody can be teachable to know medicine and what doctors know routinely.
What prods me to teach non-doctors  what we routinely know is the fact that most people play doctor in their lives almost everyday.  They suggest medicines for illnesses even though their personal experience of the drug does not apply to everybody. They insist that the the medicines they are taking is  good for others as it is with them. They self medicate and think they know better than their doctors. They take herbal drugs and those tablets with a caption: NO THERAPEUTIC CLAIMS.  HAHAHAHAHA.
This is an xray  of a patient , 28 yr old,  who was complaining of chest pain and back pains. NO difficulty of breathing. No shortness of breath ( This is different if you know medicine). He was up and about doing his routine chores even play basketball but was urged by his mother to see me because he was getting thinner and was losing weight ( again this is different if you know medicine).
On auscultation ( using the stethoscope which people think is passe because there is x-ray) I  heard a big difference of the entry of the sound between the two lungs on inspiration.  On his left lung there was a sharp flow of air ( bronchophony) while on his right lung the flow of air was muffled; a sign that there is an obstruction of the flow of air  on the right.  If I were a lazy doctor, I would send him to the radiology department without auscultation and wait for the result to come out  in the afternoon.  But I did auscultation. So, I send him to the operating room pronto and did a CHEST TUBE THORACOSTOMY in an hour's time. This is an insertion of a tube direct inside the lungs to drain the water . The white part of the right lung of the above x-ray is water. I saved the patient 4 days of hospitalization and medicines not counting his downtime all because I did auscultation and was not found wanting in my practice.
Now, I am trying to teach people this way. The fact is, you may have heard or seen on tv why a disease is like this and why a disease is like that and the medications that they take. But this does not amount to anything. Each person is unique and drugs and medicine has to be instituted by a doctor. 

HEPATITIS B

Consider this:

Hepatitis B is blood borne and can only be transmitted thru body secretions like saliva, mucus, sweat, sex and blood transfusion. In several thousand studies, if you don't get hepatitis B before the age of 5 years old, you are more likely to die of other causes rather than Cancer of the liver which is the end point of Hepatitis B. Even if you are exposed to hepatitis B infected individuals at the age of 50 years old, you are less likely to die of CANCER OF THE LIVER because it takes about 25 years to 30 years for you to develop it. You have died of hypertension, heart attack or vehicular accident by the time you will have liver cancer. 

Most working people who are vaccinated of Hepatitis b are way above 35 years old as a requirement of the company where they are working. And if they are hepatitis b positive, they are not accepted for employment or they are fired  from their work.

Not all patients who died of cancer of the liver were Hepatitis B positive. Not all Hepatitis B positive patients who died did not have cancer of the liver.

Many young people who are hepatitis B positive are refused employment even if they are not going to work in sensitive areas like hospitals and direct contact fields.

Above all these things, there is no real treatment that could make Hepatitis B patients negative. Lamivodine and Entecavir do not bring down the quantitative level of the virus. And I know this since 1986.

HARD HEADED PATIENTS

There are days when I regretted not to have been strict with patients. After a grueling day yesterday, I sat down in front of the tv before I would hit the sack later thinking I had done a lot for the day and deserve the rest. Much to my disappointment, the phone rang and my hospital resident  informed me that the patient and the anesthesiologist are waiting for me in the operating room.  Oh s....
I have been convincing this female patient to have an incision and drainage of an abscess in her breast the day before. But she thought she knew better and insisted to have some oral antibiotics and would not do anything with surgery come hell fire and brimstone. Probably because the pain was becoming unbearable, she admitted herself into the hospital and want the surgery done pronto in the middle of the night when I was supposed to have my rest. I was so reluctant to leave my music room  and the comfort that it provides; no sound from the outside including the voice of the wife ( hahaha); no patients to see and the smell that accompany diabetic foot; and the force de major to finish a surgery no matter the pain in the back, the stiffness of the legs and the hunger in the stomach.
Well, you guessed it. I did get up, drive the car, went up the operating room and did the thing. Oh sh....

NO RETREAT NO SURRENDER

One thing I realize after I became a consultant was I could not turn to other people to help me in the middle of a surgery. All the things I have learned I have to seek deep inside my brain and apply. Unlike when I was still a resident in surgery, I could call consultants who could teach ( scold and mock are the right words) the way to do it. Thus, when I am in difficulty with a surgical procedure how I wish I could have been a carpenter or a mechanic rather than a surgeon because I could turn off the engine when things don't go right. In my case today, the the engine is running and I could not turn it off to do my thing.

ANESTHESIOLOGIST

 In my 31 years as a surgeon, I worked with several anesthesiologists in my team. I had an anesthesiologist who was 12 years ahead of me in practice. He was oozing with confidence and everything was routine to him. He slept thru my major surgeries. Another anesthesiologist was so old, he wouldn't accept night time procedures. I had a lady anesthesiologist who was talking all the time while I was doing surgery and she covers everything too, from gossip in the hospital and movie industry to political scenarios and wars. Another anesthesiologist was my student in medical school. He entered the hospital scene prompting me to realize that  I was getting old. And today, I have a new anesthesiologist who is so new to the field that every change in the anesthesia monitor unit, he jumps all over including my operating field.

HUMAN BEING

While I am in the operating room or doing minor surgery, philosophical matters creep into my brain once in awhile. What if the belief of Buddhists that we are only butterflies in this world thinking that we are human beings is true? Or we are other forms of life believing that we are the superior vertebrate controlling all other forms of life.  This belief transcends  all the endeavors humans have been doing to preserve the species: curing all diseases. If it is true, we doctors do not have a role. Let a person die because it is his nature to die. Euthanasia  should be practiced for a human being should rest from all the toils that he had been doing all his life.
Especially when I am operating on a patient who has cancer, this often gives me doubts to the futility of radical surgery just to extend a patient's life. And most often, because of THE SURGERY, the patient's life is  extended all right but it is really a horrible life.

FREE CLINIC

I did a free surgical operations yesterday and finished 14 minor surgeries in the morning. I came to realize that many people really need surgery but they forego going for it because of financial reasons.  Fear is a factor but most people are educated to understand the necessity of  of the surgery.  They came readily and some were even disappointed that they do not qualify because of HYPERTENSION or HEART DISEASE.
This free surgical operations day was on line with the opening of the SURGICAL unit of a district hospital of ISLAND GARDEN CITY OF SAMAL

SEBACEOUS CYST

A lot of people including non-surgeon doctors find a sebaceous cyst as a non-disease and would brush aside its presence.
 I have seen a lot of them reverting to a serious illness like PLEURO--CUTANEOUS FISTULA ( a draining sinus into the skin coming from the lungs). I have seen a patient whose sebaceous cyst  developed into a big abscess covering the whole area of his back. He underwent debridement under general anesthesia. This happened because his doctor told him the sebaceous cyst was nothing to worry about and he allowed the mass to grow bigger and become infected.
A woman 35 years old had a sebaceous cyst on her breast for 3 months. She was breast feeding. This became infected and involved the whole breast  to develop into a severe ACUTE MASTITIS. I had to do INCISION AND DRAINAGE  to decrease the size of her breast which was enlarging double the size of the other breast.
I find it best to remove this before infection sets in. The moment it has developed into an abscess, the excision procedure becomes difficult and most likely to recur.

WATER IN THE LUNGS

I almost let loose a hacking laugh yesterday when a patient refused to drink water when I told him he's got water in his lungs. He imagined that whatever water he drinks goes directly to his lungs aggravating his situation.
There are a lot of things in medicine that we doctors thought could readily be known by the layman. One of them is the interconnection of all the water in the body. There maybe 70% of water in the body but it is not readily transferable  Water in the intestines could not go direct to the lungs  nor water in the blood could not go direct to the brain. There are regulators, carriers, osmosis factors that do this to balance the different locations of water in the body ( intracellular- extracellular - interstitial). 

MEDICAL KNOWLEDGE UPGRADE

Medicine is an ever changing art. One moment a medical protocol is the norm. The next time you wake up, somebody else is saying a different tune. Peptic ulcer was an anxiety disease. Today it is a bacterial infection. REM sleep is the best sleep you can have. Not anymore. Somebody said it is the threshold of nightmares. Freud once said this is the aspect of the human brain nobody can touch. Nah, somebody today said you can monkey  with it anytime to cure insomnia and nightmares. I still can remember my professor saying that IMMUNOLOGY has a long way to go and there is no way we can understand it in our lifetime. Nah. Somebody wrote you go to sleep and you will increase your immune system.
All these years that I have been a doctor, journals and medical books have been my morning and evening fares when I am not watching TV. But lately, TIME articles are more in depth in discussing diseases and new discoveries. I was thinking of ending my subscription a few days ago after 30 years. But they have shifted from covering gores and politics to more scientific endeavors which are  more interesting to me than to discuss what people would do next ( Syria -Assad; Obama-foreign policy, China- going down or Americans are just envious, Financial meltdown- stagnation Americans can't make up their minds). Medical journals can't keep up with the new trends. They were still discussing what antibiotics were best for what infection or whether scrubbing surgeon's arms preop  leads to more  perioperative infection. Hahaha.

NON-GONOCOCCAL URETHRITIS

What carabao is this?  It is the most common sexually transmitted disease. not gonorrhea, not syphilis, not any other STD but this. Most often it is not recognized because most patients take self-medication as soon as they feel pain on urination or they can see discharges unto their panties or underwear. More often than not a history of recent sexual intercourse had happened as early as 24 hrs ago. Most of these patients do not consult a physician until they see this discharge.They bear the pain on urination. They bear the discomfort or the abnormality in the perineum which oftentimes not considered pain. What is more alarming is women do not feel any symptom not even discharges until several days mostly 5-7 days when they had another sex partner to transmit the infection.
Because of rampant self-medication of ordinary antibiotics ( amoxycillin- ampicillin), this ordinary infection does not respond to any classic drug like VIBRAMYCIN. We have to employ 3rd generation antibiotics such as cefuroxime and  macrolides such as moxifloxacin.

DIFFERENT MEDICAL POLICIES

 There is a matter of disconnect in the medical world in different countries. We often see FATTY liver diagnosis on ultrasound which is not the case in some countries. They consider this entity as a non-disease and nothing to worry about. But here in the Philippines, a reading of FATTY  LIVER  can bar a person to be employed and doctors treat it vigorously with phospholipids and vitamins.
Several years ago HEPATITIS b positive OFW's were allowed to be deployed abroad and host countries did not bother to check them. Suddenly the Dept of Health of the Philippines ruled that these people should not be employed.
What really is the issue on this? Both diseases are not a treat to one's health nor are they communicable.
Recently, I have seen a lot of patients applying for work abroad having EXTERNAL HEMORRHOIDS . This has been made  a ground for denial of employment abroad. What is this?

BACK NECK PAIN AND HYPERTENSION

We suspect hypertension when a patient complains of pain in the back of the neck. But this symptom is very common even to young adults. The youngest age that I have diagnosed hypertension who complained of back neck pain was a 28 years old. But there are a lot of other diseases that cause this pain. Arthritis of the cervical vertebra is the least of all diseases that are suspected. Most often doctors diagnose arthritis in the  knee joints and elbows but not in the neck.
In the 60's barbers used to wring the neck after cutting the hair of males clients by turning the head to the extreme right and to the extreme left causing a snapping sound in the neck. Probably because of fear that it may cause paralysis ( as often heard in barbers' tales), the practice has stopped. But this procedure of wringing the neck was physio-therapeutic because it loosens the facets of the cervical vertebrae and thus prevent build up of uric acid substance in the joints.

ANTIBIOTICS

 When I see patients who had been to other doctors, I get this feeling that antibiotics are made to cover a not sure diagnosis. Patients with prank arthritis which manifest as swelling of joints with  cellulitis  on the over lying skin ( reddening of the skin) are given antibiotics. Chronic sinusitis with clear nasal discharge an indication that there is no bacterial infection, are covered with antibiotics. Contusions with no open skin injury are given antibiotics.
IN the last 30 years that I have been in practice, more and more patients do not respond to ordinary antibiotics ( amoxycillin and cefalexin). I have to resort to 3rd generation cephalosporin like CEFUROXIME to fight an oozing non-healing wound and often the dosage exceeds the regular 5-7 days regimen.

PICTURES SPEAK MORE THAN WORDS

If only we could show you the things that we see when we operate, it would be more exciting and you will fully understand why we do it and how we do it. Even video footages do not do justice to the dept  and extend  of surgery that we do for cancerous tumors for example. We cannot fully describe to you how difficult it is to dissect the inner areas under the breast when we do MODIFIED RADICAL MASTECTOMY. When we are doing thyroid surgery, our testicles are raised high up to our ears while separating the tumor from the blood vessels  going into the brain. And to think that we are careful doing it to prevent cutting the recurrent nerve resulting to the lost of voice of the patient. Words  are not enough and the English language is not adequate to describe  how thrilling it is.

AGAINST MEDICAL ADVICE

What makes a patient leave the hospital against medical advice?
We encounter patients who prefer  to go home than to stay in the comfort of the hospital. Money notwithstanding, is often not the reason why they do so. Oftentimes, they think they will be more comfortable to go home and die there with presence of  their relatives and friends.  They do not want to die in  a strange room with impersonal people around them.
Many people do not know how tedious post-mortem care is In the hospital, the protocol of caring for a dead patient is by numbers even before the patient is transported to the morgue. Orderlies could not just pull out the tubes. They have to follow how we surgeons inserted the tubes and how they have to pull out the tubes as if the patient is still living.
Endotracheal tubes for instance, a tube inserted direct to the bronchus thru the mouth, they have to deflate the balloons before they can pull it out. If the orderlies do not know how it is, they could pull out the whole larynx in the process. Gastrostomy tubes inserted to the stomach for feeding is equipped with mushroom -like tentacles which prevents accidental pull-out is difficult to remove without proper training.
If the patient dies in his own home, nobody knows how they could do all these postmortem care. 

TERMINAL STAGE OF LUNG CANCER

 The terminal stage of lung cancer is not only so difficult and excruciatingly painful to the   patient but also very trying to the doctor. We insert a lot of tubes into his body; tube to the nose, tube to the neck. tube to the chest, tube to the stomach; IV sites into all extremities and a urinary catheter. A clip is inserted into his finger to monitor Oxygen blood level. EKG terminals are attached to his chest not mentioning the optional AV canulas if dialysis is being done.
If it is your first time to see this scenario, you will be offended why we are doing this to a human being. But yet, we are trying to preserve his life. For several years now, a lot of advocacy groups clamor for a dignity to die. But not all patients die immediately upon the removal of these tubes. Most of them suffer a lot and will die a horrible death if analgesics and sedatives are withdrawn. These drugs are given via these tubes.
We have come to the point of medical science where it is so difficult to place the decision on the doctors hands. Before this 21st century medical care, the doctor has only to raise his shoulder and give the rest to God. Today, we can prolong a patient's life; or at least his heart and other organs.

NEXT PATIENT PLEASE

 I seldom schedule operations one after the other. This is because  the reservation of the operating room is divided among surgeons and we cannot usurp the whole day for single surgeon.With more than 50 surgeons practicing in the city and a few operating suites in 6 hospitals, this is tricky. If schedules are not well rehearsed, the OR STAFF bears the brunt of irate surgeons.
I have seen patients being wheeled out of the operating room suite because the surgeon was late 5 minutes. To the disgust of the incoming surgeon,  the late surgeon wheeled back his own patient into the operating table; carried his own patient without asking from the OR  staff and transferred her into the operating table.
Hahahahaha.
The incoming surgeon cannot do anything but stare at the unfolding scenario. He waited outside the operating suite for two hours before he could do his thing.
Now, some surgeons would blocked off one whole morning for his procedures if there are no other surgeons requesting for a slot.Thus,  he can schedule patients one after the other. But this is very seldom OR staff would ever  allow. But I did it today. It was fun.

CHEAP MEDICAL CARE

The moment I think of the possible expenses a patient will incur especially if he/she will be admitted, I start to cut corners and rely on my clinical eye and experience.  Though I have not made any mistake for doing so, sometimes this delays a procedure  or the contemplated surgery.
 I was about to do a THYROIDECTOMY to a patient when on CARDIOPULMONARY CLEARANCE ( done by a cardiologist), she discovered that the patient has a high THYROXIN meaning she has TOXIC GOITER. She cannot undergo surgery. I did not repeat this test preoperatively because she had one 30 days before the scheduled surgery. This single test would add more expense to the budget of the patient which she begged not to over spend because she only got the money from her brothers. Though we know how much would a surgery cost by experience, we cannot control possible expenses that could be incurred by the patient post-operatively; more antibiotics, more tests if there are abnormalities occurring.
Because of this finding preoperatively, we have to postpone the surgery for at least 2 weeks to bring down the toxicity of the patient. I sent her home after all the preparations we did the past 2 days. 

IT'S ONLY A CYST

A lot of times have I been confronted with a simple mass in the body which on first examination I am tempted to excise under local anesthesia in the out patient department; especially if the size of the mass is less than 3 cm and movable. I really don't know what makes me decide to transfer the patient to the  operating room and do it there. There are times in my practice that I don't really know why I make a decision not based on my experience nor from my education. All of those decisions were right to the benefit of the patient. To this day I have never done an operation in the out patient department which I have to pre-terminate because I cannot finished the procedure under local anesthesia....knock on wood. I have heard of surgeons shamefacedly explaining the situation to the patient. This situation is not usually acceptable to the patient because of financial constraints and they never prepared themselves for a major surgery under general anesthesia. But I never did over do  some procedures either  by being so cautious and doing a minor procedure under general anesthesia instead of a simple local anesthesia....knock on wood again.I have my own protocol in dealing with tumors, cysts and mass in the body that to this day I have never failed....knock on wood.

MODE OF ACTION

Many of the drugs we use today to cure illness are not known why they cure. Yes, trials and numerous studies were done before they even hit the market. But most of these trials were studies to determine the side effects of these drugs and their interactions with other drugs. We do not know how these drugs cure at the chemical level; where they go before they are excreted out of the body and be found in the urine, stools and in our saliva.We know how much of the drug is necessary to cure infection for example ( antibiotics). We know how many milligrams we need to bring down hypertension. We know how much tablets we have to give in order to bring down blood sugar to a desirable level. But there are drugs we really do not know the mode of action.
Take STEROIDS  for example. We use this drug as a last resort in some diseases like STATUS ASTHMATICUS or in ACUTE GLOMERULONEPHRITIS. How does steroid give relief to bronchospasm which is the main cause of ASTHMA? Yes, we know steroids bring down inflammation which is inherent in asthma. We know steroids decrease fluid secretions in the bronchus. But how about bronchospasm? Does it have a parasympathomimetic effect in the bronchus? Can anybody tell me?

PERSONAL EXPERIENCE

I  have been suffering from ARTHRITIS for the last 2 years. Yeah, I diagnosed myself  and made a confirmatory working diagnosis of GOUTY ARTHRITIS. With 31 years of experience treating patients, I could say that I gave myself the best medical care there is. I followed the proper protocol of RHEUMATOLOGISTS and treated myself with the same medications that they usually give to patients like me and more. The same as all arthritic patients have experienced, no treatment last for long. There is no treatment really. Medications only give pain alleviations and nothing more. They do not stop the pathological process all along.And so, patients are left fending for themselves for  the rest of their lives and mine. Most patients ( and me included) substitute medications one from the other in order to get a pain free morning. And I am consulted by many patients seeking for more potent medications for joint pains. As advised, I went to the gym almost everyday for 2 years  to prevent arthritic attacks. Nothing to it. I had joint pains most of the time and they were getting worst.When I stopped going to the gym everyday and did it once a week, the daily arthritic pains disappeared and  I get them every now and then ( and I lowered my CREATININE clearance). Most drugs alleviate pain for a the next 3 to 5 days and that's it. They become useless. I needed to shift to another pain relievers to have pain free mornings.
Because of this personal experience, I have given my patients better medical protocol .

Status Asthmaticus

Patients with chronic asthma even how diligent they are in their medications always end up with stage of status asthmaticus. Inhalers, bronchodilators, and expectorants do not prevent patients going to this stage. Pulmunologist most often shift to one inhaler to the next that is often result to the same problem.

Though i am not a pulmologist, i have seen a lot of this patient who are dissatisfied with their status. Most often they come desperate and would not like to go to another pulmunologist. So, for the past 19 years I have experimented with other medications not used in status asthmaticus treatment protocol. These resulted to prevention of frequent attacks of asthma and status asthmaticus. Since I am not a pulmunologist, I never reported this to the medical society. But this could give a lot of allevations to asthmatics.

In business as well as in other professions people are encouraged to think out of the box. In medicine, we seldom do that for fear of malpractice suits and rejection of our colleagues. 

TO SEW OR NOT TO SEW

There are areas of the body that do not need suturing when they sustain lacerations. And there are areas of the body where a laceration no matter how small need suturing.
We have a standing protocol in surgery (foremost do no harm - Hippocrates) that if the wound does not gape in motion or in stand still, we do not suture for suturing leaves ugly marks than the natural wound healing.
Lacerations on the face usually do not need suturing if they do not gape. Boxers when they sustain lacerations during a fight may not have any surgery except when the wound persist to bleed. Thus, the main purpose of suturing is to contain bleeding and not for aesthetic reason.
Sutured wounds is called in medical parlance: HEALING OF SECONDARY INTENTION, for the reason that we force nature to heal fast and to lessen the natural tendency of wounds to form ugly scars. Sutured wounds if well approximated ( perfectly aligned skin) will result to a linear scar. But if they are not well aligned, one side of the skin overlaps the other, the scar result will be ugly. Suture marks will add to the railroad tract scar.
Surgery and surgical techniques have gone a long way over the years. We had absorbable sutures that do not lose their tensile strength up to 15 days in the 60's. Today we have absorbable sutures that last for 120 days without being disrupted by the body.
On development today is a kind of ointment or cream that could be applied to the skin that bonds two sides of the wound similar to  MIGHTY BOND.

POST HERNIORRHAPY

 Patients frequently ask when could they go back to their usual activity like gym, driving and sex (not in that particular order of interest of  course). My experience tells me that over precautiousness after herniorrhapy dampens the excitement of a patient but wanton neglect of protocol will end up in recurrence. ON examination of the patient, we usually could not tell when could we allow the patient to go back to any strenuous physical activity. I usually advice gradual entry into his former physical activities. I let him judge whether he could tolerate the pain if there is. Absence of tightness and pain  in the area of surgery usually would give a go signal for the patient to have sex, go to the gym and drive his own car in that order of course.

SWEATING BABIES

In these days of mixed marriage, Caucasians entering marriage with Asians, Blacks marrying Orientals, there are a lot of normal symptoms we find in babies born from them which we do not find  in pure breed brown heritage. These symptoms often trigger panic from both parents thinking that they have not seen these symptoms form each individual families's babies.
Sweating babies for example. We seldom see this in Filipino babies nor in Libyans ( I was there) nor in the Expats's babies I often see. But when a mixed parent comes into the clinic not for the baby of course but to consult their own problems, they side-consult what is happening to their baby why she sweats early in the morning or even in cold evenings. Some babies still sweat inside an air-conditioned room. On examination, the baby is in perfect health.
The sole reason is that these babies of mixed marriage have a different thermostat setting. They usually get the gene setting of the dominant thermostat:  the Father from a temperate country. They can only adopt to the tropical temperature when they have reached  10 months to 1 yr. Some babies will take a longer time. Meanwhile, they will sweat and sweat like a worker under the heat of the sun. What they need is water to drink to prevent dehydration.

NO LABORATORY EXAM

No laboratory exam could diagnose a HERPES ZOSTER unless of course you would do a punch biopsy of the lesion a procedure no patient wants. The doctor is basing his diagnosis on clinical symptoms and the appearance of the lesion with the accompanying signs and symptoms of pain with numbness of the area.  If a doctor did not do well in his medical school days, he wouldn't have an iota of knowledge what it is. His internship was full of work in other fields and dermatology is not one of those given  more attention. Good if he went to a hospital where Dermatology is incorporated in Internal Medicine and thus would expose him to cases like this. When the doctor goes into specialty training - residency in Surgery for example - he would never see HERPES ZOSTER again until he goes into practice.
We consultants cannot refuse a patient. More than always, we see relatives of our patient who were referred to us no matter what disease it is.In some of our days, we are consulted for cases like this and these people would not like to go to another physician. They expect us to know everything since we even open up people. And this lesion is skin deep, how could we not know it.
The CLINICAL EYE  is develop, nurtured, upgraded and maintain until we doctors die.

TWO SURGICAL DISEASES AT ONE TIME

I have a patient who has acute appendicitis and Acute cholecystitis at the same time. Both diseases need to be operated on fast. The question lies on what incision to make. We always consider the patient's preference aesthetically but we also have to bear in mind the surgical technicality Acute cholecystitis incision is made under the ribs while the Appendectomy is made near the hips. There is another incision which encompasses both of them and that is making an incision in the middle of the abdomen running from the upper portion to the portion below the umbilicus. But this is so ugly most patients will not agree to it.
In cases like these, surgeons do not follow a protocol nor can we find it in medical books. We follow our experience as wells as intuition and foremost what is best for the patient. Truly, medical science is an art.

SMOKING DISEASE

Most if not all COPD patients I have seen were due to smoking. But to our surprise, we don't call  the disease SMOKING DISEASE but the high fallutin name CHRONIC OBSTRUCTIVE PULMONARY DISEASE.If you would ask all the pulmonologist in the world, they would all agree that smoking caused a lot of this illness. And yet, there is no law against it ( just like guns). The Dept of Health all the over the world has been fighting against smoking to no avail. We all know smoking is addictive.
We regulate the use of tranquilizers. We are asked to write especial prescriptions for them. Nobody can buy tranquilizers without prescriptions. And yet, you can buy cigarettes anywhere and even children can buy it.
COPD is not the only disease caused by smoking. Reynaud's phenomenon/Reynaud's disease is caused by smoking. This is numbness and pain of the lower extremities. I have seen so many of them to count. The patients are in horrible state. They prefer to have an amputation rather than bear the excruciating pain in the legs which often occur at night when they have started to doze off. The legs are anatomically normal. On physical examination, they are cold and yet I can feel the pulse. And the feet are not swollen as in Diabetic gangrene. Just as I can smell a diabetic foot from afar, I can see an incoming BUERGER'S DISEASE  in a person who is smoking from a distance.

DIAGNOSE YOURSELF

How would like to know what ills you or you will be given an inkling what the doctor would tell you later? You will know beforehand what the diagnostics you will be undergoing and how it will go about; the preparations to do before going to a CATSCAN for example. It would be cool if you know what the hospital will do to you unlike a guinea pig being brought to a slaughter, wouldn't it? And then, you can understand pretty well what the doctor is talking about in plain language unlike  someone who would be wide eyed pretending to understand the doctor. You could discuss with your doctor  and shoot knowledgeable  questions. I am sure your doctor will take care of you better if he could see how pretty well oriented you are with what ills you. Medical language will not be Greek to you and your doctor will not be exasperated repeating and repeating what he wants to tell you in plain language that you can understand. If you still don't know, we doctors are so comfortable talking our language that it is Chinese for us to talk in plain English; or Portuguese if I speak a second language.
Well, you have to go to medical school to do that. You can surf the Internet to understand a few words and some inkling how to go about it.
IN a few months from now, a website will just do that. You will walk your own  illness by clicking on an interactive page. Click what ills you; pain for example. this will bring you to a a page where you can pinpoint where the pain is on a human figure, and so on until you reach the page where you will be instructed and given choices to know your own illness without going to medical school. Watch for it.

BLEEDING WOUND

Your management of bleeding wounds could be reminiscent of the 60's movies; tourniquet on the upper portion of the  extremity. Not anymore , Sir.
Wherever the wound is, whether it be on the head, abdomen, chest or extremities, press on it with your fingers if it is small enough to be covered by the finger. Or, use your handkerchief  rolled into a ball and press it hard into the wound. If it is an artery, it would bleed no matter how much you press. If it is venous it will stop in about 5 minutes. If it is arterial, the more you wait for it to clot, the more likely the patient will bleed to death. Go directly to the hospital. Movie scenes of suicide with the actor/actress bleeding from a wrist slash could not happen in real life in a span of 95 minutes ( the usual length of full length movies). Arterial bleeds from the wrist may last for 30 minutes without stopping but it gradually slows down because of the clotting system of the body.
Way back in the 80's when cautery machine was not available yet, we do mastectomy for breast cancer manual; that is, while the main surgeon cuts, we go for the bleeders with forceps. At the end of 4 hours ( that is how long we do it way back), we wet our under-wears with blood to the consternation of our wives who did the laundries. Well, we had to transfuse blood after the procedure.
Today, mastectomy is a breeze. Not a drop of blood on the spread sheets. Blood loss is less than a menstruation period to the max. Blood transfusion? The last time I transfused for a mastectomy was way back in 1986.  

PHILHEALTH AND OBAMACARE

Fareed Zakaria  in his column in TIME enlighten me on OBAMACARE.  I came to realize that what he was writing on OBAMACARE is exactly what our PHILHEALTH is today; government sponsored healthcare, covers the whole population by law, cheap but not enough to cover hospital cost.
If the medical care of the US  today sucks, much more would it be when OBAMACARE will take effect the same as our PHILHEALTH.  Filipinos expect their PHILHEALTH will cover everything to find out later when they are admitted that it only pays 1/3 of the hospital cost. If they would get cheap health insurance same as our PHILHEALTH, they should not expect anything. Though our PHILHEALTH covers almost everyone, it covers less and less diseases same as an HMO. It is starting to choke the professional fees of doctors and repayments of hospitals. Yes, Switzerland and Taiwan have the best healthcare. But more and more companies are scouting for a place to transfer because of their overhead cost on employees' healthcare. 

INTERNET BUBBLE

I was riding the INTERNET bubble in 1996. I put up my own website and placed all my write ups published in the local newspaper hoping that I too could be rich as the others in the world were made. The website was unique in the sense that to my knowledge during that time  nobody in the Philippine medical  scenario ever made a website much more use the Internet. I was one of the few who was using a computer to surf the Internet, do my finances, manage my clinic as well as input all the on goings of my life. I even had a folder of pictures I got on all the patients I operated on and what procedure I did. It's address was www.funnymedical articles.com. I uploaded a lot of selected articles which were funny and  well received by the locales( I often get comments from these articles). Though most of them were in TAGLISH ( combination of English and Tagalog and even Bisayan dialect), I tickled a lot of funny bones. The website is already down as all other websites in the 90's who did not earn.
One of these days when I do not have anything to comment on this blog, I could upload some of them. But if you are a Filipino who can understand TAGLISH, ask for them. I could upload them for you.

MULTIMEDIA DOCTOR

I have been writing a column in one of the local newspapers for ten years. I had  a website in 1996 which ran for 8 years. This was connected to a YOUTUBE clickable presentation during its infant years based in Japan. I put up a medical cable channel in one of the cable networks and I was on TV weekly for a medical program long before a medical show was on the air. ( way ahead of Discovery channel - 1992). I wrote a book INHOUSEDOCTOR in 2005 and published it myself.
From 2004 to 2008 I had a radio program daily which entertained phone -in calls live and text messages. I  went back to this programming only 4 weeks ago.
And all these for free. I never received any remuneration and I never got rich from these endeavors. I was really trying to expand my horizon based on Steven Covey's paradigms ( Seven principles of successful people ?).
And now, today I am expanding again into mobile app ( algorithms of diseases downloaded to your mobiles which enable you to diagnose yourself whatever ills you). And if things will push thru, one of these days you will be looking at this mobile app in your IPHONES and ANDROIDS.

THE PRACTICE OF MEDICINE

 If you or your son/daughter are thinking of going into medicine, think of this.
Only 20% of the general population get sick. Of the 20%, only 10-12% seek medical attention or go to a doctor.  The rest either self medicate or they have a self limiting disease. Of the 10% who seek medical attention, 4% are admitted; the 6% go home and take medicine.
Medical schools produce doctors at a rate of 1 doctor per 5,000 population in the developed countries or 1 doctor per 10,000 population in the developing world. This is because of financial constraints. If it is cheap to go to medical school, everybody wants to be a doctor. Thus, there is an increase of about 1-2% to our ranks every year. So, if we are 800 doctors in the city, 8 doctors build new clinics nearby. But only about 2 to 3 doctors retire every year. Some doctors still practice even if they already have the signs of Alzheimer. I know of a doctor who had the beginnings of the disease and kept on asking her patient what her name was to the exasperation of the patient. The patient did not take the prescribed medication for fear of wrong diagnosis and wrong medication.
Another surgeon I know was still operating despite the fact that he cannot thread the needle nor can he steady his hand as he cut.  His junior surgeons have to take over the operation to limit complications. No one in the hospital dares to tell the doctor to retire. There is no law  limiting  medical practice. Malpractice probably.
Now, do you still love to become a doctor? You are welcome.; the more the merrier. But there is no money in it, dude!!

MEDICAL MALPRACTICE

It is true that if a person is working under fear, it will be more expensive. You build defenses before you can even focus on what you should be doing in the first place.  In the case of doctors, they order a lot of unnecessary diagnostics to cover themselves from malsuits in the future. They are saddled with the fear that the patient or his relatives will find a reason to sue him when what he was doing was to save the patient.
I don't know with everybody else. But I work on the ethics of helping the patient and never think of  what I am doing is routine and mundane. Every patient is unique and needs my 100% attention and focus. There is not even an iota of negligence. Nothing drives me to forget  what Hippocrates said: FOREMOST DO NO HARM." If I don't have the time for one more patient, I refer him to another doctor to take care of him fully rather than do a haphazard diagnosis and treatment. That is why I remain poor.
Until the  United State remove this Democles sword on the shoulders of their doctors, their healthcare will always be expensive. 

OBAMACARE

I was reading an article in TIME mag on OBAMACARE. I came to realize how the President of  the US is really thinking of the situation of his people. We in the forefront of medical care are often besieged by this same problem of providing medical care to people who cannot buy their own medicines much more pay for their hospitalization. People can afford to buy signature dresses and shoes and go for a vacation but they are not prepared to go to the hospital. Yes, nobody ever prepares to be sick. That is why, even the rich cannot spare a centavo for their illness. By making it a law, Obama has secured the future of his people  to be ready for eventuality. 

SIMILAR HUMANS

 Reading your comments, I was wondering if doctors in other countries have the same dilemmas as I have. Foremost is the fact that we have to think of the financial capacity of the patient before we do anything even ordering diagnostics to help us in determining the patient's problem.  Social medicine does not limit the doctor to do the cheapest diagnostics he could to reach a diagnosis. HMO'S in the UNITED STATES have a high ceiling of expense for each patient that their doctors could order basics laboratory exams which for us in the third country are special procedures.
But so often, with a lot of expats coming to my clinic, I encounter disappointments and complains coming from them about their countries' medical care than from the locals. We do the most minimal diagnostics to a patient in order to arrive to a working diagnosis. We forego laboratory exams that other wise duplicate or does not give any advantage to the patient. As such, we rock our brains to 100% capacity to give the best medical care a patient needs without him losing his pants in the process. If we would do all the diagnostics other doctors order, the patient will lose even his underwear.

SOAP AND WATER

You might be surprised but most superficial wounds would heal with soap and water; no povidone iodine, no ointments, no dressing; plain and simple soap and water. Before the advent of antibiotics, especially during the Spanish civil war, they only had two choices with limb wounds: amputate or TRUETA TECHNIQUE which just allowing nature to heal itself. This meant leaving the wounds open and allowing maggots to grow inside the wound. Well, most patients died of Tetanus rather than infection despite the fact that there was no antibiotics given. What Trueta did, a Spanish surgeon, was to wash the wounds, debride all dead tissues and allow the wound to heal itself. Liniments and all medicines used for wound dressing were not available yet. A review of this old technique and comparison was made with our present method of wound treatments revealed no significant advantage of the present  procedure just to show that we never advanced in the medicine of wound healing and all current washings we use in the emergency room are ineffective.

VEHICULAR ACCIDENT

In most cases, people who are injured in a vehicular accident do not feel the pain and would not have any symptoms of internal injury. It is only after 24hours that they would feel pains here and there.
Thus, it is very dangerous for a patient to insist on going home after an initial physical examination in the emergency room.  Pneumothorax for example, accumulation of air inside the thorax but outside the lungs, manifest only after 24 hours in a regular Chest x-ray. Injuries to the liver and spleen would show immediately by the drop of blood pressure and pain in the abdomen. But in cases of injuries to the thorax, they manifest late. Accumulation of blood near the heart is often missed if not for a thorough diagnostics.

HOLIDAYS

If we decide not to go on vacation, doctors do not have holidays. day in-day out 24/7 we are on call ( consultants). Though we are not in the hospital, our minds are; on patients we did surgery; patients who were just admitted; and patients who text or call my mobile phone. I really don't know if I am the only surgeon who gave my personal mobile phone to patients. But my patients would always praise me for being so easy to talk to or to contact during emergency. This is a privilege that I gave my patients since 1986 when POCKETBELL was the mode of communication. The problem then was I had to run and find a landline every time someone would call.
Today, the problem is they call anytime of the day and night. I seldom hit the sack without having to answer text messages in the middle of the night. You might be wondering how  my sex life is with these disturbances.

EXPERIENCE FIRST HAND

When we went into residency training, we were exposed to cases first hand; lectures every day,teaching rounds everyday, research everyday and operations 24/7. Our daily schedule was so full we hit the sack dead tired. Operative techniques are repeated ad nauseam and questions intraoperative from consultants-operating surgeon includes footnotes and the newest trend in surgery.
When we reached our 3rd year residency, we could memorize all questions and idiosyncrasies of all our consultants that before they could open their mouths, we know what he/she will say. Some of them would always recall their own residency training and anecdotes where they became heroes after a very difficult surgery.
Each and every surgeon has his/her own technique or way of doing surgery. And it was our own look-out to know and memorize what they want and how to do it their way. One mistake of doing another surgeon's technique would end up as a monologue of disadvantages doing that other technique; no matter how good, easy and less complicated it is.
So, when we finished our residency training, we also develop our own technique derived from all these techniques we memorized from all consultants we had been under.
This then is  the patient's advantage. The younger the surgeon is, the more he has seen several techniques but his weakness will lie on his own confidence when he handles his own patients where he cannot pass the buck to another surgeon.

FARTING IS SUCH A GREAT SORROW

FARTING

Farting is such a great sorrow

The absence of which there is no tomorrow

After an exlap if there is an absence

Nothing could check the intestine's function and presence

Catscan, ultrasound, blood exam patient can undergo

They have nothing the Stethoscope can do

Sounds doctors could hear

that would lift spirits dread of fear

You don't know how much we anticipate farting

From a patient who underwent major cutting

Post surgery If we don't hear its murmur

We worry and scratch our head what can we do more

It's the only indication that everything inside is ok

We have not left a scalpel or even a tray

How disappointing and  horrible would it be

To tell a patient we have left something inside thee

Ho ho ho ho farting we smile when someone does it

Because not only sound but smell we get it

We say how bad you did what you did

But in the wards it's the sound we always anticipated 

UNKNOWN DISEASE

People are afraid of the unknown; UFO'S, Dracula, to name a few. That is why the movie Twilight was a box office hit and the Dracula has a thousand sequels and refilming.
In medicine, we face a lot of unknowns and to think that western medicine has been around for several decades at its present form. The patient that I have been mentioning for the last two days turned out to be a not well known disease. In fact, the hematologist was baffled by the diagnostic findings. To be exact, we don't know what it is; an unknown disease. If it is an unknown disease and we don't know what it is, we also don't know how to cure it. Yes, we can give symptomatic treatment like pain relievers and antipyretics.  But to give a complete cure is unknown to us.
There are still a lot of illnesses that we don't know. To say that we are in the 21st century in health care, we are delusioning ourselves.

LOW PLATELET COUNT

As I see the patient, I am really baffled by what I see on physical examination. He is normal but his laboratory result of platelet is way way below normal. He went down as low as 16 ( normal:120) which oftentimes show rashes and bleeding from the nose and mouth. He does not have all these symptoms. If not for the laboratory result, he could pass as normal. I referred him to a HEMATOLOGIST whose specialty is blood diseases ( blood dyscrasia in medical parlance). She too does not have the answer. Peripheral result showed what we see, low platelet count but the cause, we still do not know. It is not DENGUE. I am waiting what the HEMATOLOGIST wold suggest next. TO BE CONTINUED.

MORNING SURPRISES

A patient came to the clinic yesterday complaining of abdominal pain and body malaise. No fever, no vomiting, no loose bowel movement. On examination I did not find any abnormal findings in him.  But I suggested for a complete blood count and urinalysis to rule out the possibility of Acute Appendicitis or gall bladder stone. Ultrasound was out of the question because our laboratory does not do it late in the afternoon.  I also suggested for him to be admitted if the abdominal pain is not relieved by the anti-spasmodic that I prescribed.
Late in the evening, he cannot bear the abdominal pain any longer and begged to be admitted in the hospital. I was informed by my resident of his admission and workups were done on STAT.
This morning. lo and behold, his complete blood count revealed a very low platelet count of 27 ( normal of 120) indicative of Dengue without fever.  I could not think of any other disease that could bring his platelet so low and yet there are no physical findings. In other patients, platelet this low warrants blood transfusion of platelet concentrate. but there was no sign of impending bleeding like petechiae ( red spots in the mouth or extremities). TO BE CONCLUDED

MAN WITH MULTIPLE NAMES

Aside from my Christian name, I have a lot of names. Doc ( pronounced as in knock) is what  I often hear when Caucasians from the US call me. Not surprising because they often take the effort to enunciate the proper  pronunciation of  my profession. But what I  hear from my fellow countrymen is surprising. Duck ( as in duck the feathered one)is my name from the old people who have the propensity to mimic the movies  of the 50's ( Frank Sinatra- Marilyn Monroe gen set). Old professionals call me Dec ( as in deck of the ship) to follow the Australian gang ho stars of the 70's ( Crocodile Dundee?).
There are nurses who come from the government sector who call me Dokee ( as in spooky) which is unnerving because I feel being shelved off to one sector of society: the UNTOUCHABLES - envied but not an idol, praised but not followed, oogled but one side of the eye only; talked about but never derided.

BACK PAINS

A patient, 54 yrs old, male came into my clinic complaining of chronic back pains. He had been feeling this pain since 4 months ago and have been told that it could be muscle aches. He had been to so many doctors and given so many medications and found no relief; cough medications, muscle relaxants, pain killers and all kinds of analgesics including opoids. NO relief. As a last recourse, he came to me because of a mutual friend ( always happens in my practice).
I did a lot of workups including a CAT SCAN of the chest. Lo and behold, small minute lesions were found in his lungs and a marked destruction of his chest vertebra. After the CATSCAN, he revealed that he was a chain smoker during his younger days up to 2007. And then, he also revealed that there is numbness in his lower extremities.
Oftentimes, in my career, patients keep facts from their doctors only to reveal them when we find something dreadful for fear that it could influence our diagnosis or our management decisions.
Far from the truth, what we see and what we hear in the history will always make the diagnosis. Some people think that keeping secrets could help them retain some kind of control of their medical destiny. It  does not help any most especially if it is cancer.
Watch for the result of the biopsy of the lytic lesions of the THORACIC VERTEBRA to be done tomorrow.

FEAR OF SURGERY

No one likes to go under the knife. Absolutely. In my 31 years of practice, never have I encountered a patient who willingly would say yes. If they could do away with surgery, they would. But there are a lot of illnesses that could never be cured by medicine or drugs alone. Acute Appendicitis, gall bladder stone and the management of cancer where a biopsy is a basic necessity  are some of them to name a few. Some patients after so much explanation would agree to surgery but others would seek other solutions to their problem. One of the weakness of medical education is that we were never taught how to face patients and convince them to have surgery; like in marketing and business management. If I could have my way, I would insist medical students to learn psychological warfare and mind reading and Stephen Covey's "How to convince people".
The weakness of medical education does not lie in convincing people alone. We are weak in making people happy no matter how good we are in our profession.

AMAZING RESULT OF PERSEVERANCE

2 years ago, this foot could have been amputated. It was gangrenous with the bones of the feet showing and darkening of the toes. The patient refused to have the amputation. Instead he beg me to debride and dressed the wound for almost 6 months  every 3 days. I used an unconventional preparation of wound dressing with SILVER SULFADIAZINE CREAM impregnated into a gauze with H2O2. It grew new tissues and even exceeded its skin covering. The foot looks very normal except for the wound and with the absence of the darkening of the toes.
If  the patient did not persevere to ask and I succumb to the surgical dictum of remove what dead tissues there are, this foot could have been long gone.

Enlargement of the Prostate

90% of patients with Benign Prostatic Hypertrophy do not want surgery. They take expensive medications rather than go under the knife. The fear of surgery is unfounded. Though the procedure is not without risk, post-operative results are very satisfying. To the present I have not heard of any mortality. The cost of medication usually surpass that of operative expense. However, because of fear surpass all other options the patient prevails of taking the alpha-blockers. The medication has a lot of side-effects including dryness of the mouth and constipation. Some patients develop depression of hepatic function. But all these are temporary and the side-effects disappear upon discontinuing the medication.