In the past, I work closely with rehabilitation physician in the course of treating my patients.  Since I went into private practice  in the province though the lack of a Rehab physician in my area pushed me to learn and give rehabilitation regimens to my post op patients. What i discovered first was not really about the nitty gritty of giving exact instructions on physical rehab regimens. The necessity to communicate clearly and cultural sensitivity plays an important role and could save you from embarrassment or worst, the barking look of your own patient.

Mrs. Cruz (not her real name) is a 56 year old soon to be retiring school teacher I operated on after she sustained an bi malleolar ankle fracture from a vehicular accident. She was a stern looking bespectacled woman, barely smiling but very sharp with her unending probing questions. She claimed to know me when I was still an elementary grade pupil (although, I couldn’t remember exactly if she was one of my teacher), but I suspect she isn’t the type of teacher you and your nasty classmates could play jokes on. Anyhow, I operated on her uneventfully and she is on her first week of follow up post op. Time for rehab I said.

She was accompanied by her equally stern looking husband, a former military man from the looks of his eyes when she came in my clinic.One of her son was waiting outside the clinic and was I guess an added “assist” should the need arises. I just came from two succeeding ORs, barely had any sleep and was pretty tired from whole day of running around the hospital seeing patients. I am in my usual cool emphatic composure, but it was 4PM and my energy is almost spent since 7 am that day.

“Good morning Mrs. Cruz,.. Sir!” I said. Greetings which was met by a querying look from both persons. “Hows your operative wound madam?” “Have you been dressing this daily?” I continued. “Yes” she said. I went through the routine of checking her post op wounds, examining it and then removing the sutures after seeing the wounds are all healed already. I then checked her ankle joint’s range of motion. It was a bit stiff even if I did one good operative job and has checked the range of motion intra op to be “full”.

Time for a “rehab” I said nonchalantly to Mrs. Cruz.

I was skimming her chart and fumbling on my phonebook at the same time for the cell number of our in house physical therapist. I noticed the couple looked stunned and was looking at me squarely liked I said something really awful.

“Rehab, doc?”. Mrs Cruz didn’t blink to ask me again. Half stunned, half in disbelief.

“Yes, Rehab” I replied a bit annoyed and spent.

Then Mr. Cruz, face red in embarrassment, looking more serious and agitated now,  butted in “Doc, my wife is a teacher, she doen’t have any vice at all, at this age, I really find it hard to believe she is using any drugs!!!” in Tagalog.

“Ugh!Oh no, no..that’s not what I meant! Her ankle needs physical therapy so she can walk painlessly again on that foot!”

The rest of this story brought back the adrenaline in me that day. I was totally insensitive, perhaps because I was so spent with toxicity. In a provincial community where I practice, social stigma for drug addicts and sensitivity towards implying one is using any addictive substance may cost you your life. In this part of the country (and in some other parts too), “Rehabilitation” means drug rehabilitation. Many believe its derogatory and I guess, I learned my lessons that day.

Perhaps clarifying things out, being socially sensitive and a bit more of patience, will save you from your own “close calls” with ‘rehabilitation”.

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I’ve always been strict about time. I make it a point to be on time whenever my presence is needed. Or I’m I don’t go to any appointment or meeting at all. During my residency training  that obsession with time worsened. I get edgy when someone else is late for a meeting or something. Even if the late comer is me.

Training thought me to develop the habit of coming into surgeries way before anyone else in the team does.  I rehearse the  surgical procedure and arrange  instruments way before the actual surgery. I also “acclimatize” myself into the OR room during this brief period of pre OR time, condition my mind and shutting down any external nuances that might bother me or the operative procedure. I require total concentration from me and my OR staff. That includes coming on time for the surgery itself.

One emergency OR night during residency and after waiting an hour or so for this perennial late comer anesthetist , I took steps to freeze stop this bad behavior. I rolled my patient  to the side and into an induction position. Then I  prepped his lower spinal area and asked for the “spinal set”. I asked the staff to warn me whenever the anesthetist is already in sight, so I could assume a position of inserting a spinal needle into the patient’s lower back. (Of course I’m not going to actually do this on any patient, even if I’ve done a few during my medical clerkship, but just to scare the late comer, I’m willing to be an actor).

When the anesthetist entered the room, he gasped for words and is shock seeing what I’m about (or acting out) to do. The OR door is situated opposite the induction area and the patients back so he didn’t notice the spinal needle was inches away from the patients skin.

“What the…?!” He panicked and called the circulating nurse to tell me to stop while he was still changing OR gown.

“Please, stop doing what you’re doing now sir!” He shouted .

“It’s OK I can handle this one” I answered without looking, leaning and bowing forward to my patients back as if inserting a spinal needle.

“The Bupivacaine ampule was accidentally opened hours ago and I’m just afraid this would expire before you would even come to our OR room. Added cost to patient if  you ask for a new one, you know..” I added, grinning.

The anesthetist hurriedly donned a sterile suit and took my position at the induction area. He is surprised the needle was not in any way near the skin of the patient. Before he can even muster a word, I went out the room and re scrubbed again to prep my operative site. He was not uttering any word from then on.

The OR room was eerily silent. But I can see the smiles behind the mask of all those nut cracks with me in the OR. Needles to say, my OR went totally silent and fast without any grumbling word from the anesthetist. I was even singing “Estudyante Blues“..

“Ako ang nakikita, ako ang nasisi, ako ang may kasalanan…” Alluding to a perennially wrong doer, caught red handed.

Near the end of my OR, I noticed the familiar “restless” standing and walking of the anesthetist around me, peeping into my operative field and guessing when  will I finish. “He must be ashamed to ask me now” I muttered.

But he persisted with the annoying peek a boo. So I secretly nudge the extremity a bit and shouted

“Patient is moving!. “I’m not yet done!” even if I’m already closing the wound. Orthopods usually put splints and cast around their operative site post op. I have encountered anesthetists in the past who would prematurely wake patients up and make casting especially difficult. So this time, I asked to delay “waking up” the patient. I suspect the anesthetist is inkling to get out of the OR faster than anyone, so I made it a point that this time, he will be the last one.

When the anesthetist went out of the room for some reason, I hurriedly applied dressing and did my casting in less than a minute. I asked all the staff to clear up the table fast. When the anesthetist came back, he was in his second shock. The OR table is clean save for  the patient, who is snoring heavily.

Then I left the OR room whistling…”Wake me up before you go, go”…

I hope that anesthetist learned something from that OR. But I never found out really. That was the last time he induced a patient for me.

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I just came back from an orthopedic fellow’s convention and the Ruby Anniversary (40th) celebration of my former orthopedic training institution. Aside from the maxed out celebration with former (tor)mentors and alumni, I got one serious question unanswered afterwards- What now?

Seeing the glorious past of an iconic institution, and sensing the current status of a top notch residency program, I am reminded by the vision and mission the department. The same vision and mission somehow answered the very question thrown on me by an alumni and mentor.

Where are you now in your orthopedic practice? Are you in pursuit of our department’s pillars of leadership and excellence  in training, research, and service?

A very had question to answer and I can swear I had to think deep enough into the recesses of my orthopedic practice to assemble my answer. There is no doubt in my mind the department’s alumni are in the forefront orthopedic’s training and service in Philippine orthopedics. What I saw and heard during our Ruby Anniversary partly reaffirmed this.  Well, I  ”rubbed elbows” and chit chatted with famous/celebrity/controversial orthopedic surgeons in the Philippines I listened to stories of alumni who practiced unknown territories where no other Filipino orthopod dare went into. In fact, almost every nook of Philippine orthopedics nowadays is led or being push up front by no less than the graduates of our institution, be it for excellence or some other things.

Research on the other hand, lags behind among these pillars that the department is excelling at. Such was an assessment by some former mentors and alumni, if we are to base it on the number of quality, evidenced based researches published on peer reviewed journals here or abroad. Sadly, such also applies to me. The last orthopedic related research I’ve done was six years ago and thats was during my residency training. In a community practice outside a training institution, the chances of you doing orthopedic research is practically nil. I blame it on nobody, but myself. During residency, we had this one common “Limitations of the Study” written in almost all our orthopedic research. It says “not enough study population”. Today, in my practice, that would still be a limitation. But many of former mentors mention this one reason:

“Many of our graduates outside a training institution don’t do orthopedic research anymore because research don’t feed mouths. Instead of providing money, you need money to do research. Research entails a great deal of commitment in terms of time, money  and effort. Commitment who couldn’t compete with the drive to earn money for living, comfortably”

Yes. I’m guilty too and these was an aye opener. At least now, I can set a direction to where my practice could focus more to improve service. Perhaps one day I can still live up to the expectations of my department’s vision and mission.  No it’s never late. Like what many have said, there’s so many areas to learn and research on Philippine orthopedics. Not many formal and evidence based researches have been done. Not many got published. That makes Philippine orthopedics still a fertile ground for research.

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In one community where I practice, no hospitals offered diagnostic procedures like CT Scans or MRI (Magnetic Resonance Imaging). Thus the current practice is to immediately transfer the patient to a nearby hospital with such capabilities. This, in spite of the fact that medical professionals here can actually perform the needed medical procedure after the CT was done. This practice went on for so long as I can remember and physicians bothered less and less about honing their skills managing ill patients diagnosed with the help of  a CT Scan.

Until one day, one hospital invested in a cat scan. Many physicians suddenly find themselves in a dilemma. That despite, the availability of a ct scan now, many physicians lacked or simply forgot to learn or re-learn how to manage patients that was diagnosed with the help of a CT scan.

The quandary is not about what you don’t know, but about how confident are you in managing those that you now knew because there’s a CT. Should they still refer the patient to another city for treatment despite the fact that the diagnostic technology is available here already? Would you see this as an opportunity for re-learning or would you simply refer the patient and free yourself the hassle of it?

This is just an example of technologies that threaten conventional practice. Many physicians view it as a threat, simply because they lose patients in the process but somehow, there’s this lukewarm acceptance for re-learning of skills. For some, this an opportune moment for seizing the timing for creating value added services (like ICUs and neurosurgery) in the hospital. For patients, this is totally a welcome development and improvement. Lower costs and convenience for both the diagnostic procedure and the value added service cannot be simply ignored. New technology, if indeed necessary, is here to stay.

So are you going to just ignore it and go on with your old practice or re-learn skills to adequately manage the influx of patients as a result of new technologies? Put your comment below.

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Of all orthopedic trauma cases I’ve worked on, my heart bleeds the most for pediatric patients. I don’t know but their helplessness and innocence always evoke this feeling of worry. Many pediatric trauma cases are often a result one adult, guardian or parents, gone remiss in guiding or understanding a child growing up. While many adults blame kids for crossing streets alone or unguided (thus running their vehicles over them), they too agree its the kids guardians or parents that really had an oversight. An irony?

Maybe. But the pediatric trauma patient is almost always a victim. Why? Imagine suffering an injury as a result of a road mishap only adults understands, or being blamed for violating traffic rules even licensed drivers rarely follow? And they wretch in pain for something they rarely know?

This is exactly why treating pediatric trauma patients entails stretching a surgeon’s patience more than you can offer any adult patient. Why adults busy themselves finger pointing on so many things, the child wretch in pain for an injury he or she rarely knew of. That is something pitiful than any other thing. Don’t you agree?

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