HINDU GODDESS

In my role as a personal-family physician, I sometimes take the role of a Hindu goddess with multiple hands and arms and multiple faces.
Some patients would not like me to divulge whatever my medical findings are to the patient. I face the relatives with grim face in serious cases while I smile to the patient while discussing the case. Though I always insist of letting the patient know, some relatives fear that divulging his real situation would aggravate and lead to early death which is not often the case.
Some people expect us to perform surgery in different locations at the same time or to finish pronto in a wink. We haven't finished injecting anesthesia and they would ask:" Are you done?"
During surgical residency, some consultants expect us to hold the retractors steady while suctioning the blood and holding their sutures tout. . In other times, they would expect us to answer  all questions right while retracting the liver away,; the intestines to the left and below and the gall bladder up.
Oh! How we wished to have all the arms and hands of the Hindu Goddess.

DC HERALD

I am starting to write a column in a local newspaper DC HERALD; a Catholic weekly newspaper circulated among church goers every Sunday. It is a compulsory reading for Catholics here in Davao City. With a circulation of about 2000, this could be a good spring board for my marketing.
Ever since I became a doctor I have been marketing myself with the use of leaflets, radio, writing a news column, television and Internet.  I was involved with so many free clinics and free surgical programs just to market my practice. This was because I read Steven Covey's books and was convinced that even medical practice need marketing to survive. He was right. If not for my marketing, I could not have survived with so many doctors in our city.
My computer had been busy the past two weeks making marketing letters. All marketing gurus I have known including Suzi Orman have been saying not to sit on our laurels. We have to be on our feet most of the time innovating ourselves following the trend of the time. That is what I have been doing to this day until I drop dead.

TUBERCULOSIS OF THE SPINE

In this age of enlightenment ( think  Google, Ipad, cable), we should not have any tuberculosis of the bone much more tb of the spine. The last time I diagnosed one was 5 years ago. But lo and behold, I saw one yesterday with a partial destruction of his spinal vertebra at the thoracic level. And he has no symptoms except marked lost of weight. He claims he really does not know where the disease came from since he never knew of anybody having the disease coming near him. The sad fact is most of these people are resistant to anti-tb drugs. I started him on regular medicines plus an injection and cross my finger.

SEQUELA OF steroid injection for scorpion bite

Just as I have foreseen, the patient who was injected with steroids for scorpion bite developed facial edema and generalized mild bloating in the upper and lower extremities. The hand where incision and drainage was done drained out pus up to yesterday. But the hand has markedly diminished in size except the fingers.  I have seen scorpion bites where the whole surrounding skin sloughed off. What remained was bare ligaments and tissues. This entailed skin grafting and more expenses to the patient. Good that this patient did not have that. They had difficulty in going home because they paid a lot for the hospitalization including medicines.
While managing this patient, I came up with the idea why not develop a RETAINERSHIP PROGRAM where at Php50 per employee per month, the employees of the company could have free consultation together with their first degree relatives. I would charge PHIC coverage only (medicare ion the States) and no extra in the professional fees including surgical procedures. Most health insurance in the Philippines charge each member hand and foot ( about 1/8 of their take home salaries). And they block any coverage on preexisting diseases which are most often the complain of these people. They seldom get sick and if ever, what they spend in the hospital for medicines and daily room rates do not consume the usual annual fees of these HMO'S. The Philippines Health Insurance Corp covers room and 1/3 of surgical procedures with a minimal fee to the physician/surgeon which is good enough if we don't change our cars yearly. PHIC covers a very minimal amount on medicines. That is why, this is the main  problem of employees when they get admitted. I was thinking what if I facilitate credit account for them in accredited pharmacies where they can charge their medicines and pay for them in small amounts ( monthly salary deductions for instance). A pharmacy I know would readily agree with this arrangement because it is a captured market and they would be assured of payment because the companies where these employees work will see to that.  What do you think?

BOUNDARIES OF SPECIALTY

Whose specialty is this? Plastic surgeon, ophthalmologist, dermatologists, general surgeon? Some people would even claim that this is  for oncologist or radiologist not to mention the HEAD AND NECK SPCIALIST and the ENT. Confused? So am I. What did I do?
I cauterized it and excised the base of the wart. Yes, it is only wart and if you go to a doctor who do not think of expense for your sake, he will do biopsy first. Wait for the result. And then, do z-plasty excision if he is a plastic surgeon. Or for ENT man, he will do V-EXCISION. Or if he is opthalmologist, I don't know what he will do with it.
IN this era of specialists and subspecialists, we get confused where to go or to refer and this adds expense to the patient. For me, if I can do it and if I believe that I can do better, I will do it for the sake of the patient.

SCORPION BITE SEQUELA

5 days after bitten with a scorpion on the hand, the patient's hand swelled despite the steroids given intravenous and subcutaneous direct to the site of the bite. The fingertips became pale signifying ischemia due  to the pressure created by the swelling. On examination, the dorsum of his hand was fluctuant signifying accumulation of fluid. This prompted me to aspirate the hand with a 10cc syringe. Lo and behold, the aspirate was pus. The patient confessed that he punctured his hand on his own using a needle thinking that he could be a surgeon on his own body. The scorpion bite became infected. In my past cases, scorpion bites produce a fluid filled vesicle which were clear and non-turbid. Definitely he needed incision and drainage. I did it this morning and extracted about a 100 cc of pus.
Moral lesson: let us surgeons do the management. You can never treat yourself.

QUESTIONING DOCTORS ADVICE

Have you ever thought of contradicting doctors' prescription and advice? Dangerous but there are some things we say that are not rational. For instance not eating meat for those who are hypertensive. But you were eating meat ever since you were born. Why would it be dangerous to eat them now? If you read medical and fad books on diet, meat is the only major source of protein. It could never be substituted by any other form. Besides, is there a study showing that meat aggravates HYPERTENSION? Yes it increases cholesterol; the cholesterol that is floating in your arteries and veins. But the meat you ate this morning could not increase your blood pressure because the cholesterol responsible for it was taken 20-25 years ago. It will affect your blood pressure 5 to 10 years from now when it deposits in your vascular system. If you take it from your diet, there is no way the body could replenish the fat based vitamins and the cholesterol necessary to produce hormones.  

SCORPION BITE FOLLOW UP

I saw the patient this morning. He received 2 injections of SOLU-CORTEF yesterday afternoon; 1 intravenous and the other given subcutaneous near the bite wound. I was horrified when I saw him. The hand was darker; more bloated. The fingers are more pale than yesterday. In other words, the steroid was not working. But the patient insisted that the swelling has diminished in size. The pain has subsided and there was no numbness on the tips of the fingers signifying CARPAL TUNNEL SYNDROME or the impingement of  the nerve passing thru the wrist. The treatment was working but the doctor cannot see the difference or the effect of his management.
In here, you can see the importance of communication and rapport between the patient and the doctor. If I did not believe my patient, I would insist surgery; open up the hand to release the pressure. But I believed him and he believed in what I was doing. 

SCORPION BITE

If you have watched SKYFALL where Bond is playing with a scorpion, you would think it was cool . Wait till you will have a bite too. The pain is so excruciating very difficult to relieve with ordinary pain relievers. There is a burning sensation inside the tissues and the pain shoots into other parts of the body. Then, the bite site swells double the size of the affected area and starts to darken.  A vesicle forms and in 24 hours, this bursts and leaves a large raw weeping area. It does not heal until the venom disappears  and will need skin grafting to cover the wound. If the affected area is the upper extremity, amputation is more likely.
Anti venom injections are not available in many third world countries where the incidence of scorpion bite is more prevalent.  What we do is to inject steroids to mask the effect of the venom. It is the only medical armamentarium we have.