There is one thing admirable with state ran health training institution- the constant struggle to an ideal, efficient, low cost, health care program. Residents in training are constantly hammered to provide the best health care at the least  possible cost both for the patient and the institution. This is typically a result of maximizing an undermanned and under budgeted, capacity filled government hospital. On the plus side, innovative care do evolve from these type of health training institutions. On the downside, devastating results sometimes happen because of shortcuts (treatment protocols outside of the accepted standards of care) that we were push to vis a vis the dwindling financial support and logistical problems.

One of the more common dilemma we face is the timing of surgery. It is one of the more commonly debated factor that ultimately affects health care provision and utilization. An early surgery will simply equate to a lesser hospital cost for both the patient and the health care provider. The lesser time to surgery from admission, will result to a lesser hospital stay which in turn, lessens logistical utilization and expenses for both the patients and hospital. This should be the ideal situation.

The problem lies with the accuracy of studies and the mix of factors needed to predict the “best” timing for surgery. Knowing the right mix of factors needed to achieve favorable results is quite uncertain. Timing of surgery studies are usually done on relatively ideal, controlled (developed world) health care facilities. Hospital setting and patient profiles rarely fit the situation where a third world surgeon is facing. Of course there is room for extrapolation or innovative standards of care. But that makes the predictability of results (of surgery) quite uncertain!

Take this for example.

A VA patient came in the ER 12 hours post injury with an open type II fracture of the medial malleolus and close lateral malleolar fracture . He was brought in from a far flung community with no previous medical or surgical intervention. His vital signs were stable and no other life threatening injuries were noted upon admission. After I saw the patient and his xrays, I talked to him, about the advantages and disadvantages of the different treatment options and surgical intervention for his type of injury. The options are basically between an emergency debridement plus open reduction internal fixation (ORIF) or just a debridement (repeated if necessary)  and delayed ORIF after possible infection is ruled out. Spending about an hour of explaining the risks and advantages to the patient, I got an answer like this one- “which do you think is the best doc?’.

With all honesty, I mustered to say that personally, I would prefer the delayed ORIF since all the patient and injury factors (plus the delay in treatment) points to a greater risk of infection secondary to a skin breakdown. Surprisingly, he wasn’t convinced somehow, even after that lengthy explanation. He told me he understood the risks I’m explaining  but he really wanted to get out of the hospital ASAP for financial reasons. I don’t know if that was his real reason since he’s kind of without problems procuring his medications and stuff needed for surgery. The patient which seemed to be hurrying up, wanting an immediate fixation so he can go out of the hospital after the first OR. I couldn’t convince the patient and couldn’t get a consent either for a debridement only and delayed ORIF. He then asked to be transferred to another hospital somewhere else for treatement. I got no choice but to give a referral letter. I thought that was the last time I heard of that patient.

Two months later, this patient showed up in my clinic, in crutches, with a draining sinus just below his medial malleolus. “Good afternoon doc” His previously fractured left ankle is warm and swollen. He couldn’t walk on it because of pain. His ankle is with peri-implant infection, an osteomyelitis, and probably septic ankle joint. He told me that the next day after I saw him in the ER before, he transferred to another hospital, insisted for that immediate ORIF and went home 2 days after his surgery. He never followed up with his surgeon. Still aghast at the turn of events for this patient, I was visibly distraught at the wasted extremity that needed more costly surgery now. I told the patient to go back to his surgeon and ask for advice and treatment. I sincerely told him I cannot treat him unless his other surgeon is away or will endorse him to me. The guy was devastated and was teary eyed when he left. That was the last time I saw that patient.

Looking back, I empathized with that patient. I know he was trying to save up on cost. But in the long run, it cost him his ankle joint. That for me is a the worse you can get for a shortcut that seem so easy. I’m not saying this is what will happen in ALL of such cases. I have a few of my cases too, that I got away (meaning procedure went out well and patient was satisfied with the treatment) with such “shortcuts” (call it innovation for lack of term) because of logistics and patient’s financial concerns. My point is this: That the predictability of results for an ideal  timing of surgery is quite uncertain. The right mix of factors is often very elusive and are sometimes, based on patients or surgeon biases. They are too difficult to qualify in an academic sense.

In the third world, undermanned and under buffeted  health care facility we’re practicing , chances are, we too are fraught with such dilemma. So, how do you handle such cases in your practice?

Last night when I was reading Bongi‘s blog (Other Things Amanzi), I came across his brutally hilarious (but freakishly realistic) post on (his sort of) “surgical principles”. Bongi is a general surgeon based in South Africa and though I see striking similarities between our “surgical worlds”, I found the guy’s witty and humorous ways of narrating his surgically bugged life, intriguingly interesting. Anyhow I’m particularly inspired (nah, copycat) by his post on how he came up with “his principles”. Not that I subscribe to all of  these but most went straight out of his operating theater making it egoistically fascinating for us surgeons and surgeons neck peckers. The one thing that strike me most was this “flat” referral to his bloody (or organically graphic) reality and how he finds way to “enjoy” it ( at least once ) to the point of gas-tronomic absurdity.

So I thought, why not write about disarming eccentricities of provincial orthopedics too? I surely can make up a few wigwams out of my usually unusual orthopedic (mis)encounters. Obviously, these are anecdotal too and are tested only by me. Some may even be unique to the proverbial orthopedics to which I am helplessly thrown into. So Bongi, don’t care about my being a copycat. I call mine ‘ironic absurdities’ (instead of your principles) for Bonedoc anyway.

1. You are (not only) the captain of your ship.
2. Slowing down makes (near) perfect. Haste makes waste.
3. Schedule surgeries on your vacations (and not on patient’s ‘ workdays).
4. Flirt, to make surgeries less boring.
5. It is always the some other surgeon’s fault. I mean, your “other” surgeon.
6. Exercise outside OR.
7. Have lots of fun, even when your obviously exploding in rage.

Somehow those are the more common situational ironies I can think of for now. Others, I will add (or subtract, depending on my gut feeling) up as soon as they hit me hard with a hammer. Some I actually relish now. I will link each of these absurdities to their individual post as soon as I figured it out of my mind and into my computer’s main memory. Hopefully,I will not kill my practice and blogging career with this ghastly concoction of experiential ironies .

I must admit.I’m a bit compulsive and freaked whenever a close person get sick or will undergo a surgical procedure.

In our family, I’m the only medically “knowledgeable” person. Being a  the medical guy in a family is a whooping responsibility.

Yes it is.

The three or four surgeries my mom and sis went through plus the numerous getting sick moments other family members experiences extract a heavy toll on my stress reserves. Of course my medical training helps, especially in the part where you plaster an emotionless face to keep a cool composure.  Yes,we play the hands of god to heal. For that, we need a calm, fluid, sewing, hands.

But this time, not even my M.D. training could ever down play such stress on my composure. Ironically, being an MD fine tunes your senses and pushes you towards compulsion to details whenever someone close to you get sick.

Why? Frankly, I don’t know.

As one good surgeon mentor told me before..

“you can never be a real surgeon unless you went through the knife yourself”..

Then suddenly it dawned on me. The closest thing for me to go under a knife until now,  is for any of my my closest people to go under the knife.  And that for the nth time, my mom would undergo one soon.

Her past surgeries were all emergencies. The decision making is emergent. The preparation is shorter and the options, close to nil.She’s left to a single emergent choice and then pray she’d wake up outside of the slim “margin for error”.

So you’d think  cataract surgery is minor. If you have seen how the almost blind, seemingly helpless elderly gropes in the dark while being carried to the OR, you wouldn’t think so. Better preparation, more choices and therefore less risks? Heavens no! With such wider margin for error comes the greater responsibility and risk of not missing any slightest detail. You bought only time to prepare, and therefore reduce the risks. But after that, it is still a surgery. If you miss something on the preop, given the longer preparation you have chances are the results would be a catastrophic guilt for the family. In a closely knit family culture of th e Filipinos, the guilt is pretty much an issue. And If your mom is on the OR table, everything is definitely “major”…

So never mind if my mom is diabetic with beginning retinopathy. Never mind if she has had 3 major surgeries before and countless other hospital admissions due to some sickness. Never mind she survived all of those. When your face by this same predicament and even on better circumstances, no surgery is still minor. Especially, if it’s your mom is on the receiving end of a surgeon’s knife.

So I go on with my usual compulsion to detail,  to my often obnoxiously redundant reminders of doing this and that pre-op. To most this might be an overkill. But If I were the patient, I’d love my surgeon to do so the same for me. Take the extra steps of care. That extra effort gives me a little security about my surgeons care for me.

This is one of the good  insights I learned from my mom’s procedures. You feel for your patients, you put yourself in their situation and imagine the best option your surgeon can offer. I always apply them to my patients. I teach this to my residents. Stressful? Yes it is. But who said the life of a surgeon is easy anyway?

So thank you mom. For undergoing the knife for me. You help mold a better surgeon.

(An update: I know my mom’s surgeon don’t read this write up, but I’m all praises for the guy. He didn’t just made an extra effort for my mom. Everything he did was a piece of his class. Masterful. Thank you..)

In just about a year and half of teaching orthopedic residents, I became interested in finding out which of the more familiar teaching styles works best for our crop of trainees. Honestly, I’m still continually experimenting.

The unique set up with which medical-surgical training programs thrive is continually changing. With the influx of medical information everyday, a program has to adapt to the call of time and for greater efficiency in preparing this ‘padawans into full pledged surgeons.It is not simple as it seems however since in this unique set up and unlike the usual academic, lab rat experimentation, a mistake might cost someone else life.

The “Master-Apprentice” method ( probably the more popular and is what I’m familiar with) involves  the “master” (attendings) showing the “apprentice” (residents) his way of doing things (skill) for a certain given situation or problem. Such teacher-student relationship is basically anchored on the assumption that the master is more experienced and adept than apprentice. This is usually an “I teach, you follow” approach to learning. One advantage of this approach is the specific skill imparted by the master to his apprentice for any given orthopedic problem. The obvious disadvantage is its limited applicability and the temptation to spoon feed a resident.

The rapid influx of modern technology and a deluge scientific evidence paved the way for a more radical, and holistic approach to learning in orthopedics. To the end of my training I was deliberately hammered by mentors to think rather than learn a specific skill, to criticize the validity of any information presented and above all, develop a logical framework for decision making process in any given orthopedic problem. Skills and techniques came in later as my mentors believe that modern technology will techniques change every 5 or so years. I am not an expert on education or teaching styles, but the latter method seems to work best for me. To my understanding, this sort of teaching style fall into the Socratic method of teaching. I’m really not interested into that. What I’m interested now is, if it’ll work too for my residents?

In every opportunity I have with our residents, be it conferences and pre ops, I focus on continually challenging their minds,  make them think harder, analyze a given situation,  criticize an evidence, present facts properly and then develop a sound decision making process. Obviously, I’m not a fan of residents trying to impress attendings with techniques and implants when he can barely utter a word on the biomechanics involved in those implants. Often, the common excuse for residents (this is awful) is the absence of patients  logistics and financial support common among government hospitals. I actually do not contest that. What we want for residents however, is to incorporate these specifics into his decision making process so he can plan ahead for his patients surgery Lastly, I wanted my residents to empathize with their patients. One common question I throw in during pre-ops is this

If you we’re the patient, what would you want your surgeon do to you?

 Usually this type of questioning gives the residents an idea as to the best option for the patient!

All of these teaching style have one thing in come though. To pass on knowledge to the new generation of orthopedic surgeons . In short, were training them to be surgeons not residents.

Will these teaching style work for our current residents? Personally, I don’t know.Not yet, but perhaps in the future.

I overheard this conversation over one radio/tv show that made me gulp in disbelief. Probably pressured by parent’s questions regarding how much weight should kids carry on their bags going to school, the lady anchor asked one orthopedic surgeon from a known celebrity hospital in Manila. Frankly, I found the good surgeon’s answer a bit complicated and technical.

The simple answer should have been within 10-15% of the kids body weight, assuming that kid use a backpack to carry his/her school stuff. Beyond this carrying weight “cap” the kid will probably experience back strains and muscle strains NOT a slipped disc or arthritis as the anchors are trying to insinuate. Of course if you let this kids carry tables or chairs regularly, then probably!

In choosing backpacks for your school kids take note of that weight limit and the following important pointers:

1. Find a “lightweight” pack, usually made of water repellent (not necessarily waterproof) material but not leather. Leather weighs heavier.
2. Get a double strapped well padded pack. Find  a pack with a well padded back. This will ease back pressure a bit.
3. It’s preferable to have multi-compartment packs as they promote organization. But make sure the heavier objects are placed nearer the kids back so they won’t stoop back often and get back strains.
4. Waist belts keep the pack from “jiggling” on their back, preventing weight shifting that hurts their back.
5. Don’t get bags that are too large (meaning the bag “material” is bigger than the kids back) nor buy packs higher than his neck. With large bags, comes the tendency of kids to just load everything in there.
6. Lastly, dont buy packs with too much plastic and paints on the outside. Some of them easily peel off and contain lead materials.

Why do I know this stuff? Well I’m an orthopedic surgeon and a frequent mountaineer/backpacker too. We use this “guides” to pick our bags and gears. This will at least prevent back sprains and strains from carrying to heavy stuff.

For more ideas on buying and choosing your packs wisely, visit this site (www.kidshealth.org). They’ve got more tips for kids’ backpacks.