changing protocols

We used to tell our patients who have FASTING BLOOD SUGAR of 6.5 ( normal: 5.4) to go on a diet low in carbohydrates such as sweets, cakes, and pastries and go spend their high caloric intake in the gym. Not anymore. For the past 10 years that we had this protocol, there have been an increase of uncontrolled diabetics and cases of kidney dialysis. 10 years ago, we had 5 dialysis machine and these number could cope with the number of hemodialysis done every day. Today, we have approximately 400 dialysis machines in the city but the backlog of patients have increased almost triple.
This statistics was approximated to the population increase and increase of  the people's per capita income. These factors do not influence the present crisis of dialysis. Thus, the protocol was change. Today, we advise  people with this FBS result to take medicationsas early as this.

symptomless

I often encounter patients who have a lot of pains and yet physical examination would not show any abnormality.  We employ all diagnostic exams and would find negative findings. Then, suddenly after a few days, examination would show he is on the terminal stage of cancer. What is happening? We don't know.
I see the lot of patients who in their whole life was never sick. They had a very healthy lifestyle and all annual physical examinations and diagnostics were all normal . Then when they retire, they succumb to STROKE. What happened?  We don't know. 

dilemma in the operating room

I often encounter in my operations the dilemma whether to dissect a tumor cutting a nerve in the process or leave a portion of the tumor to spare the nerve. To a patient what is important is his/her appearance after the operation. They would like to see a normal face or body after a major surgery. In surgery of cancer, this dilemma is often aggravated by the decision to do the best for the patient.

colloid goiter

You always hear and read that mass in the anterior neck does need surgery. It is true. Goiter does not really need surgery.  But if you were the patient, would you allow this to grow large noticeable to people facing you? You would risk losing your voice because of surgery  because it is ugly to look at.

result of scratching the scalp

This is a tumor that developed on the scalp of a woman who scratched her head too hard. The scalp was abraded resulting to the lost of its skin cover allowing the soft tissue under the skin to come out. It bleeds easily and starts to smell. I have seen this to grow big as large as a fist of a child. A lot of remedies  like povidone iodine, Merthiolate, ointments and lenements had been applied on this tumor without any relief. It got worst from them and grew bigger.  Removal of the tumor by surgery is the only treatment.
Moral lesson: no matter how big your problem is, don't scratch your head.

Do you need antibiotics for this?

This is a furuncle near the arm pit caused by previous abrasion of the skin and became infected by scratching.
Most cases would flare up into an abscess and pus formation and would need surgery for incision and drainage. If the doctor would not give oral antibiotics, it would take days for it to  mature into a  full blown abscess; usually 7days. If the doctor would give anti-staphylococcus antibiotics, it will turn into an abscess in 3 days time; less pain and less time to endure it. But I encounter patients who had been misinformed about taking antibiotics and taking medicine in general.  They thought taking herbal supplements could help. Naaaah.
Cold compress would help ease the pain and reddening of the area.  But the abscess will continue its course. You still would need to see a doctor for it and take antibiotics.

miscommunication

With the hundreds that I operate every month, I cannot remember who was the patient operated with what. And so, when they communicate to me via telephone, cellphone, email and text messages without identifying what I have done to them, I am lost. Never mind the name. I cannot even remember their faces much more their names.
This is where our modern communication has failed no matter how high tech they are. The records of a patient is so important  for follow ups. This has become my problem because all my patients have my personal cellphone number. Anytime, anywhere, any place they are, they can always talk to me and ask questions about their cases.... if they tell me what operation I have done to them. Do you have your personal doctor's number?

avulsed fingernail

A s you can see in the picture above, after removing the nail you can see the bed containing a new nail. I was able to evacuate the blood clots surrounding it and a fresh nail bed is showing.
The problem with the textbook management is that no one challenged it up to this time. Medical schools still teach the old method to young students. And so, we end up with patients treated the wrong way.
Another thing, the old method of boring a hole into the nail bed produces a dead nail which is ugly to look at and this eventually falls off if it does not generate attachment on the old nail bed.  This usually takes about 21 days and  the patient would have a black fingernail all this time. To some, this is  advantageous since they don't have to use black nail polish.

to remove the fingernail or not

There is no consensus among surgeons what to do with this much more laymen what to do with their partially avulsed fingernail. This was pinned by a car door 3 days before consulting me.  There was hematoma ( blood clot) around the fingernail with pus formation and the fingernail is movable not fixed as in normal fingernails.
Textbooks would tell you to bore a hole right on top of the fingernail to release the blood clot formed underneath. The problem with this procedure is that you scare the patient while you are doing it. It employs  a heated syringe needle while the patient is watching  and piercing the fingernail with force. I have not seen a patient brave enough to see a glowing metal being inserted to his fingernail.
See the result tomorrow.

patient going home

What a happy moment to see a patient going home after a major surgery. The anxieties of the surgeon and the patient dissipate the moment the patient exits out of the hospital. But though, he/she maybe out of danger, complications of surgery may occur for the next 30 days.
This has been played for thousands of my cases but I still experience the anxiety with the patient.

VOICE AFTER THYROIDECTOMY

To both patient and doctor, the day after thyroid surgery is anxiety day. The doctor wants to know if the voice of the patient was not destroyed. The patient needs to know if she can still speak her own natural voice.
When that hour of rounds arrives, my car speeds up and my steps to the patient's bed is lighter. Though I have done hundreds  of thyroidectomies  in my career, no case is similar to the other. I still can remember  those cases that  gave me cold sweats and headaches; those cases whose blood wet my underwear; cases that gave me sleepless nights thinking that they might bleed; and those cases that gave me heart attacks.
When I see my patients post op, the first thing I do is to make them smile. I crack jokes  and make fun of whatever I can see in the situation of the patient. And then, I force them to speak in a loud voice. If the patient's voice comes out normal, that is the time I ease and relax. Satisfaction creeps into my face and a smile. Done it again!

GOITER SURGERY

I did surgery for goiter this morning. It took 3 hours with an excitement akin to BATTLESHIP and AVATAR. I enjoy  my work. But the question is it took 1 year for the patient to save money for the surgery.
Anywhere else  money is not the question, the care is. They have the money to pay the doctor and hospital but the doctor does not have the compassion, tender loving care and attention for the patient. How do we equalize this?

impersonal doctors

Much to my regret, I was dismayed listening to a patient her experience with other doctors. She waited for hours in the clinic of a doctor to be brushed aside with few questions. She was out of the door in 5minutes. That was the consultation. I thought this was something unique of a doctor. NO. More and more patients are complaining that doctors do not have time to discuss their cases. Doctors were practicing to fill out a quota not to take care of patients. In my 30 years of practice, I enjoyed making jokes and talking about everything under the sun with them. I become so personal with them that I became godfather of marriages, confirmations, baptism and get invited to so many functions.
Why had doctors become so impersonal? HMO'S, medical insurance coverage, and the drive for more money (greed). During the days of the medicine man in tribal communities, he receives whatever re-numeration the patient doles out in the form of vegetables, farm animals, whatever. And he was not rich above the others.
Today, the lifestyle of doctors are way above middle class. He's got to own, a fleet of cars, 2swimming pools , a large estate to be called a successful doctor. Many students go to medical school because it is where the money is. The Hippocratic oath of service above all else is gone.
This is the main reason why alternative medicine and herbal supplements have flooded the market. Patients do not trust their doctors. Who would with a 5minute consultation? The salesman of a herbal supplement stays longer with the patient than the doctor does.
I really hope that before the end of my lifetime doctors would turn around and care ....really care for patients.

CIRCUMCISION 1

If we survey the world, a lot of countries are adopting the ritual the Jews started 4,000 yrs ago; circumcision. The only populace who does not believe it is necessary are those who live in Europe. Circumcision is practiced in most countries in Asia except in Korea and Japan though  Christians are a minority.
I used to have a website way back in 1996 and I featured the necessity of circumcising children for hygienic reasons. A lot of readers reacted to it even violently with a lots of exclamation points on their blogs.
Today, WHO is recommending circumcision to all children especially in AIDS prone countries. Before, I used to do the surgery for the simple reason that in my country it is the tradition whose majority population is Christian. When I was in Libya in 1984, circumcision was a practice done to young boys in that country. The procedure is so simple. It is just cutting the upper portion of the prepuce ( penile skin) and trimming it. Surgical techniques have been developed reducing blood loss and pain. I usually do it in 10minutes flat. I dampen the fear and anxiety of the boy by talking about school, classmates, teachers, peer group, toys, movies and friends

medical education

I did a z-plasty on a patient with contracture deformity on the right middle finger yesterday. He sustained an injury in 2010 lacerating the base of his middle finger. He was brought to a local surgeon and suturing was done.A year later, his finger cannot be extended anymore because of  a large contracture pulling the finger down. I did a usual z-plasty release of the contracture for easy repair. And guess what, the finger was not release. It took another incision on the side of the finger to release it.
We can find a lot of procedures in the medical books as well as in lectures and medical education proper. Nothing could surpass experience.  Thus, if you are facing an old surgeon on his twilight years, think EXPERIENCE.

wound healing

In my 30 yrs of medical practice, I have never seen wounds to heal faster with ointments and liniments ( povidone iodine, merthiolate, alcohol, etc). They aggravate the scub formation and thus cover the normal healing phase. Often times, pus forms under the scub and makes the patient think it is healed when in fact it is not. Nothing is better than soap and water. I have seen abrasions and scratches sustained from vehicular accidents and they heal in 24 hrs if washed with soap and water properly.
The practice of emergency rooms all over the world is to paint povidone iodine immediately and place some bandages. You have the option to refuse....if you believe my 30 yrs.

breast masses

I am just flabbergasted why doctors subject women who have breast masses to needle biopsy? If I am the patient and the needle biopsy will turn out to be benign, I would not allow the lump to stay inside and wait for it to become malignant. There is a chance for it to turn malignant in the following years. We cannot know. Needle biopsy samples only a portion of the lump and not the entire mound. I would rather go for excisional biopsy to remove the whole thing and forget about it if turns out to be benign.
I opt for needle biopsy if I suspect malignancy and the breast mass is too big for excisional biopsy under local anesthesia.

dengue drama in real life

Platelet is 96.Patient is weak; no bleeding episodes. We are discharging the patient tomorrow. If a doctor has patients like this everyday, he will die early unless he is not affected by his patients condition. Most doctors are affected.  But some have become numb.

dengue drama in rel life

I don't know with other countries but our red cross here does not give or sell blood to patients if they cannot provide a replacement. This is really a crazy policy . What if one has never donated blood to the red cross? He can never asked for blood from them. And then, a policy was promulgated shutting down all blood banks in the city which could have provided an alternative source for blood.
My patient's platelet hovered between 6 to 9 yesterday. This morning, it has gone to 32. Alleluliah. We are not out of the woods yet. We will wait for the next platelet determination in 6 hrs.

to xray or not to xray

Xrays do not make a diagnosis. Nor ultrasounds and Catscans. Doctors do. Consider this xray of a needle in the foot. It was done to find the needle. Even with the xray it took me 30 minutes to find the needle. If I did not do the xray and went direct looking for the needle I could have done it in 10 minutes. I could feel the needle. But I was misled by the location in the x-ray film.

dengue drama in real life

The patient's platelet is now 6 only from a normal of 120. We have consumed 6 packs of platelet concentrate. We have requested for 4 more packs. But we don't have any bleeding from the nose, mouth or anywhere. The patient is weak with rashes coming out from his legs and arms; signs of impending hemorrhage. Urine color is normal . We are hydrating the patient to the max to prevent hyper-concentration of  his blood which occurs in DENGUE patients causing renal failure; one of the causes of death.

dengue drama in real life

The platelet count has gone down to 9 as of 12 noon today. 3 units of platelet concentrate are available and running.

dengue drama in real life

Platelet determination is being run in the laboratory as of this moment. Blood samples have been taken a minute ago. If only someone would invent platelet determination that could be done at the bedside, this drama could have ended a few seconds ago. You see, we have to do platelet lab every 6hours rather than doing it every minute because it is too painful for the patient and platelet does not go down drastically to catch us napping.

DENGUE

A patient was admitted under my care last night. Platelet 36 but no bleeding or any signs of hemorrhage both inside his body or outside thru the nose, mouth or any rashes on the legs and arms which are signs of DENGUE. You see, once the platelet count of a patient goes below 50, some of them bleed profusely inside the intestines and thru the nose. The normal is 120.
At midnight, text message from my resident showed platelet 25 but no bleeding episode. Most patients die when they bleed without platelet concentrate transfusion. But if transfusion is done too early, it is useless. By 6am this morning, my 16 yr old male patient has only platelet 12. I have requested for 6 units of platelet concentrate Let us wait for the next platelet count this 12 noon local time.

time in the clinic

The moment you sit in front of the doctor, make use of his time, not yours by telling a long story about yourself. You CONFESS your pains as  you do to a priest. You LISTEN to his questions as you do to a police officer. BELIEVE in what he is saying as you do to yourself. And MAKE UP your mind as you did when you got married to your current wife. Never mind the previous ones.

your doctor friend

60% of stroke cases happen to people who stop their anti-hypertensive medications due to advice of neighbors, relatives and friends who are not medical professionals. Your doctor friend is the only one who could stop them. Befriend your doctor now. Don't seek another one unless he dies ahead of you. Of course.

how to self medicate

So, you got fever? If you have sore throat and colds, don't take any antibiotics. Take meds for the relief of fever, nasal congestion and muscle pains. You are just taxing your liver and kidneys by taking them. And get some sleep.

Some people resort to so many drugs to find relief from this. And yet, it takes only a small puncture  with  a needle  for a complete cure.

Do you really need  to have surgery for a small lump? Go ahead  and see the picture and decide for yourself. Most lipomas and sebaceous cyst of the skin grow this big and need to be removed under general anesthesia. Would you prefer to have yours removed under GA or under local anesthesia?

cyst in the breast

 A lot of general practitioners will always do breast sonogram or mammogram if they can feel a mass in the breast. What for? Ultrasound does not make a definitive diagnosis nor does mammogram. A biopsy of the mass be it a needle biopsy or excisional biopsy will give the right diagnosis.