CARPAL TUNNEL SYNDROME

There are times in my career that I hesitated in the operating room; whether to do further surgery or be conservative. And this is one of them.
A patient who drifted in the high seas for 3 days after their boat capsized during the HURRICANE PABLO which devastated Mindanao sustained contusion of his left hand. This became swollen and the fingertips darkened. He was in pain while drifting holding on to a small wooden flank. He was picked up by another boat barely surviving with other multiple body injuries. When he was brought to the shores of General Santos, attention of the doctors were focused  in reviving him by placing him in the ICU. His hand was misdiagnosed as an ordinary swelling. He was always severely in pain and complained about his hand. Nothing was done to it. The family decided to transfer him to Davao for further treatment.
When I received him, his index-middle-ring and small digits were black on the tips with severely swollen phalanges. The swelling also involved the palm and the dorsum of the hand.
He was in a late stage of CARPAL TUNNEL SYNDROME; severe constriction of the middle nerve and venous system of the hand.
The patient wanted me to cut the tips of the fingers. I explained to him that that is not the main problem right now. He was losing the whole hand. I wanted to do FASCIOTOMY; cutting the fascia of the hand to relieve the compartmentalization. But in the back of my mind, I wanted to do what the patient wanted me to do.
After doing FASCIOTOMY, I argued with myself whether to proceed with the finger amputations or not. But I was sure, the amputation stumps will not heal because the phalanges were so swollen. Despite the wish of the patient, I did not amputate. I went out of the operating room and came back several times not knowing whether my decision was right or not.
The next day was a cliff hanger for me. I made my rounds and the first thing that I asked the patient was: is it still painful. The patient was smiling and told me he had a good night sleep the only one since the HURRICANE.  

RESULT OF SELF MEDICATING

 I have been vocal against self medicating and the use of herbal medicines since 2004 especially those being applied on wounds. This is the result of MX3 placed directly on the wound. This was once a small scratch but because the patient listened to the radio and her neighbors, this resulted to a large gaping wound nonhealing for more than 2 months now. The wound does not epithelialized ( form new skin) because the MX3 killed and burned the new skin being produced by the body every day. A scub is forming on the rim of the wound preventing further migration of the new skin into the center the wound. Wounds heal by forming subcutaneous tissue inside the wound and it is covered by new skin from the periphery. If something is preventing the skin's migration, the wound does not heal. Nothing stimulates fast growth/migration of the skin. Absolutely nothing. Take it from me and my 31 years of experience as a surgeon. Facilitate the skin formation and you will have wound healing. 

FRACTURE OF THE PUBIC RAMUS

An 11 yr old boy was hit by a van and thrown 4 meters away hitting his right side. The only physical signs of trauma were multiple abrasions on the face and right shoulder and a contusion-hematoma ( bruise) on the right flank. On xray, there was fracture on the right ramus of the pelvis similar to this xray picture from the Department of Health Gov of Australia

Sorry, guys, I forgot to upload the xrays of this boy. But, this is just to show how trauma may affect everything in a human person's body. The trauma was on the right but the fracture was found on the left rami of the pelvis. I could not find any reason why.
The moral lesson is, if your doctor examining you suspects something, urge him to suspect everything.

POVIDONE IODINE

Time and again I have proven that povidone iodine placed on a wound will delay healing. It forms a hardened scab over the wound accumulating pus, preventing proliferation and growth of new tissue and even killing it and forming a big crater of a non-healing wound.
I have stopped using povidone iodine solution on wound dressing since 1986 right after I noticed that it takes time for the wound to dry up even ordinary abrasions sustained by patients who figured in a vehicular accident.
I have seen with my own eyes under a microscope how povidone iodine dehydrates skin cells and kills them the way it kills bacteria.It is good for preoperative skin preparation but not for fresh wounds and dressing.
But until now nobody seems to know about it. IN all emergency rooms in any hospital here in the Philippines, povidone iodine is the routine dressing solution. Soap and water are forgotten; the right solutions for wounds.

PROFESSIONAL FEES

In these years of medical insurance coverage and MEDICARE (PHIC here in the Phil), medical professional fees are pegged on value units and whatever coverage these insurances pay ( on what protocol I don't know). But we always feel that these payments are not enough for the risk of our decisions when we treat patients. IN fact, we feel that our decision making is priceless.
     IN the years before these value units were instituted, we charged patients based on how much risk our profession was exposed in the  treatment decision making. I am talking about surgical cases. Most people find these professional fees exorbitant. I have never encountered a patient who said that the professional fees of other surgeons were just enough. My professional fees were often gratis and if ever they pay, the money is just enough for my daily needs.
   How much really is the risk of our profession when we do surgery? Foremost we are subject to the satisfaction of the patient. The less we explain, the more likely the patient will sue. And if people around the patient starts to bile the work of the surgeon because somebody they know had this and that though not a single patient is exactly the same as another, the patient will likely to question the work of  his surgeon. Even if the outcome is perfect ( to me as a surgeon), the patient will likely find the reason to ridicule the handiwork of his/her surgeon.Not fair of course but not all patients are like this. I had a lot of patients who go home with a mile of smile

74 yr old with a breast mass

A very active 74 yr old woman developed breast masses on both  sides.She had a history of excision of a breast mass 10 years ago and turned out to be fibrocystic. This time, she wanted them removed though I suggested a fine needle aspiration biopsy; less trauma, clinic procedure, less expense. But she rather would have them gone instead of thinking about them for the rest of her life if they turn out to be benign. But cardiopulmonary clearance prevented the procedure to be done under general anesthesia. I opted for local anesthesia which she dreaded because of the trauma she experienced in the previous surgery. My anesthesiologist would not like to use neurolept anesthesia because of her age. So, I have to be contented with diazepam plus lidocaine.
Everything turned out to be uneventful and finished the surgery on both sides of the breast in 40 minutes; 20 minutes on each side.
This always reminds me of the show :NAME THAT TUNE"......I can guest it in 2 notes.