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.