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.

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.

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.

What to eat and what not to eat - GALL BLADDER STONE

GALL BLADDER STONE

If you don’t have the desire to have surgery for now and you would not like to have the symptoms of bloatedness, epigastric pains, back pains and the feeling of indigestion, don’t eat fatty foods, dairy products, any food cooked with cooking oil, very high carbohydrate concentrated delicacies (cakes, pastries). That is almost everything in Asian diet and dinner for Caucasians. Well, if you don’t like to have those symptoms above. If you cannot live without indulging in these food products, have the surgery. It is a matter of this or that. This is because the gall bladder stone is forced to enter into a smaller tube whenever you eat these food products. The smaller the stone, the acute the pain. If you are forced to eat them as in parties or socials, you can find relief of the symptoms by drinking citric acid containing juice: pineapple, apple juice, lemon juice ( lemonsito) in high concentration; meaning, no water mixed with them. Of course, you have to make way for the bad air coming out. You will pass flatus in a few seconds. If there is no relief after drinking the above concoction, do it again until you pass flatus. You will have watery stools (poops) after that. No amount of anti-spasmodics could surpass the effectivity of this concoction. I have prescribed this to so many patients who fear gall bladder surgery in the past 31 years including myself.  

ANESTHESIA MYTH

I always hear patients complain that they were operated without anesthesia for furuncles, abscesses and pus forming wounds. The common concept of surgeons  is that pus or the presence of infection-abscess will prevent anesthesia to diminish pain. But I had a different experience. All of my patients had local anesthesia infiltrated around the pus formation or infected wound and I was able to debride or do incision and drainage on them without pain. Of course, The surgeon should never inject the anesthesia on the abscess itself since the milieu in this area is acidic and local anesthesia like lidocaine would never do its job. Inject it around the affected area where the boundary of normal skin and cellulitis is. The patient has borne so much pain already having those boils. A little less of it is heaven for them.

food poisoning

130 students were admitted in the hospital yesterday because of food poisoning. Vomiting and loose bowel movement  were the main complaints of the students after consuming several kinds of food including coco juice, adobong chicken and chicken salad.
Nobody could prevent cases like this. The smell of the food could not give away the presence of bacteria if it is consumed early.
Though dehydration is the main result of this illness, this could trigger graver problems if not admitted to the hospital.

HEALTHCARE

Which country really provides the best health care?
I have a lot of patient expats from all over the world. They have one complain in common: their healthcare sucks! Whether it be socialize medical care, Obamacare, HMOCARE, or no care at all, no one seems to be satisfied with the delivery of healthcare in their respective countries.
What is the best medical care that I could think of? Social medicine provides cradle to grave support but because of the bureaucracy, a lot of their population complain of seeing their doctors 30-60days after their symptoms start.. Well, they say that if it is an emergency they could go straight to the emergency room. Private medical care is best if you have the money. Most social medicines are being abused  in countries ruled by totalitarian/dictatorship governments. I have seen how medicines are thrown into the garbage cans by patients dissatisfied with the service.
We have seen how taxes rise when healthcare is increased in some countries. If only we can balance healthcare with taxes, we can have an ideal healthcare.  If we can have the technology wherein taxation is individualized and pegged on the usage of the healthcare service, this would probably deliver an ideal budget for healthcare.

breast masses

It is fear of cancer that drives women to seek medical consultation. The information on breast cancer has generated a lot of awareness to the point of producing fear in women. To think that only 5% of breast masses are cancer and only in the ages of 30 years and above that we find breast cancer. Thus, I often face a very anxious girl in her twenty's  with a breast mass and it takes a lot of coaxing and talking to tell her that there is nothing to fear.
But before she had decided to seek consultation she injured nights of useless anxiety which to my mind is so depressing.
This is a set back to medical education extended  to layman. On one hand, it is good people are made aware of cancer. But on the other hand, we cannot impart the whole gamut of medical information unless you go to medical school. Little knowledge is a dangerous thing.

WHAT TO EAT AND WHAT NOT TO EAT - DIABETES

DIABETES MELLITUS
You are in for a surprise. You have a very high blood sugar and yet I tell you that your body lack sugar. It is because the sugar that your body is producing and the sugar that you are eating stays in the blood stream and cannot enter the cells and tissues of your body which need it most. And the reason for this is the lack of insulin which is the hormone responsible for carrying blood sugar inside the cell.
Your doctor would insist that you have to bring down your sugar intake in the forms of soft drinks, pastries and plain sugar in the coffee. The reason for this is because your organs are being destroyed by the excess sugar and yet your cells are still hungry for sugar. The brain for instance cannot use any other source of energy but the sugar you are eating and the stored sugar you have in your body. The moment your insulin is not adequate to bring in to the cells the sugar they need, you start to get hungry and the body manufactures more sugar from your tissues ( body fats).
If you are still hungry and you start to diet, this will trigger the body to produce more sugar from your own tissues. You are eating yourself.
Even if you are diabetic, you can eat anything; in fact everything on the table can be eaten except the spoon and fork, of course. But in moderate amount. Even sweets, pastries, cakes, ice cream and whatever food rich in sugar can be eaten but in moderation.
Nobody ever told you to starve yourself. But because most doctors do not explain, most diabetics overdo themselves.
How do you know what you have eaten is enough for a diabetic? The size is usually half of what the non-diabetics are eating. One half of a  slice of cake, for instance,  is good enough. It will not raise your blood sugar to very high levels if you test yourself the next day. What is important is that you did not miss your medications. Make sure you have achieved the best level of blood sugar with the medications by having a regular check of your HBA1C. But never indulge on anything sweet. Always bear in mind that you are just preventing your body from eating itself.

WHAT TO EAT AND WHAT NOT TO EAT DURING ILLNESS - HYPERTENSION

WHAT TO EAT AND WHAT NOT TO EAT
DURING ILLNESS
I
IHYPERTENSION
You have heard from friends and even doctors tell you not to eat fat if you have hypertension. But you have to realize that the fatty food you are eating right now is not the cause of your hypertension per se. It was the fatty food you ate when you were 25 years old  and all the cholesterol laden meals you ate up to this time.  The hypertension is caused by the cholesterol(fatty food) which have deposited in your arteries and not the cholesterol floating in your blood stream. These floating cholesterol may be contributory to more hypertension in the next 5 years of your life.  No medicine can remove the plaques that are deposited in your arteries and the rigidity of these tubes due to aging.  The statins you are taking (simvastatin etc) are preventive drugs that would block further increase of cholesterol plaques. If you have been taking these stains when you were still 25 years old, you won’t have cholesterol plaques today causing hypertension. So, go ahead eat a few bits of fatty foods. Remember, a lot of enzymes and hormones are made from fatty substances you eat. Decrease the supply of these important factor of your diet, the lesser will your body function. Even the digestive system and the endocrine system of your body responsible for absorbing protein and the production of sexual hormones are dependent on fatty foods you take.
Daily intake of Fatty food the size of a match box is enough to supply the necessary fat nutrients of the body.
But the food you must avoid are those with so much salt in them. Salt or Sodium increases the volume of blood because of its water retaining  capacity thereby increasing the blood  pressure. Salt and fatty foods are a deadly combination.  Join a water retainer and cholesterol producer will produce a tsunami effect in your blood pressure.
OKRA has a diuretic effect. It causes release of water thru urine formation. However, it increases the amount of Calcium and Potassium in the blood. If you are taking calcium blocker anti-hypertensives, this will diminish the efficacy of the drug.
Some doctors think that diluting the viscosity of the blood may help in lowering blood pressure. Thus, they advise patients to eat a lot of lycopenes. Tomato is one.  However, the benefit of eating a lot of tomatoes have to be further studied.
Here in the Philippines, a  fad has risen a year ago in the consumption of ginger to lower blood pressure. Studies have shown that it only thins the blood and lower cholesterol. However, it is not a good anti-hypertensive  per se.
Garlic has long been known to lower high blood pressure by lowering cholesterol. But a massive study done in Europe showed that it does not have any effect in lowering it. In fact, it interferes with anti-hypertensive medicines such as calcium channel blockers ( nefidipine).
Lemon grass ( tanglad) despite its being commonly mentioned as good for antihyperntension never showed any properties of lowering blood pressure.
Some people notice the rise of their blood pressure when eating sea foods, goats and lambs, spicy foods and protein rich foods such as peanuts and butter. If the rise of blood pressure occurs a few seconds after ingestion, this is psychological and should never be pinpointed as the culprit because this reduces the choice of food a hypertensive could have in the long run. Though hypertensive, these patients should have a well-balanced diet.
Some people with hypertension start to refrain from eating eggs (some eat the white portion only) in the belief that eggs causes increase in cholesterol. It does in large amounts. But a single egg supplies most nutrients the human body needs. It is the most complete food there ever is. A single egg does not increase the risk of hypertension but it provides 90% of the vitamins and minerals and nutrients we need.
Source:www.whfoods.org     Wikipedia

post operative pain

With the advancement of medical science goes along with it the lowering threshold of  pain. We have conquered pain  and have diminished it to the point of  painless diseases. But the drawback is more and more patients need higher and higher dosage of these medications. We cannot tolerate even a tinge of pain.
We used to administer ordinary pain relievers for simple surgeries like herniorrhapy. But nowadays, some patients need opiates to be relieved of post operative pains.
There will come a time when we will be needing injectables for a simple migraine headaches. 

BORN TO BE A DOCTOR

I really didn't plan to be a doctor. In fact, I went to the seminary to become a priest. But someone or something really lead me to become one. I breezed thru medical school and residency training and found myself caring for people whom I did not know from Adam. I never thought of the money and stability and prestige. In fact I usually find myself pitying patients in the other beds not under my care. I have so much compassion but not so much patients. Anyway, I find myself enjoying  patients who smile and thank me after a major operation. Every patient who comes under my care is very fulfilling for me. If  I could have been a priest, I could have been a Bishop or probably a Pope. Do you think so?

SURGEON'S DECISION MAKING

All these years that I have been a surgeon, the time that I most dread is when I open a patient after so much deliberation, diagnostics and sleepless nights.We really do not like to be surprised by a different finding intra-operatively. The reason why patients undergo so much work-up before surgery is because  we are trying to answer all the "what ifs" under heaven.  You cannot imagine how much anxiety a surgeon feels when intraoperatively he finds a different ball game. That is why, an experienced surgeon is the most sought after operator there is. We do not have the luxury to open books or ask our colleagues when we are in the middle of a surgery. The buck stops in our hands.

FORGOT TO BREATHE

Funny, but a lot of us forget to breathe properly including me. Headaches, chest pains, palpitations, anxiety and even depression may be caused by improper breathing. Our breathing is composed of two phases: a voluntary one wherein we decide consciously to breathe and the involuntary component which is an automatic inhale-exhale cycle of which we are not aware of. The latter is controlled by the amount of carbon dioxide in our blood. But if we have the habit of short breathing, this becomes the benchmark of our respiratory center to stimulate the lungs to expand as much. Though many people do not realize it and even the doctors they consult , this is a simple thing to cure. I have seen a lot of patients who complain of these symptoms and have consulted a lot of doctors after which they underwent diagnostic exams to find nothing wrong with them.
 If you have the above symptoms, start breathing deep for a few cycles  but do not overdo it. It may cause dizziness and headache and even lost of consciousness too. Do this frequently in a day's time and reset your respiratory center baseline. Doing so, the respiratory center will adjust to a normal ventilatory cycle which do not cause headaches, chest pains, palpitations, anxiety and depression caused by low oxygen in the blood.
You will also feel good,too, and beautiful pinkish face as a bonus.

OPEN MINDED DOCTOR

We doctors believe in ourselves and believed in what we have learned. Most of the time we need this in order to have the courage and the convincing power to ask a patient to go into surgery. Because of this, it is very difficult for us to accept a new dimension of treatment if it was never taught in our medical curricula. Peptic ulcer for instance. It was only a few years ago that the dictum of ulcer pathology  was changed to a infectious one. It is caused by a bacteria: H.PYLORI. We never learned that in medical school. It took sometime for us to adopt to the new thinking.
I never heard of CHIROPRACTIC MEDICINE in my medical school days. Either my professors never heard of it or they just kept mum about it. But what a surprise. When I was able to hear and listen about Chiropractic medicine, my mind was opened to a new dimension of healthcare. I used to refer my spinal stenotic patients to Orthopedics or neurosurgery for treatment. Disc pathology I thought was included in the realm of  surgical procedures. Then, here comes CHIROPRACTIC MEDICINE.
I had a lot of patients who underwent a lot of orthopedic referrals without any relief. Then, with my new knowledge of CHIROPRACTIC medicine, I was able to find relief for them. Foremost in my mind is to find them relief from pain and analgesics and anti-inflammatories never provided them.
If only we could be opened to other modalities like holistic medicine of India; herbal medicine of China or even the voodoo practices of  Dominican Republic just for the sake of the patient.

SLIMMING

If you have noticed, slimming salons have sprang up in almost every corner of the city together with spas and massage clinics. But magazines and newspapers scream of  overweight pandemic all over the world. I also kept noticing a lot of people having beer bellies even in poor countries. Now, what is this? We can always blame junk food and buffets and a lot of unhealthy cuisine. But what do you see on cable tv? FOOD. Where are we going in this generation? ON one hand, high cholesterol and on the other hand, sumptuous food. If you keep on listening and looking at these situation, we all will get crazy. LIVE AND let live.

KIDNEY STONE

This is a kidney stone passed by a male patient by urinating. Imagine how painful it was. It is as big as a bean and you cannot imagine how difficult it was to pass out thru the urethra. This gives you an idea that the body could produce amazing things like blue colored or white colored poops.

alkaline water

In college, we doctors have 20 units of biochemistry dealing on the real ionic situation of the human body chemistry. Then, in medical school, we had 10 months of biochemistry and 10 months of physiology. In all the subjects that we dealt with up to the time that we graduate as an MD, biological chemistry was always on the subject matter. During my surgical residency, the first year training was on the physiology and nutrition of the patient.
Now, here comes this new vogue of alkaline water good for the body and prevention of cancer. Hah!! If you monkey with the pH of the human body, it responds with great consequence: metabolic alkalosis very dangerous to one's health. Here is how it is:
The body always maintains its pH: 7.4; no matter what you do if the body is healthy, it will find a way to go back to that physiologic pH because it is the normal level of the human body to function. If you drink alkaline water, this disrupts so many organs in their normal function just to cope with  presence of this unhealthy level of the pH; the lungs will increase respiration, the kidneys work hard to expel more bicarbonates and minerals; the intestines would not absorb a lot of nutrients to prevent ALKALOSIS.Why? At this level of body pH, the brain cannot work well; the nerves cannot transmit a lot of signals; the heart cannot pump well and every thing else in the body do not work properly.
Why do people who take this alkaline water feel good? For a time, it is. But in the long run, they will have easy fatigability because their organs are working double time.
I am really amazed by people who claims things they don't really know. More amazing, there are a lot of people who are gullible enough to believe them. You can always ask the people who know the real score before you jump into a vogue.

complication of obesity

Seldom do we see this complication, but I operated on a 53 yr old female who had a VENTRAL HERNIA. This is hernia or outbulging of the intestine into the wall of the abdomen. Her case  was caused by the thinning of her abdominal wall due to the increase of intestinal fats enlarging her abdomen to extraordinary proportion. But there is weak point in the abdomen which is usually the point of the herniation and it is located at the level of the umbilicus.
On operation, there was a matted portion of the omentum protruding thru a hole the size of a golf-ball. I had to trim the  omentum to allow the rest of the intestine to go back inside the abdomen.

DIABETIC FOOT GANGRENE 24DAYS

Judge for yourself whether it was right we allowed the patient to have his foot. This is his 24th day with daily dressing of silver sulfadiazine impregnated in the gauze bandage, vascular dilators and  oral antibiotics. The foot has regained its pinkish color.  where it was whitish 24 days ago. Demarcations of good flesh are coming out on the edges of this pinkish area. Where there was soft subcutaneous tissue palpable, it was replaced with enduration and hardening of the area. The foot does not smell anymore. The toes are going back to their normal color except for the tips. I give him another 30 days to decide whether to amputate or not. His creatinine is going down from a high 400 to the present 370.

MOVIE REALITIES

I was watching an episode of "I COULDN'T  HAVE BEEN ALIVE"  in Discovery channel where the man went trekking and broke his legs. I was wondering why he never thought of splinting his broken legs when there were a lot of sticks around him. For people who do mountain climbing and leisure walking in the mountains, they should have a training in survival and how to care of themselves in an emergency. In this case, he should have brought duck tape with him for emergency. And then, splint his broken legs in such a way that he will not be placing any weight on them. by extending the splints way down about4 inches below his feet, he could walk with the broken legs hanging and the splints bearing the weight

abdominal pain

Distinguishing between an abdominal pain secondary to a surgical illness to a medical one is very important when you think of self medicating. I have seen a lot of patients whose symptoms were mask by the medications they were taking trying to save on hospitalization. We ended up with a complicated surgery.
The dictum in knowing whether you need to see a doctor or not for an abdominal pain is the persistence of pain. If after self medicating and the pain recurs or persist within 24 hrs, you 've got to see a doctor.

SUPERMAN 15

Well, the movie is not even conceptualized by DC comics ( or is it Marvel) yet. But what I am talking about is almost similar to Superman. He loses power whenever he stays in the dark for a long period of time and not just kryptonite.
We humans have the same tendency. We go into depression.  Many people  have not realized it but staying outside of the sun's rays are detrimental to your health.  It only takes 15 minutes under the sun for a cure of depression.  Patients most often depend on drugs to get them out of depression by sleeping on it. What they could have done was to get out of their houses and stay out under the sun for 15 minutes.
I do not have any explanation but I have subjected a lot of patients with this ordinary treatment who underwent major surgery for the last 31 years. It was really surprising. Most if not all patients who went thru surgery go into depression especially those who had cancer treatment. After so much coaxing, I had convinced them to go out into the sun and leave their antidepressants. Most of them have not taken any antidepressants ever since. 

weekends

How do you spend your weekends fruitfully?  Everybody knows it is the time to recharge and relax. But what really is the best thing to do during weekends. Most people would think of exercise,  go for a picnic or get some tan.  But there is something left out  in this process. Most of these activities are physical  but the brain is the most taxed organ in the body during working days. Give it a rest, too.
One way of providing rest to your brain is exploring nature or involving in extracurricular activities which are not related to whatever you are working. Acquiring new knowledge about nature and the things around you not necessarily going out of the house. There are a lot of things we do not know. By giving your brain activities which have never been involved with, you are giving it respite from a cyclic neurological response which consumes a lot of energy at the same time diminishing the nerve's capacity to respond to stimuli. The nerve pathway involved in routine work practically numbs its normal response.  This the reason why you become bored and your work becomes haphazardly done.  By involving in a different knowledge quest, you are opening a lot of new  nerve pathways refreshing the production of new nerve trunks thereby renovating the makeup of your brain.

column writing

I wrote a column in our local newspaper for 10 years about medicine. Though I seldom got any response from my readers, It was very satisfying to hear from them that they were reading my articles. But what is more fulfilling was the fact that they learned a lot from them.  Tome, what is lasting is the pinnacle of my happiness in practicing medicine

COMA

When do you say that you are giving up on your love one who is in coma? In my 31 yrs of experience, it is not the people around the patient who decides.  It is the pocket or the finance. When the relatives around the comatose patient even how close they are starts to feel the pinch of money, that is when they decide whether to go on caring for the comatose patient or remove the life supports. When the people around the patient are greedy and would rather take care of their own lives than to spend for  their love ones, they will go to court just to remove the life support. And most of the time, these people would argue under the pretext of giving rest to the patient.
Caring for a comatose patient is psychologically draining no matter how strong the love is. And the people who care for them lose their own psychological identity and  even would not care for their own health. So, when you do say enough is enough? You don't have to. The money will make the eventual decision for you.

SYMPTOMS OF HYPERTENSION

A lot of people ask why they don't feel anything when their blood pressure is on the rise. The word is INSIDIOUS,. Blood pressure does not rise overnight. It rises slowly as if to accommodate  the rigidity of the aging arteries.  Headaches and dizziness come later . Thus,  when you wait for the symptoms to come in before you will have your blood pressure taken, you are too late.
Other people stop their medications when symptoms disappear.Wrong move. Antihypertensive medications only protect the patient from eventual stroke because they lower down pressure  by blocking  ( in the case of  beta blockers) or prevent ( in the case of  calcium inhibitors)  further rigidity of the arteries. This is like a car on a hill being pushed upwards. The moment the the car is let go, it goes downhill.
Why do exercise bring down blood pressure? During the physical activity, the heart pumps more blood and increase pressure into the blood stream. These two factors dislodge cholesterol plaques in the arteries responsible for  the rigidity and blockade of the blood vessel. More blood vessels are reopen, less pressure. Nothing can substitute  exercise in the treatment of hypertension.

cholesterol

The medicine you are taking for anticholesterol is only for the cholesterol floating in your blood and not on the cholesterol plaques which is the cause of narrowing of the arteries. Now, we are giving medicines for anti-cholesterol in the hope that less plaques would form. In the meantime, the preexisting plaques remain. In some hypertensive patients, the cause is the presence of these cholesterol plaques in the arteries. Taking the anti-cholesterol reduces the likelihood of stroke and/or the persistence of very high blood pressure. But not all patients benefit from this therapy. If all patients are forced to take the present protocol of hypertension management taking the anti-cholesterol,  cases of liver cirrhosis will rise. Where are you now in your hypertensive therapy? Talk to your doctor if he is aware of this. I usually discontinue anticholesterol medicines when my patients do not lower their blood pressure after 6 months of taking this anticholesterol.

contradicting therapy

Medicine is really an art. We know that a diabetic has to lower down his sugar. But if you analyze what really is happening inside the body of the patient, it is not the sugar who is the culprit. Though it produces a lot of bad effects in other organs including the kidney, it is not the reason why a person has diabetes. It is the lack of the delivery boy who carries the sugar inside the cells of the body: the INSULIN. If insulin is not adequate enough to deliver all the sugar inside the cells, high blood sugar results. Now, if a patient is weakening and has lost energy to perform basic daily routine, he is lacking sugar inside the cell but so abundant inside his blood stream. His cells are calling for help from the organ makers of sugar: the LIVER. From the calls of the cells for help, the liver responses by producing more sugar from the fatty deposits of the body and even from the muscles. But there will come a time when these sources of sugar produce byproducts harmful to the body. What does the liver do? It stops producing sugar. The patient becomes weak and unable to do routine chores. If the patient refuses insulin, he is given oral hyopoglycemics which bring down sugar by throwing them out of the body via the kidneys or preventing the absorption of sugar from the intestines. Where is the cell at this point? It is still hungry for sugar all the more because the blood sugar is depleted by the presence of hypoglycemics.

Nothing can substitute insulin. What do we do with a diabetic patient with a normal current determination of blood sugar who is becoming weak and lethargic? Let him eat sugar.

chiropractor

Chiropractic medicine is new in my country; about 10-12 yrs. IN fact I introduced the first practicing chiropractor to my city in my local newspaper column. This added a new dimension in the care of our patients. I used to insists surgery for slipped disc but because I found the chiropractic therapy better than surgery as I found out from my patients who underwent chiropractic manipulation, I have been drawn to their care in some other diseases that  the western medicine has not provided.