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. 

UNDILUTED MIINDS

It is very difficult to teach surgical residents  when they have learned wrong techniques. I have been teaching young doctors in specialty training for 10 years and most often when they have learned something different to what I have learned, it is very difficult for them to change it. I end up trying hard to convince them that what they have learned is wrong.
It is different with fresh graduates. They have undiluted minds and brains that soak up all the things you teach. When you see them 5 years later, what I have taught them before they still are doing it making me proud.
Techniques in surgery seldom change unless someone wiser comes up with an easier one. Surgery for  breast cancer, for instance, was refined by HALSTED in the 1900's. Until now, it is the standard  practice all over the world; how we approach and make an incision to  dissecting the axillary region. No other wise guy have come up with a better idea.

TEMPLE OF SURPRISES

Medicine really is an art. You don't know what will happen next; what you will find and we always expect the unexpected.
Yesterday, I operated on a patient who had a mass on the left arm as big as a ping-pong ball. I expected to find intraoperatively an ordinary LIPOMA - a bulk of fat. But lo and behold, it was a big whitish tumor attached to the nerve surrounding it actually ( ulnar nerve) and no matter how I infiltrate anesthesia on the surrounding areas, there was pain and I cannot proceed. It took me several minutes before I can free the tumor with a lot of pains to the patient ( usual for tissues around the nerve).  I could only think of FIBROSARCOMA which is malignant or a NEUROMA - a tumor coming from the nerve itself.
If a surgeon is not well experienced in finding cases like this, he would surely close the wound without removing the tumor - an open-close case which always happened to young surgeons.
To me, medicine is the most exciting profession excluding the military life of course.