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.