TINUY-AN FALLS

What does this picture got to do with medicine and health? I have been in practice for 31 years and because of my hectic schedule I have not visited any of the wonderful tourists sites of my country. When I went to this falls, great pride surged into my being and a lot of good endorphines flooded by senses. I have been in financial crises lately and this place gave me a boost to face odds which to me were cliff hangers. If you feel down and depressed, go for a vacation  just near your place for you to free yourself from psychological handcuffs

17 days of a diabetic foot gangrene

17 days after

10 days

1st day

You can see on the left upper corner of the picture of the diabetic foot gangrene 17 days after I first saw it. Compare it to the first day, you can see the viability of the foot. If I could have been in a hurry to cut it, this patient could have been an amputee all his life. The camera could not show how good the skin has become. This is just to show that there should be patience in the part of the surgeon. But the protocol followed by most surgeons could have amputated this foot. 

RIGHTS OF THE PATIENT

More and more companies control the lives of their employees. When they register their employees to an HMO or to a retainer physician, this practically ties the employees to a particular doctor not of the employees choice. This disrupts the medical history of the employee to that particular doctor and more often than not, dissatisfaction creeps in between the patient and the new doctor.  The new doctor examines the employee routinely ( most often haphazardly) because he receives a fixed amount for every patient unlike the enployee's doctor of choice who had created a rapur in the years that they had seen each other. And this is the main reason why patients sue their doctor in the event of un-acceptable result of medical care. If we doctors want to decrease the incidence of malpractice suits, we should insist to the patient to develop a personal touch with his doctor before he goes into a more complicated medical care procedure. 

INSOMNIA

You can always take some drugs to go to sleep. But the natural-normal way to go back to sleep is to make your brain rest. When you hit the sack and you cannot bring yourself to sleep because of so many things entering your mind, get up, walk or do some readings. Or,  think about what is bothering you until the time you are nodding. This comes when you have already made up your mind what to do with the problem or you have come up with a solution. Drinking milk or sipping tea is a ritual that could help but this is due to the calming effect of the act of drinking just like smoking. Most people stay in bed despite the fact that they cannot sleep. This causes more problems to your brain. You toss and turn which activates a lot of muscles thereby increasing a vicious cycle of muscle contraction and thinking. Get back to bed and close your eyes without forcing yourself.. Think of empty space like a beach or a desert and nothing to see except the sand or the sea or the space where nothing is moving nor anything to attract your attention. Some people think of clouds. But this usually triggers a lot of memories just like the beach or the desert for some people. If all these scenarios cause you to think more, think of other things that would bore you. 

depression

Though we seldom see a lot of patients complaining of depression, the incidence of depression is rising due to the economic situation and personal reasons. And the treatment of depression is often inadequate to address the problem. Once the patient wakes up from the anti-depressant drugs prescribed, he/she often dives back to the depressing state if his/her problem had not been solved. More often than not, his problematic situation will be solved on its own even without the patient finding the solution. Suddenly, the future looks bright despite the fact that the problem was not solved. The main ingredient in the sudden change of his psychological situation is ACCEPTANCE of whatever will happen next; no worries, no more anxieties  and plain acceptance of whatever the future holds. And this acceptance can always be initiated by going out of the house and finding any distraction from the present situation. The new location like a beach or a mountain perverts your senses and your brain to go back to the problem which you think you can not solve on your own. You have done whatever you can and the problem does not go away. So, by distracting your brain from depression, you go out and find happiness in everything different that you see no matter how trivial it is.

to shave the armpit or not to shave

Because of social norm, women today shave their armpits to remove unsightly hair. But because of abrasion  or small lacerations caused by the blade,this usually caused furuncles or small abscess in the area. This in turn causes the blockade of the normal growth of the hair follicle producing cyst or small lumps in the armpit necessitating surgery.

The appearance of liquid  hair removers has diminished the incidence of this tumor formations. But the side effects of these liniments like blackening of the armpit have prevented widespread use. 

herpes zoster

Painful vesicles on the arms are not very common for herpes zoster to form. More often, we see them on
the chest  in the elderly. But nowadays, we see them all over the body; lips, forehead, legs, flanks and back. We have to rewrite medical textbooks for these changes.

diabetic foot gangrene 10days

The patient refused to have the amputation. He had episodes of depression and for the last three days  could not sleep. And look what happened!! There was improvement in the blood supply in the toes. The dark point on the toes disappeared. There was marked improvement in the blood supply of the foot. Moral lesson: longer patience for the doctor; and perseverance and a lot of luck for the patient.

result of self medication

He may look normal for an Asian child. but if you look closely, his eyelids are puffy and swollen. This is the result of self-medication of Co-trimoxasol; an antibiotic very commonly given to Filipino children when they have cough even without prescription. There was an allergic reaction to the antibiotic. Good that the allergy did not affect the kidneys as was shown by ultrasound and creatinine determination.

need of medication

30% of patients do not need medication when they consult a physician. Most of them have self-limiting diseases usually viral and there is no treatment for viral infection  except for a few. If you have fever for example, check if you have colds. Definitely you don't need antibiotics if you have colds. You only need antipyretics for fever and pain relievers and a lot of rest.

amputation refusal

Most patients if they can only do away with surgery, they will refuse it. My  patient who had diabetic foot gangrene refused to have the surgery. Instead, he went home and nurse his own wound. I don't know when I can do the amputation.
The preservation of one's limb is always the primary goal of a patient no matter how critical the amputation is. Most would not accept the explanation that if we cut his limb he will survive.. Many patients would rather preserve their gangrenous foot than to lose them no matter what. But all of them would beg to have the surgery when it cannot be done anymore because he/she could die during the procedure.

diabetic gangrene 72 hrs later

You can see in the pictures how the gangrene has worsened. But the fact is, the patient still insist to have his foot and would not like any kind of surgery. There is a slight increase in the vascularity of the surrounding tissues by the presence of bleeding during dressing but the yellowish portion is not improving. The dark portion of the  plantar area is slightly lighter than before signifying improvement of blood supply. I talked to the patient  this morning and tried to convince him to have a below knee amputation but he would rather die.

diabetic foot

All patients with diabetic gangrene of the foot would always choose to have their foot and never agree to an amputation. They usually would only give their consent on the last minute. In some cases, it is the doctor who will make the decision by force to save the life of the patient. Because of this, doctors would tend to be radical and amputate further up the limb instead of conserving the remaining foot. For a small lesion, the whole lower extremity is not spared. For the last 31 years, I have geared towards conservation. If I can spare the foot, I will  do debridement conservatively and allow the foot to grow more tissues instead of amputating. And I had very successful rate in these patients to preserve their foot. Though it took months for them to have a normal foot, at least, they had their foot and walked normally unlike amputees.

to amputate or not to amputate

Enclosed is a diabetic foot of a 52yr old male, diabetic.This is the appearance of the foot 1wk after onset of symptoms. He had been diabetic for the last 5 years and drug intake was irregular. Pulses on the foot are normal. Do we amputate?

dropping dead

We seldom see people dropping dead on the streets nowadays. But it was very common in the 50's because of the absence and/or the existence of preventive medicine like annual physical examination and blood chemistry.  Today, when people feel something abnormal, they go to the doctor. In those days, it is something big to go to a doctor and they usually go to one when they really feel bad. Thus, we seldom see people unable to reach the threshold of the hospital.
Now, unlike medicine, computers just blink and drop dead without you doing anything wrong. My computer did yesterday. That is why you didn't  see any fresh blog yesterday. If only somebody would install preventive maintenance on our computers long before they just drop dead like the thing will just repair itself in the evening while the unit is not being used.

25 yrs post breast cancer

 A patient of mine recently visited my clinic whom I diagnosed to have infiltrating ductal carcinoma ( breast cancer) stage 1 in 1987; 25 years after I removed her right breast. Most of you would surely say that most breast cancer only survive for 5-10 years. I do have a lot of patients who did survived more than 15 years after surgery after chemotherapy. If you keep tab of the multimedia releases, what you often hear on breast cancer is grim. The long survival rate of my patients is due to early detection by physical examination not by ultrasound or mammogram. Some women do away with physical examination by an expert surgeon  and go straight for these diagnostics. Nothing could substitute for a good physical examination

prostate cancer

We should be thankful for people who do statistics and trials. If not for them, we would be following the same protocol of medical management. Look at PROSTATIC SERUM ASSAY. Study was done on the significance of this test for prostate cancer. The study showed that it only heightens the panic of the patient if it is positive but does not extend his life; and to the doctor to do radical surgical management like prostatectomy which produces complications like impotence without so much benefit to the patient's life and well-being.  Using PSA for prostatic cancer screening does not even give any significance in the management of  this disease. And yet, we never hear of statisticians being given awards or a Nobel price.

engrown toenail

You will be surprised how many I operate every week because of engrown toe nail. And the reason for this illness is because of frequent pedicure. Let the toenails grow more than the toe for a awhile. Don't cut the corners. This will allow the toenails to insert into the side tissues

hemorrhoids

I operated on a very large external hemorrhoids yesterday. I was wondering why  people wait this long to have an operation such as this. The operation is simple for me but the problem is complications such as wet anus or incontinence is very common in large bulging hemorrhoids. Many people would postpone or rather would not have the operation for fear of these complications. But they do not know that a simple technique for simple hemorrhoids has absolutely no complications ( diamond technique as compared to white head procedure). Many people end up with fistula in anu which is a more dreadful complication because this creates a canal way up the anus. I forgot to take pictures of my operation yesterday but you could not imagine how big it was.

legacy

While I was reading TIME's  100 most influential people, I was made to think of my career for the last 30 years as a surgeon. The perineal problem that I often encountered in my practice was the lack of money to buy medicine. The doctor was available and consultation can be had in most government hospitals. But the biggest problem that patients encounter was how to buy the medicines prescribed. I got to thinking that why is this. A lot of movements and foundations face problems like AIDS, MALARIA, TUBERCOLOSIS but none is addressing the most common problem of patients: the treatment of very common illnesses such as UPPER RESPIRATORY TRACT INFECTION AND URINARY TRACT INFECTION. These diseases need antibiotics and no charity foundation or cause is addressing this problem. Why not form a group that would address this common problem and help a lot of people more than AIDS, MALARIA, TB, POLIO combine.

Belief in doctors is dwindling

I was just wondering why so many people would rather believe in what they hear from their neighbors more than doctors would say. They would believe everything they read and see on tv or internet and doubt the doctors whom they consult. There is an increasing mistrust with the medical world. Back in the 19th century, what the doctors say would be taken hook, line and sinker. Today, a second opinion is a must or even a third would be preferred by a patient rather than plunging direct to whatever medication is suggested by the physician. Most of the patients I see either had began self medicating before coming to the clinic or had seen several physicians and did not believe what they said.