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  • SMS -remote-controlled orthopedic surgery, anyone????

    This interesting news caught my attention just today.

    A British doctor volunteering in DR Congo used text message instructions from a colleague to perform a life-saving amputation on a boy.- BBC News Health

    It is not unusual for surgeons to refer to other surgeons for guidance on opinions regarding some cases they do. Some are personally being coached by more experienced surgeons actually. Residents in training are actually required to refer and if necessary ask the help of a consultant in all surgeries they are doing. And intra operative referrals, especially on emergency cases, is not uncommon.

    But I have yet to hear an actual surgery being remotely controlled via text messaging, step by step. These surgeons, from Medecins Sans Frontieres (MSF) in Rutshuru have done it. If we believe their report as true, it was labeled as a “success”.

     The surgeons (Dr. Nott, in the middle) who performed a four quarter surgery via text messaging guide (Picture from BBC News)

    Tell that to surgeons in most tertiary centers and you’ll hear “What??!!!” and “Uh no, not in my OR!”

    Such textual surgery (for lack of a term), may be life saving in some third world countries like Congo who lack surgeons to perform life saving surgeries. I wonder if this is also possible in the far flung communities of the Philippines. More importantly, what if the telco’s sms service sucks??? or the cp doesn’t have enough load to send all the chapter long step by step procedure???

    “Nurse, pa load muna!!!”

    I shiver in such predicament…

  • Logging back to The Orthopedic Logbook and some interesting jolts of imagination.

    I’ve been away from this Logbook long enough to think, my medical blogging enthusiasm suddenly died a tragic death. The blogging hiatus emanates not from the dearth of medical issues hounding this country (there are at least a handful that I read on newspapers), but by the distracting circus of politics plastered by the mainstream media. The sickening politics of the corrupt dampen spirits even of the most politically apathetic medical blogging community where I belong. But then again, those are just my two cents opinion.

    Going on to a more immediate cause of concern for me, is the stalled Blog Rounds. Something amidst the rounds itself that dulled our enthusiasm. Or are we just plain busy doing something else? One thing I’m sure though, The Blog Rounds will continue in cyberspace for as long us we joust with our imaginative free thinking physician mind.

    Another point of interest for me is the reproductive health bill (Prudence hosted the rounds for this topic here) currently overshadowed by the political and partisan mayhem in the congress. The quick uproar created by RHB earlier was also quickly muted by the “circus of honorables”. This politics of diarrhea (called it that way because such politics is nothing but frequent bouts of mumbo shits by dishonorables) somehow reached epidemic proportions nowadays that nothing seem more important to our respectable leaders than their political continuity.

    I might as well go on to blogging more about web 2.0 and health 2.0. How can this information tools improve our delivery of health care? We might not know it but some of us are actually making use of these tools to improve our practice and deliver better efficient health care for our patients. So watch my posts on this topic.

    Well, the global recession might be very interesting to follow for countries like us exporting health care workers. Is the medical community affected also? Are we seeing a decline in demands for health workers abroad? How about us physisicans? Are we affected by this recession? Should we be wary?

    Lastly, since “presidentiables” keep popping like mushrooms nowadays, I might be very interesting to observe who among these wannabes own a pragmatic medical agenda for Philippine health care. Taking cue from US presidential campaign, health issues and policies should be a major part of any presidentiable’s programs.

    “We need change, but it should be a change for good, not just of faces”

  • Lessons from the pulpit: My MBS2 summit experience and E-health 2.0

    E-health 2.0
    Since I started a medical blog (The Orthopedic Logbook) , I’ve been very enthusiastic on bringing on Web 2.0 and health together in marriage, so that the medical blogging community in the Philippines will have a distinct voice undiluted by mainstream media. The powers of Web 2.0 has this potential of revolutionizing health care and health care delivery systems in the country. In my upcoming posts, I will be tackling Web 2.0 and how Filipino physicians can take advantage of this promising tool to efficiently and effectively deliver quality health care to our fellowmen.
    Amazing Feat
    My Mindanao blogging community experience and how the forerunners of this very vibrant group in the blogosphere made me really gasps at the powers of Web 2.0 and blogging. The recent Mindanao Blogging Summit 2 humbled the reach of a usually constricted mainstream media. With attendance going up to a hundred, imagine how many readers and blog visitors these participants have or how far their reach are when they’ll finally “post” their experience. Thus, an attempt at Blogging the Mindanao Consciousness helped correct some of the negative views about Mindanao. Five years ago, you hear nothing but bad news about Mindanao. Try goggling for the word Mindanao and you’ll see what I’m talking about.

    Taking cue from the organizers of MBS2 and how they collaborate to attain goals via the blogosphere, sort of made me ponder. What if we do that for the Philippine health care? For one, some controversial issues in Philippine medicine caught the “Web 2.0 attention” and somehow changed the Filipinos maturity. The reproductive health bill for example, made rounds in the blogosphere and you hear not just the health bigwigs in the mainstream media. You read common Filipinos enter the limelight and discuss on this issues via blogging! Mind Boggling? Not really. But wait till what web 2.0 can do for health in the Philippines!

    “Collaborative information by the people, for the people”
    This is where the power of Web 2.0 lay. And that’s why MBS2 and the Mindanao Blogging community is so successful.

  • I was crying dry….

    (Disclaimer: All names and characters in this story were deliberately changed to protect the privacy of the patient concerned. If you felt the story was referring to you or someone you know, you are wrong.)

    “Hepe, you might want to go the ward now.” The nurse on duty ‘s voice on the phone, sound a little bit gloomy. I just came down from assisting a junior for an OR that extended to almost 12 midnight and I barely touched “the bean bag” to rest. My team wasn’t on duty that night.

    “Bakit hepe?” (Hepe, is our pet calls for male residents and male nurses in the wards, sort of brotherly respect). “Nag code si Nanay Delia..Ikaw yung hinanap nya…” For a moment, I don’t know what to think of or how to react to this news. I immediately ran to the wards and joined the code team doing ACLS on Nanay Delia.

    Just 5 hours ago Nanay Delia and I are happily exchanging goodbyes and hugs in what supposedly a very heartwarming patient-doctor relationship punctuated by a successful OR procedure. To thank me, she insisted I’ll take a gift wrapped Pierri Cardin hankies and neckties fresh from underneath her pillows. To Nanay Delia, I was her savior-son. To me, she was a motherly patient I can never forget. I am her surgeon.

    “She what???!!!”

    I first met Nanay Delia in the outpatient clinic two weeks before this incident. She was this jolly faced 56 years old lola with a very happy disposition and a charming talker. Without make up but only the ever infectious smiles you see in your grandma’s face, her wrinkles in the forehead looked like lines of happiness. Needles to say, resisting her motherly charms is totally futile. Unable to walk because of nagging pain in her right hip, she was totally unfazed by her predicament and was in fact very much hopeful she can walk again.

    “Sa tulong at galing nyo doctor!” Nanay Delia was proudly chatting with some patients at the end of the clinic room. She was already infecting the whole OPD team with her crazy punchlines and contagious laughter. We can’t help but be swooned by her charm.

    After examining Nanay Delia and her xrays, a decision was made to have her right hip replaced (a procedure known as Total Hip Arthroplasty) to ease out pain and make her ambulate again. I asked her and her son who was assisting her to come back next week for admission and OR.”Talaga duktor? Makaka pamalengke pa ulit ako??!” Everyone in the clinic saw the face of Nanay Delia lit up. She is over flowing with joy giving hugs to all the members of my service. A gesture that touched everyone in my service. Nothing extra ordinary, but a gesture in the right timing and execution, will melt the hearts of stone cold surgeons that we are. “Nany Delia just smooched us all!” Said one of my juniors.

    Our arthroplasty service see quite a number of outpatients everyday . Believe me, Nanay Delia seem to be an epitome of hope among these poverty stricken and ill patients. In this institution, residents spend hours and days haggling for funds and implants among sponsors, philanthropist and politicians(with their CDF),so that these patients can have their OR, free.We were able to get funds for her implants, and since the surgeon, anesthesiologist and procedure itself is free, Nanay Delia will be operated with minimum of expenses.”Hay, salamat talaga duktor!”

    Nanay Delia passed the cardio-pulmunary clearance and labs easily. The internist classified her “low risk” for this surgery. So the next week, I saw Nanay Delia happily sitting in one of our ward beds. A number of bantays and ambulatory patients were already crowding near her bed. I can even here the laughter and giggles these people made because of Nanay Delias funny stories and punchlines. She was the center of attention in our wards because of her friendliness, jolly type personality and talkativeness. She even talk loudly with patients on the other end of the ward, at least 10 meters far from her bed! “Kung tayo nga na infect ni nanay, mas maganda tong mga patient natin masaya din!” I jokingly told my service.

    When Nanay Delia saw me and my team coming for the ward rounds, she shouted: “Shhhhhhh! Tahimik na tayo, nandyan na ang mga gwapong doctor natin!” She was gesturing her companions to keep quite but I still could here giggles from the other beds. “Nanay, napasaya mo ata ang buong ward ah!!!“

    I talked with the cardio fellow and seek out another CP clearance, this time asking for repeat ECG and echo cardiogram. This premonition somewhat baffled me also. She was already cleared for OR twice and I was still asking another one. Obviously the fellow hated me for that, but I got what I wanted. Nanay Delia was cleared for OR. Nothing in the repeat labs picked up anything suspicious. Getting the final pointers and go signal from my consultants, I scheduled the OR in two days.

    Talking to Nanay Delia about the procedure, the risks, the benefits and preparations, we were all set for the OR. If there was one happiest person involve in this procedure, she was Nanay Delia herself. She was so happy and proud that at some point, we heared her overtly exaggerating our scalpel wielding prowess that I can only sigh in disbelief and smile.

    It was not my first THA as a resident and I have planned for this procedure several times In all of my previous surgeries, I have been chided for being too detailed on preparation and precautions to the point of obsession. Nanay Delia‘s case was no special procedure and she too did not escape my obsession to preparation. Ironically she was a symbol of hope for most of our patients admitted to the wards. Her happy disposition is so infectious that my service actually felt the outcome of her surgery will be the barometer of how good our delivery of service was. “If this procedure will have a glitch, we will be devastated. So lets make this again, our best!” I pleaded my team.

    It was an uneventful OR indeed and the most satisfying one, finishing faster than we expected. Nanay Delia tolerated the OR well and we were so admiring of the outcome of the procedure. The planning paid off and more. Everyone in the OR team had a pat on the back and even Nanay Delia, who was mumbling my name under anesthesia.

    The next day when I made my rounds, Nanay Delia was already sitting at her bed, her eyes glowing in joy. “Dok!, salamat po sa inyo. Maraming salamat talaga!” Coupled with a hundred more praises and exaggerations, I can’t help but gave her our “akbay barkada“, a gesture we made to our nicest friends. She was already inviting me to her upcoming birthday and the christening of her grand son, to which I would be a godfather.

    “Nanay, you still have to start your hip range of motion exercise so that by tom, I can teach you how to walk with quad crutches.“I deliberately changed our topic of conversation.”Yes doc” was her smiling reply. I just shrugged my head. But deep inside, I was extremely please at the sight of one very happy and satisfied patient.

    The next rounds she was motioning my team again to her bed. “Kain tau dok!” “Mamaya na po Nanay after ma dress natin yang sugat nyo and maturuan namin kayo ng quad crutch ambulation.” Teaching Nanay Delia ROM exercise was no sweat at all. She was even proudly showing off to us that her h
    ip pain is gone. I was just smiling at her antics. “Hinay-hinay lang nanay!” I told her, she will be discharged tomorrow, once I inspected her wound and assessed her fit for home ambulatory rehab program.

    That discharged never happened.

    “Another epi please!” I was shouting while doing chest compression(CC). I am perspiring heavily since nearly doing CC for almost 10 minutes already. I’m still dazed as to what has happened but I’m racking my brains at reviving Nanay Delia. “Why was I not informed immediately about this?!” I was shouting already. “Hepe, ginigising lang si nanay nung bantay nya for meds nung napansin di na pala humihinga. Before natulog yan nakipag kwentuhan pa sa mga katabi at tawa ng tawa. She was asking for you and looking for you at may sasabihin daw.”

    It was a massive MI according to the IM in the code team. “How can that be?” I said, Nanay Delia was cleared two times before this OR! Even the 2D echo did not pick up anything! It is frustrating to look for impossible answers. The obvious reason was, I, my service became attached so much to Nanay Delia. Nobody was expecting this event to happen because everything went well and she was one hundred percent happy just before sleeping. She never woke up to walk again.

    When the IM declared Nanay Delia dead, I was still shocked and dazed. I was literally angry and frustrated at the same time. “Why did this happen? Was there anything we could have done that might have save her life???” I can see Nanay Delia‘s smiling face in my mind.

    I mustered enough courage to talk to the family gathered around her bed. I offered my best consoling words. I almost cried when each of the family member hugged me. “She was asking to see you before she slept, doc. She was very fond of you.” I was in the OR

    I excused myself and hurriedly left for the call room. I sat in one corner staring at the blank wall. I am looking at nothing. I still couldn’t believe what has happened. Nanay Delia and that this whole procedure meant nothing. I wanted to cry, but I couldn’t. I don’t know where to get my tears..I just sat there and wanted to cry but couldn’t…I was crying dry…

    In my most isolated and stoned cold medical life, . I am hardened by pain and several deaths to our patients. I have trained myself to get detached and not be affected by emotions. I was trained to empathize, not sympathize.Yet, every time something like this happened, I felt it is easier to just cry and make ease the burden of guilt. It feels lot lighter and starting again, becomes easier.

    But tears never came.

    Perhaps, it was because Nanay Delia‘s jovial face smiled on us every time. That for a short time, we were able to make another patient happy and satisfied with what we can do with our god given knowledge. That we learned from this mistake and that she gave hope for our other patients. More importantly, Nanay Delia taught us all that happiness is a constant state of mind. And you need no superfluous things or event to enjoy it. No excuse.

    I cried dry…

  • How to find the "best" physician in your area…

    Do you have any health concern needing attention? How should one actually go about looking for the “best doctor” if you need medical advice?

    Such questions only come up to the minds of most Filipinos during medical emergencies were choices are usually limited. I frequently end up seeing patients who have been through a number of physicians but don’t have any idea about what they just went through or why.Thus, patients and relatives end up in a dissatisfying doctor-patient relationship or  worst, end up in the arguing courts rather than quality medical service. Not that I am better than the rest, but certainly such predicament put so much pressure on the MD and patients alike that quality service to patients suffer most.

    Here’s some tips I can give to patients or parents when they’re looking for a physician (or any specialist, like an orthopedic surgeon) if they need medical attention

    1. Ask from a medical practitioner or paramedical personnel you know. The best opinion usually come from someone you know in the medical field, preferably a physician too.
    2. Ask from relatives and friends.Past experiences from previous physician-patient interactions give valuable insights to the quality of patient service.
    3. Browse the net or search online for MDs in your area. In the Philippines such network as Doktorko have listing and profiles of MDs in the area. Some MDs and specialist maintain a website of their own, publishing  the area of expertise, credentials, and clinic time of the physician. Most hospitals also list their doctors and alumni on their websites.
    4. Inquire about the physicians credentials and expertise regarding the health problem you are about to seek consult. It’s not improper if you ask the physician yourself.
    5. Evaluate if you can effectively communicate and trust this physician He might be the most competent specialist in the field but if you cannot communicate with this doctor, chances are you won’t get the satisfying treatment you want.
    6. Opt for a second opinion if you are not satisfied with your physicians interactions. It is alright to inquire for second opinion from other MDs in the field so long as you don’t get confused in the process. As a courtesy, always inform the first doctor you consulted.
    7. Stick with the MD whom you can effectively communicate and trust. The physician’s competency in the field your interested with coupled with good communication and trust, constitute the greatest chance of your problem being addressed satisfyingly.
    8. Ask for recent, evidence based knowledge regarding your medical problem. Check what you researched and read about your medical condition and clarify doubts by asking the physician of choice.
    9. If you need to be referred to another more specialized level of care, ask for a formal referral from your previous physician.
    10. Pay your physician’s services – even with just a warm thank you and smile. Physicians knew all the sad predicaments we have in this world, and chances are with a warm thank you, most of us will all be a lot inspired in our noble work.