RemoMD Rebuild

Author: Remo Aguilar

  • Orthopedic Logbook re-examines patient when he is in doubt!

    “I think it’s Septic Arthritis.”

    Twenty six years old male farmer with a history of fall from level ground, landing on his buttocks, able to stand up and walk immediately after without pain. The next day he felt excruciating pain in his swollen left hip, was unable to move his L thigh nor ambulate. He was brought to a bone setter who “massage” his L thigh but patient wasn’t relieved of the pain at all. In severe pain and febrile the next day, he was brought to the hospital immediately.

    “It looks like septic arthritis to me.”

    He was referred to a surgeon instead, who took x-rays and showed a less than 5% compression deformity of L5 . His differential count showed leucocytosis with lymphocytic predominance. He was started on Cefuroxime IV and pain meds. Four days after patient still has fever spikes and increasing trend of leucocytosis with lymphocytic predominance. Unable to move his swollen L hip and thigh he was referred to me.

    “I’m leaning towards reactive synovitis or septic hip here, bacterial or otherwise”.

    Short of doing formal arthrocentesis, I asked for an ultrasound of the hip-looking for water filled masses or pus filled joint. There was none according to radiologist. The white cell count is still increasing with lymphocytic predominance. I started the patient on Metronidazole and re -examined the patient carefully. He was afebrile for 2 days and noted an improvement in L hip range of motion. But there was still L hip pain and is unable to walk. The white cell count is still increasing. Lymphocytosis?Mature lymphocytes? Let’s call in an internist (we don’t have infectious disease specialist here nor a hema-oncologist)! See if it’s a possible lymphoproliferative thing!

    “I still think its septic arthritis, but I have no hard evidence yet”

    Instead, the IM gave more pain relievers and suggested patient be seen by a neurologist for a radiculopathy 2 herniated disc. The neurologist agrees triumphantly and advised more pain meds and bed rest. Sighed. Febrile, 26/male with L hip pain and elevated white cell count? Radiculopathy? I re-examined the patient. I courteously asked the patient if they can afford a CT scan of the hip and then asked the Radiologist to make the cuts up to the lumbar area and “peek” at possible herniated disc.

    “I’m still convinced this is septic arthritis L hip”.

    “No lumbar disc herniation nor radiculopathy. The L hip and anterior musculature is enlarged and fluid filled much more than the right. No fractures. Septic Arthritis highly considered”. Double sighed. Tomorrow I have to open up this patient’s hip joint, drain it’s pus, wash it carefully and apply traction. I gave enough time for guess making here.

    So when In doubt, go back and re-examine your patient!

  • The Blog Rounds First Edition at The Orthopedic Logbook:Call for Submission of articles.

    The Orthopedic Logbook will host the first edition of “The Blog Rounds“, a weekly compilation of the best posts , medical and otherwise, from the Philippine medical blogosphere. Thanks to the pioneering Filipino MD bloggers who willingly joined the project and will soon host TBR in their blogs!

    The Blog Rounds!

    Like what Doc Tess felt, my heart’s “thump” is audible from the write ups I made for TBR. But the first ed will also be one of the hardest edition to produce because of the grand expectations attached to it. Choosing a theme as an icebreaker for the chilled Philippine medical blogosphere is a though one to make!

    For TBR’s first edition I’ve chosen a theme related to the history of medicine in the Philippines, with a twist of humor of course that will make the readers (and us) say something something like “uh, I didn’t know that!” I’m putting an edition punch line and title,

    “History of Medicine in the Philippines Made Ridiculously Hilarious!

    Caution though, that the article should be factual (more commonly anecdotal?) and not fabricated nor twisted. It should nevertheless funny and interesting and may pertain to an icon, an institution, heroes or any event in the history of medicine in the Philippines. An example would be the hilarious investigation into the true cause of Apolinario Mabini’s paralysis.

    “Did you know that the body of the “Brains of Katipunan” has to be exhumed and examined by a panel of competent orthopods, just to disproved an allegation he was paralyzed because of a sexually transmitted disease?”

    I now put the challenge unto the blogger contributors to read about our history, find some fascinating facts about medicine, create a post about it and submit it to TBR via my email or you can submit this to the official submission site (which will also forward the permalinks and to your posts, to the host’s inbox), here. For those who haven’t read the “rules”, The Blog Rounds submission guidelines are posted here. Schedules for upcoming editions, hosts and publication dates are are regularly updated here.

    And to those MD bloggers (and anyone else interested) who haven’t written their introductory post yet, please do so. It will be the official ticket of your entry to the BEST OF PHILIPPINE MEDICAL BLOGOSPHERE.

  • The Blog Rounds submission updates and guidelines

    I answered most of the questions regarding “The Blog Rounds” medical blog carnival project in my previous post, The Blog Rounds: Blogging through Medicine and Beyond. Quite a number of fellow medical bloggers contributed posts and hosted this blog carnival. And TBR is continually expanding!

    I am inviting all interested MDs, medical bloggers and everyone else who can write about medicine and issues related to it, to join TBR. E-mail me kokegulper[at]yahoo[dot]com, or any of the blogger already in the carnival, introduce yourself briefly, your blog and subscribe to The Blog Rounds. I am targeting Em Dy‘s list of physicians who blog, here. I’m near stalking them already.

    If you want to join here are the steps you need to do first:

    1. Introductory post. Write a post in your blog (like this one, by Prudence MD), regarding your intention of joining The Blog Rounds. You may include suggestions and comments about TBR in that post. Just a post. Make an announcement of that post in your blog and link back to the The Blog Rounds page here. I wrote my reasons for starting TBR in my previous post. You can take a cue on the format of your intro post there.
    2. Tag two other MD blogger or medically inclined blogger who write about medicine( or MDs who write about non-medical stuff) and invite them to join the carnival. It is not necessary though, that you get them to join us (although this will be a desirable outcome).
    3. Put any of these icon-links on your main page and link back to TBR.
    4. Join and submit articles to the ongoing blog rounds. Archives and hosting schedules are listed here.
    5. Subscribe to TBR yahoo groups using your email here.
    Here are the guidelines for both the host and contributing bloggers joining TBR. Note that these guidelines can be changed depending on the sentiments of the majority contributors. Suggestions will be highly appreciated:

    1. Call for articles for the upcoming TBR edition should be posted on his/her blog by midnight of Tuesday on the first week.
    2. Blog articles for carnival are due by 11:59 PM PST Monday two weeks after the “call for articles” post.
    3. The Blog Rounds round up of posts will posted on the host’s blog, 7AM Tuesday two weeks after the call for article post.
    4. Send the host- blogger for that edition (schedules are listed here) an email containing the title and url link to your post.
    5. One entry per blogger.
    6. Recent posts between 500 and 1000 words are preferred
    7. Posts are to be written for a general audience and may be medical or non medical, depending on the category or topic chosen by the host blogger.
    8. The host blogger has the sole authority and responsibility of choosing the topic, announcing them, receiving the contributions, proof reading it, and posting them as he/she deemed fit for his/her topic of choice.

    Potential topics include:

    1. Issues (maybe political) affecting the Philippine Healthcare System
    2. Practice of Profession
    3. Business of Medicine
    4. Other things the health care professional do non-medically, like travel, sports, hobbies, blogging and whatnots)
    5. The rest of the topics not mentioned above (which makes it practically everything outside your steth.)

    Keep those blog post interesting for everyone.

    If you got more questions, or if you want to host TBR, email me or comment below! I’m continually looking for hosts blogger!

    So what do we get out of this?Blog traffic maybe?Money from ads? Maybe. But the whole idea is about sharing our experiences and thoughts (rather than stare at the ceiling of our clinics) to anyone willing to read it.
    (Updated: 7/2/08)

  • The Blog Rounds: Blogging our way through medicine and beyond.


    “Why not”     ?
    Was the first thing that came to mind when a fellow blogger suggested the idea of a medical blog carnival, Pinoy style akin to the Ground Rounds and SurgExperience abroad. I’ve been stalking these blog carnivals for so long (joined some) and read their posts. Frankly, on what they’re good at, our healthcare scenario just doesn’t fit. I’m often left pondering how these issues affect my life as an MD here in my land? That’s why I thought starting our own blog carnival would seem easier than getting lost in their discussions.

    But why duplicate those already existing?
    Duplication?No. Except for a few superb Pinoy MD bloggers already in those carnival (Doc Emer of Parallel Universe or Tess Termulo of Prudence MD) reading most of the posts in those carnivals made me feel my medical world is ten years behind. Indeed, I had a hard time relating to their banter simply because our health care arena is different from theirs!

    Is there a need for such medical blog carnival, here?
    Yes. Our unique experiences and the healthcare environment seem to be different in some way from that experienced by our foreign counterparts. Take the case of our Doctors to the Barrios MDs (Abyan ka Batch 23 DTTB) and Merry Cherry) who blog about their experiences in the boondocks or of those newly trained physicians (Doc Claire‘s In the Middle of Nowhere) and Bone MD, (To cut for living) trying to find their cut in the business of medicine. Some Pinoy MDs left (actually, just slashed a big portion of their time spent on medical practice) their comfortable practice and offered to render a different form of service to their country, like Martin Bautista (On My Way Home) and Dorothy (Doralicious). There are nameless MDs who are in another country in search for better practice conditions and those that have chosen to shift into some business for living here in the Philippines. Others simply talk about everything beautiful and non medical (there’s a lot, as their blogs have taught me) in this world, like Megamom’s Pinay Megamom, Em Dy‘s Pulse and At Random Ness. For the majority, simply surviving in this harsh business of medical practice is already enough topic to whine about by blogging!

    And there are a lot more topics , more issues to tackle or just simple “other things non medical” to blog about.

    There already forums for issues affecting the Filipino medical world. Why add one more?
    Pinoy MD has done a great job of uniting Filipino MD’s in the net. Some of these MDs got blogs too. Doktorko has a repertoire of blogger and great posts for us to read. But one different thing about a blog carnival is that the posts are hosted to your blog site and you need not change your posting style or topic to you wish to talk. The “host’ blogger will just “introduce ” your post for the week, and put a link to that post in your site. And topics is updated every week.

    Will it add (or diminish) anything to our healthcare environment? Will it add “something” to my blog, popularity perhaps?
    To which my answer will be, “will you loose something if you join”? There is so much to gain. Knowledge is power. Blogging and reading someone else post(s) and blogs made me a little knowledgeable about so many things med school hasn’t taught me-including life. If the blog carnival will be a venue for “voicing out issues” affecting our health care, why not? It it affects our medical practice, the more we should get involved.

    I bet majority of the medical bloggers out there don’t care about popularity and fame as bloggers. Some do. And it is alright to do so. Site traffic maybe increased, perhaps with the curious readers if we make a buzz. I blog as a form of exercising my finger flexors and lumbricals. If blogging increases the convolu
    tions of my cerebrum and deepens my pocket (oh really now! I wish) then it would be a bonus.

    Next: Blog carnival title and guidelines, who have joined and what to do if you want to join!
    (Author’s note:     Due credit and acknowledgment is give to the owners of the pictures used here and published at Deviant art, my favorite art repository)

  • TBR List of Blogger Contributors

    A number of fellow medical bloggers already expressed their willingness to join and contribute posts to this blog carnival. I’m flattered by their willingness to join.

      Other MD or medical bloggers and everyone else who can write about medicine and issues related to it, who are interested , please don’t hesitate to join , email me kokegulper[at]yahoo[dot]com,or any of the blogger already in the carnival, introduce yourself briefly, your blog and yes, subscribe to The Blog Rounds. I am targeting Em Dy‘s list of physicians who blog, here. I’m near stalking them already. Help me.

    1. Blog Rounds Season One Archives

    2. Department of Orthopedics, Davao Medical Center: Answering the call to excellence in orthopedic training and services in Mindanao

      Just recently, The Department of Orthopedics at Davao Medical Center went under the sharp scrutiny of the esteemed Philippine Board of Orthopedics (PBO), for the department’s yearly accreditation as an orthopedic training institution. This process of evaluation and accreditation have very important goals namely;

      1. to determine if the institution is capable of training aspiring orthopedic surgeons in the area or
      2. was it successful in training current orthopedic residents and render orthopedic service to the region that is at at par with the board’s standards and the orthopedic profession in general.

      Being a newbie to this institution (and as an attending at that) it was also an opportune moment for me know my DMC Orthopedics family and learn how I maybe of help to them in the light of the staff’s main thrusts and the boards recommendations . No, I am not with the board, but I am happy I will benefit from their efforts and recommendations.

      The “board” is probably the best “external evaluator” of orthopedic training institutions within the national orthopedic community. Not only because the board are the ones who accredit training programs but because they are also in the best position to oobjectively assess our training program and give recommendations for its improvement. The board consist of elected and well respected orthopedic fellows from different training institutions around the country. Their collective experience simply equate to the “third eye” for any orthopedic training program.

      The Department of Orthopedics is probably one of the best department here in Davao Medical Center, if we base our assessment on the latest P.I.A.D. conducted by the DMC administration. PIAD was a patient satisfaction survey of all the DMC departments, in terms of services, facilities, personnel among others. The Department passed this evaluation with flying colors (100% mostly) and garnered probably one of the highest “grade” according to patients surveyed, if not the highest. This form of an “internal” evaluation has boosted the moral of the Orthopedic (consultants and residents), medical and allied medical support staff, and gave us greater resolve to improve more of our services and training capabilities.

      There is no doubt that in the DMC orthopedic community, talents and innovative ideas abound. The department graduates has been 100% passers on the Orthopedic Diplomate Exams since it started. It’s current residents also landing in the top of their batches in the in service training exams. On the national level, DMC ortho is probably at par with other training institutions, if not better. And we are just beginning to think globally and interact with foreign orthopedic community.

      But like any government training institution, challenges to DMC Orthopedics’ existence and goals are enormous if not astronomic. We are perpetually lacking in funds to support our services, maintain our facilities and equipments, conduct innovative research and support healthcare delivery to our patients. This is where the staff’s devotion to providing top notch service, despite odds, become utterly heroic. One third of the consultant staff are voluntary, meaning they don’t have plantilla items and thus don’t get salaries despite seeing patients and breaking brains to render services. Our resident staff is dwindling every year (might be again, brain drain or pocket drain whichever applies) and the MD to patient ratio is bloating, which I peg somewhere between 1:50. Our allied medical support staff like the nurses so often changes we barely have time to train a permanent younger one.

      Despite these odds, our department shines. Keeps us, the staff, smiling at the end of a tiring day. Thanks to the unwavering devotion of both the orthopedic and the non orthopedic support staff. We have so many goals to achieve, and so many ways of achieving it, but only one thing in mind(as our chairman will say)- give top notch patient care and train top notch residents. . We see a future in all these hardships. Maybe, the Orthopedics Department is after all, bound for greater heights.

    3. Streamlining our OPD services (Orthopedics)

      We’re streamlining our Orthopedic outpatient services. And this is all to strengthen our out services especially to the indigent ones. The proposal will try to achieve the following

      1. Provide a better, quality and cost efficient outpatient service for patients.
      2. Better case documentation and improved follow up of patients.
      3. Improve our residents’ training program with better documentation of cases and outpatient follow up.
      4. De congest the outpatient department with unnecessary follow up and costly diagnostic procedures such as x-rays.

      Hopefully, this will alleviate some of the service concern of our patients.

    4. Training Perspectives Part I: Dummies guide to surviving an Orthopedic pre-operative case conference

      It’s never a pleasant experience for me, as an attending, to see a resident tremble in front of the consultant staff, his pre- op case vanishing in room air and his morale at the level of the floor mat. I was in the same undesirable instances before, as any resident would be, not a long time ago. Often, the deja vu, nauseates my academic appetite. Ironically some of the best lessons I learned in my training came from such spectacular display of “enlightenment”.

      I am in the opposite sitting arrangement now, as an attending, throwing the same bullish questions I lovingly evade before. But then again, if you are a resident and you accept your status as it is, this might be the best way of freeing yourself from such lowly self esteem!

      A word of caution though. This is not Us, The attending vs You The Residents sort of set up. As Someonetc said, were all in these together. Nethier you or us nor the patients should lose. We all learn from it.

      The common question from the frustrated resident is “How will I ever satisfy this ever critical attending? I’m always wrong to him!”So our residents will ask me, “how can I ever avoid such hell questions during pre-op?” In the short time I’ve been an attending (and the long time hibernation as a resident) these are the “attributes” I look for and emphasize during rounds and pre-op. In this particular order.

      1. Present the case for your patient. Know your patient, examine him well, take care of him, and decide according to his realities and situation. Put him in the top of your indication list. Err on his side. Overdo things for his welfare. I cannot emphasize more. Nothing irritates us more when the patient is not on your number one list or if you forgo the patient’s welfare just because you were busy with something else.It is always wrong to reason out that way!
      2. Never lie or bluff your way out. We will be sending you to vacationland for good or force you to jump-off training. Believe me.
      3. It’s the decision making process that I look in more. The logic behind why you do the labs, why did you decide to do the the surgery or not. This separates you from as a scientist and surgeon to a technician. Treatment protocols may vary, gold standard of treatment will change in the future, but logic and decision making attributes remain the same.
      4. Read for your case. Read voraciously what is relevant to your patient and case at hand. Hit your ortho books but new relevant studies will always grab our interest. Never come unprepared to the pre -op. No patient (not even you as a resident) would want a surgeon who doesn’t know what hes doing, to operate on him
      5. Accept mistakes and make good at your promise to do well next time. The attending will always remember the next time.
      6. Talk to your attending or consultant after the conference (and the patient) to make sure you got what they advised you.Its always a mark of a dignified resident to clarify his lessons and make sure he understands them well.

      Again, we’re all in these together, you residents, us the consultant staff and the patients. I still believe no consultant is in there to personally destroy a residents career. Most of us are there to help you learn, learn the right way for you“-free of charge. Perhaps, thats the best assurance you can get from us.