Cast & Curious

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  • Close call on rehabilitation

    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”.

  • Last in, last out….

    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.

  • Orthopedics six years after residency training, what now?

    Four major subspecialty service of UP-PGH Orthopedics which also parallels its pilars: Leadership and excellence in training, service and research

    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.

  • Do you want your healthcare professionals or healthcare institutions to have a social media policy?

    Yesterday I started a survey  asking healthcare professionals (physicians, nurses and allied medical professionals) if their healthcare institutions have a social media usage policy. (If you’re a healthcare professional you can still vote and comment in that post. ) Now its time to ask our clients, the Filipino patients:

    Do you want your healthcare professionals (physicians, nurses allied medical personnel) and /or healthcare institutions (hospitals, clinics) to have a social media policy?

    Philippines, the social media capital of the world!

    This question is important and highly relevant. Why? Philippines is the social media capital of the world and there’s a surge of content sharing in these social networks. That is according to this report by the Global Web Index. Sharing health related patient information on these social networks threads dangerously on an already greyed (if there is/was) privacy and health information laws here in the Philippines. Without enforced laws or governing policies, a breach of patient’s privacy and confidential information have consequences that pose a threat to the mutual trust between patients and his/her physician or that of his/her healthcare institution.

    The other reason is about enhancing patient communication. Social media is  an alternative, revolutionary way in which healthcare professionals or institutions communicate or interact with their patients.  Social media (though research data is lacking on this) could be  a venue for positive reinforcement of actual clinical consults and follow ups. A recent survey also shows that social media is now gaining ground as source of health information in first world countries. The absence of policies regarding its use defaults the interaction to a “free for all” and often negatively affect the overall outcome of these patient-physician  or patient-healthcare institution interactions.

    So again, I’m asking you, Filipino patients, or anyone since obviously you are the ones will be ultimately affected by this policy.

    Do you want your healthcare professional or healthcare institution to have a social media policy use?

    Please vote below and comment (in the comments section) if you wanted to explain your answer. Should you want to maintain anonymous, just email me privately thru this contact page and I will assure you of your confidentiality)

    [poll id=”3″]

  • Do you have a social media policy in your healthcare institution?

    Philippines ranks first in the global social media penetration according to a February 2011 market survey by Global Web Index. In this survey, it was also pointed out that asian countries do more ‘content sharing‘ than sharing messages as in other countries (UK, Canada). What is the implication of this survey results to Philippines’ healthcare system?

    Philippines tops social media usage globally! (Infograph from Mashable by Global Web Index)

    Possibly huge. Possibly positive. Sometimes, menacingly negative.

    For Filipino patients, the surge of content sharing and social media usage puts a huge stress on prevailing (or lack of) Philippine laws that govern patient information confidentiality. The lackluster enforcement of such laws, if there is/was, is/are sporadic. One does not need to look further. The gruesome photos (trauma, surgical, etc) that somehow lands on your Facebook wall is a testament to this breach. It’s also not uncommon to read patient blogs, tweets and comments on Facebook that cast doubts on healthcare professionals or or institution’s credibility. Some even lead to sensational malpractice suits.

    To healthcare professionals (physicians, nurses, allied medical professionals) the responsibility is even greater. In first world countries, there are stringent rules of engagement for healthcare professionals on how they relate to their patients and to healthcare institutions on social media. Such policy govern healthcare professionals employed in healthcare institutions and who’s social media usage directly or indirectly affects that of his or her employer. In the Philippines , while majority of healthcare professional and institutions  does not seem bothered  yet,  catastrophic consequences still hangs in the future . How many times have you encountered photos on Facebook that are in one way or another health patient or institution related? Too often?

    For healthcare institutions, this surge is promisingly positive should they take advantage of social media usage. This study by the Global Web Index for example is a market survey for business entrepreneurs. This could be an area for healthcare institution to reach out, communicate to their clients and improve the institutions online visibility. This is what the Mayo Clinic, Mount Sinai hospital for example is doing crafting their own social media policy to enhance patient – institution communication.

    Filipinos spend one fourth of a day on social media network.(Thanks to Dr. Iris Isip Tan for posting this infograph)

    But without a policy to govern such social media practices by their employees (internal) or their patients (external), the healthcare institution risks running into so many potential negative social media issues aside from economic ones (employees using social media at the workplace).

    As an afterthought, let me share another info graphic about use of health related IT technologies in US (source). Take a look at the social media usage. To think, Philippines is ‘ahead” of US in terms of per population social media usage. I don’t know if Philippines has have similar figures in terms of health related social IT. This should be an interesting research for healthcare markets.

    Health related IT technologies usage in US (source)

    So to answer this post title-question, I’m making an informal, non scientific survey here. This is open to all medical and allied medical professionals. Please answer the poll and please comment below if you need to explain your answer.

    [poll id=”2″]

    Thank you for voting!