HUMAN SUFFERINGS

I had this patient yesterday who never consulted a physician all her life. She never got sick probably or was self-medicating for whatever illness she had. For 6 months she noticed a mass on her right thigh the size of a pingpong ball. This did not disturbed her  nor gave her something to worry about. So she thought. 3 days ago, the mass suddenly became painful and enlarged to this size almost double the size of her thigh. She was 64 yrs old and thought she could do without a doctor. But yesterday, the pain became so unbearable and she could not walk because of the pain. And she did not have any money despite the fact that she was once the general manager of  a Yamaha School of Music. She started to have fever. She was forced by her husband to seek consultation. When she came to the clinic, I came to realize I was facing an elderly who does not believe in Western Medicine but who obviously need it. The abscess was as large as the picture full of pus. Incision and drainage is necessary pronto. After much convincing and a long wait while they count their money ( in front of the secretary of course), I did the I and D. The abscess contained as much as 1 liter and the smell was as putrid as a 3 days dead cat. I did the procedure in the clinic to save cost. But the whole office smelled for 24 hours. Why would a person suffer if treatment is available? Why does fear rule our lives?

VACATION

I usually go on vacation every 2 years outside the country and indulged on all the perks that I can afford: night golf in Shanghai, eco tour in Penang, night life in Mumbai, elephant ride in Bangkok and gold shopping in the suks of Amman, Jordan. But my clinical mind does not go on vacation. I worry about the patients I left behind in the care of my associates. And then, these patients have my mobile number. Not a vacation really.
One time I was in the middle of my golf swing in Singapore when my patient who had RIGHT HEMICOLECTOMY (partial removal of ascending colon ) because of colon cancer  called up to tell me that her poop was always watery ( normal post op with this procedure). Well, wouldn't you mind if someone is calling you because of that? I shank the ball and got a double bogey. Lost Php 3,000 on the bet. What did I do or say to her? Weigh her poop whether she could hit the Guinness. Hahahahahaha

PATIENT'S SURGERY DECISION

To this day, I still do not know why one patient agrees to surgery immediately or procrastinate. Is it to the tone of my voice which does not fluctuate or change whatever the situation is?
Take for instance 2 patients who need surgery of the breast with the same tumor size, same preoperative diagnosis, same financial situation, same stable psychological background. They both come on the same day; one after the other. And yet, one agrees to the excision while the other postpones it for a simple reason that she just don't want the surgery today. For 31 years, I have been searching for the bug or virus or wind or wall paint that could influence their decisions.  Since both of them come with their husbands who readily agree to the surgery, one agrees to the procedure and the other goes home.
Sometimes, I come to believe that two whisperers are influencing my patients; whether they be angels or demons do not matter.
And these musings have brought me to conclude that we could not be alone in this world and that Somebody is making the decision for  us.

EBOOK

In a few weeks from now, my publisher + Bob Bare will launch my book "SELF-MEDICAL DIAGNOSIS" under the management of his general manager here in the Philippines +Mecos Pacana.
We hope that with this book, we could help a lot of people who want to know what disease they have prior to going for consultation especially those who are living  in the third world where medical specialists are out of their reach financially and logistically.
<http://www.amazon.com/Self-Medical-Diagnosis-Self-Medicate-ebook/dp/B00ENIFKPU/ref=sr_1_1?ie=UTF8&qid=1380524831&sr=8-1&keywords=self-medical+diagnosis+dr+cagape>

THIS IS THE HAND NOW

This is the hand now after partial amputation of the  of the gangrenous fingers.

AGGRESSIVE APPROACH TO SURGERY

I have been aggressive in doing surgery lately. Because of financial constraints a lot of patients cannot afford to go to the hospital  to have a minor surgery done under general anesthesia. Most if not all minor surgeries go under general anesthesia because the patient cannot bear the pain and the size of the tumor is too big for a local anesthesia.  I have done hemorrhoidectomy, varicocoelectomy and excision of breast masses the size of a child's ball ( 10cm x10cm) under local anesthesia all because of the patient's limited resources.

The above tissue came from a a big subcutaneous tumor ( LIPOMA) on the side of the patient's abdomen the size of  12cm x 12 cm. I have become bolder and bolder nowadays. But it only took me 30 minutes to remove it sparing the patient to spend Php 35,000 for a hospital surgery.

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.

HINDU GODDESS

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

DC HERALD

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

TUBERCULOSIS OF THE SPINE

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

SEQUELA OF steroid injection for scorpion bite

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

BOUNDARIES OF SPECIALTY

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

SCORPION BITE SEQUELA

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

QUESTIONING DOCTORS ADVICE

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

SCORPION BITE FOLLOW UP

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