Cast & Curious

Tag: Medicine

  • No where to go but up!

    (I wrote this article while savoring the brutality of starting a practice and endless whining of a slow start.)

    My struggle has always been between filling up my empty stomach or satisfying my impoverished brain. To the millions of hungry Filipinos like me, this our “class struggle”-an unarmed, non-violent but similarly aggressive perspective of seeing past our choices of everyday life.

    To a proletarian who have gone to the bottom lowest of the pits, the best assurance one can get whenever you start a career or something is an old adage that says “you can go nowhere but up” or something to that effect. Like a messianic prophecy, I fanatically held on to this belief since high school days . The capitalist notion of incentive-driven success vis a vis hard work is as ironic as it is baffling to everyone in this “stomach” struggle. Yet, I survived half of my lifetime living in such altruistic ironies that neither my myopic deconstruction of choices nor the risky jumps I made could explain the extraordinary luck I had ending up being a physician.

    The dream of donning a white blazer and treating a patient is as fascinating as it is exciting. I am so entwined with that dream I forgot I have neither the financial capabilities nor the intellectual giftedness needed to attain such lofty dreams. I went into this profession simply because I wanted to prove to myself (and to my less encouraging social caste) what everyone in my bunghole has failed to do before me- don the white blazer with the least expense I can- financially and intellectually that is. Everyone think it was suicide in the making. I thought I have nothing to loose. I don’t have anything to loose anyway.


    That dream however grew into a vision, thanks to my alma mater. I practically crawled and bled to finish top of the line education for a career not everyone in my caste will experience- not even in their dreams. Fifteen years of Hippocratic studying did wizen my outlook about this noble profession. But it also shattered some idyllic notions I once have about doctors’ blissful life. More importantly, it brought my bourgeois upbringing to its knees and gave me the awakening of my comfortable life. My mission is never confined to the personal and financial self gratification kind of success. Because if it is that myopic, I could have never gotten this far.

    I have all the necessary ingredients for a successful medical practice. Ingredients that when “cooked” rightfully, would lead me into the much coveted goal in life that is termed success. Such “ingredients” are big words indeed, taught in bold letters, eaten in gastronomic amounts and digested in herculean way. It’s funny after that word found its way into the neurons of my brain, I have been deluded of a blissful life outside the academe, akin to the Renaissance Man. Little did I know about the truth that lay ahead in real medical life that is called “the Practice“


    Starting an upstream professional career is never an easy thing for the not so typical surgeon wannabe like me. I neither possess the inherited practice most other surgeons nor the coffers to buy a new one. Most people believe though, that having trained in one of the best medical schools in the country prepared me for one of the most formidable foe of the real life physician practice- an empty stomach.

    Of course being out of the academe and starting your own practice has its exciting advantages. The thought of having to take control of one’s time and spend it according to what you want is exhilarating. I can spend more time with what I want most, or with my loved ones I neglected when I was still studying. Gone are the Sundays where you have to read and prepare for pre-ops instead of having to eat dinner with family. I see non emergency patients on a scheduled time I myself created. Most of all, I have time to take care of my body while taking care of patients as well. I can eat full meals in a day and exercise regularly to maintain a sound and fit body. It is ironic that while we take care of patients 24/7 in a hospital, I lost tract of my own health in the process.

    I am into the practice of my profession for just barely two months, and it’s neither the blissful stride I once dreamed nor the catastrophic frustration I’m so afraid of before. Somewhere in between these extremes is the horrible spectrum of uncertainty where my minute practice existence resides. I wish my practice was as dramatic as the scenes in ER and Grey’s Anatomy or as wacky as unnerving as House’s one liner ass kicking. Nonetheless, the uncertainty gave me ample excuse to whine and be cynical about everything I get my hands on. Blame it on inexperience surgeon wannabe that is me. Everyone says that staring a career is shitty enough to make or break your soul. My soul has undergone so many breaks it neither can feel any shattering this practice has to offer nor enough time to recover form constant battery of changing lucks past choices.

    I bet it’s easier to just look at it as the paradigms of opposites. The definitions of success (and failure) in ones’ professional practice defined by simplistic phrases like-great clinic practice, successful surgeries, acknowledged researches, magnanimous services to patients and yes, professional fees enough to buy what we need. In essence, the very opposite of such adjectives and superlatives defines failure . Of course almost everyone believes that such simple dichotomous definitions don’t exist in reality. The theory of relativity seems to apply even in the psychology of success.

    So it seems. But that, I have yet to uncover.

    (Photo credits: All photos were taken from Deviant ART, my favorite repository of artistic shots.)

  • The Orthopedic Logbook on Physical Fitness and Conditioning for Mountaineers

    The author with a few trekking pilgrims to Mt. Apo, post for a group picture while at camp at the highlands of Makalangit, New Israel. This camp is considered station 10 of the long, arduous station of the cross climb towards Mt. Zion-just north of Mt. Apo

    The “holy week” is of special interest to outdoor pilgrims like me not only because of an important Christian tradition it celebrates, but also because of the long vacation time it offers. It give us trekking saints longer time to troop to our mecca hit those peaks again! I am one of those outdoor buffs who spent the last two successive Lenten season on top of those mountain ranges.

    Ironically, no matter how low profile I keep on what my real job is, I often get questions related to it and mountaineering, a hobby I soon enjoyed.

    “How do you physically prepare for this climb Dokie? Is there a way for us to prevent injuries and muscle soreness during and after climbs? Why do some people pass out of exhaustion or get headaches at high altitudes?”

    These are the common questions fired at me, by my climbing buddies and often by newfound trekking friends.

    Oftentimes asked about questions related to his job and his hobby, like in this picture, a post climb socials, the author sometimes grapples for answers he wished taught in med school and training.

    Sometimes, I wish I have a tape player with me, so I could replay my answers to these questions. Because of these recurring questions, I have been inkling to write about the medical aspects of mountaineering. Specifically, I would like to start off with physical fitness and conditioning based on what I know and experienced, both as an orthopedic surgeon and an aspiring mountaineer.

    The author after a extremely cold night on top of Mt. Dulang-Dulang, in a recently concluded double major, double strenuous traverse climb

    A word of caution though. As much as I want to claim bragging rights of being a mountaineer, I am still a novice in this sport. That I am an expert sport physician and wilderness doctor is also too capricious a title. But I have developed a fitness program for myself, trekked a few mountains (read my other blog, Talakudong Mountaineer), endured some accidents and injuries from climbing but was able to go back to work as an orthopedic surgeon again. That in itself perhaps led me to study and learn more from my experiences and share it with anyone willing to learn and try it themselves.

    The author, after a river trekking (Penek Busay, Digos) accident last September 2007, sustaining bilateral 2 inches gaping cut on both his knees.

    Physical fitness and conditioning for mountaineering is a complex topic to discuss, often involving the ideas of a multi specialty training team but basically anchored on sound scientific, medical principles that is fine tuned by personal experiences. My fitness regimen was a product of reading, experiences of me and others I know, of trial and errors, of accidents and injuries I got whenever I hit the peaks or outdoors. I realized though that such experience and knowhow is of no use if not shared or taught to newbies willing to learn, and to experienced climbers avoiding accidents to happen while at their beloved sport.

    Before we go further, I highly recommend that any serious climber should seek advise from their physicians before embarking on this task or scaling any mountains. In developing a fitness training program for your mountaineering expeditions, I also suggest the guidance of a certified fitness instructor. I understand that these two person may not be available in certain areas for certain people either for monetary reasons or lack of specifically trained personnel. But these are essential persons if you want to have a fun and less strenuous, less accident prone climbs. There’s no doubt about that. Ultimately, I (and this blog) hold no responsibility for whatever will happen to you, on training and on your climbs, whether you’ll follow my advise or not. That is entirely a personal
    risk you have to take.

    Personally, I always make it a point to know my current fitness status and goals before I embark on a training program or climb. There are numerous factors that can affect the fitness capacity of any person scaling a mountain, be it the weather, difficult trails, steep inclines and the altitude itself to name a few. To be able to face these unforeseen factors squarely and hurdle them, you have to be fit enough to adapt and survive. Aside from your basic mountaineering skills and survival tactics, this is where a fitness program and physical conditioning is all too important and beneficial.

    Chris and Lemuel, the author’s climbing buddies while maneuvering a 20 meters slippery 90 degrees steep descent, holding only to jutting root parts and mostly dangling helplessly with no footholds. This is an extreme, “hard core” trail we manage to pass during our late traverse climb in Bukidnon.

    A good fitness program for mountaineers consist of two major groups of exercises, the cardiovascular (aerobic) and motor (anaerobic) fitness exercises. Cardiovascular fitness is measured by your aerobic capacity to take in and use oxygen. In most instances, this is a function of pumping blood (and oxygen) into the muscle system with the help of lungs. A motor fitness program consists of exercises to enhance strength, endurance, power, balance, agility and flexibility. With better cardiovascular capacity and good motor fitness, the third component of fitness training for climbing, which is acclimatization, will be a little less painstaking.

    The author, on top of one of Mt. Apo’s peaks, terribly out of shape but happy. He promised to develop a better physical fitness and conditioning for himself next climb. (Aguilar 2007)

    For purposes of discussion, I’d be using the goals I set for climbing Mt. Apo (which I climbed on a Maundy Thursday last year) and the fitness program I tried to implement. Mt. Apo is the Philippines’ highest peak (2,954 MASL) and also have one of the coldest open air temperature nigh time. Considered as a Level 3 (strenuous, major) climb, the “trip” to the peak consist 3-5 days of passing through wet, tropical rain forest, with some objective hazards, rope maneuvering, and walking for at least 6-8 hours a day on mostly steep slopes of up to 80 degrees. Mt. Apo is a popular destination for newbies and experienced climbers alike not only because of the bragging rights conquering the highest peak but also of the beauty that lies within that solemn mountain.

    Here are my specific goals I set before I embarked climbing Mt. Apo last year:

    1. To be able to carry a 40 litre backpack (NF Flight Series) , for 6-8 hours a day, for 4-5 days.
    2. To be able to recover from climbing exhaustion for 8-12 hours sleep on a cold (0-5 degrees) night.
    3. To be able to ascent to the peak on summit assault day on usually 60-80 degrees slope and back.
    My fitness program and physical conditioning starts well before the climb date usually at a minimum of one month. But effective training is noticeable after least 3 months, studies have shown. I usually go on interval climbs to train for another major climb though. And this might explain why I get conditioned even if my fitness program only start at least a month on some climbs. And the exercise I do are often, close simulation of climbing.

    Simulation and training climbs conducted by the author’s group, TAMAC, often on hills and benign trails like this one going to Lake Maughan in Tiboli South Cotabato is needed to augment climb conditioning

    The first few weeks is centered on getting myself into the routine of exercises, emphasizing discipline but at the same time, carefully observing myself for overenthusiasm injuries. Using a timed fitness program, I vary and progress my exercises depending on my month to month progress. It is usually a regimented but often flexible program that suits my work days and schedules.

    There are many cardiovascular exercise you can do that may be available to you in your location. I chose exercises I can do easily in my place, like running, stairs climbing, biking or swimming. These exercises not only increases cardiovascular capacity, it also increases strength and endurance for climbing. Here are other benefits of cardiovascular exercise.

    Some general guidelines for aerobic training:

    1. Aerobic training should be monitored by your heart rate or pulse rate, which should be 65%-80% of maximum heart rate. Maximum heart rate is computed by subtracting your age from 220. This should be your training heart rate.
    2. Training each day should be at least 30 minutes to one hour to be effective. A longer period of training time each day, on special locations and equipments is needed if your going for lengthier climbs.
    3. The frequency of training should be regimented but flexible. I train 2-3 times per week and daily near the climb date and watch myself for over use injuries. Rest is very much recommended between training weeks.
    When I developed discipline for training routines, I advance my cardiovascular training using interval training. Interval training includes upsurges in exercise intensity during an elevated heart rate and is very strenuous. Interval training when used over long period of times, increases the capacity of heart to pump blood even on emergencies and unexpected hazardous treks. Here are my examples.
    1. On running, I start with a thirty minute moderate intensity pace then increase this pace 3 times for ten minutes then go back to moderate intensity. I repeat this every 20 minutes.
    2. Track or oval running includes running one round on moderate pace then sprinting 100 yards then one round again on moderate intensity.
    I use stretching, weights and calisthenics to develop my motor fitness. I have yet to develop an effective program with weights as I have at the moment very limited access to a fitness instructor, but I’m working on light weights (15kg) of 2 sets consisting of 20 reps each. Then I rest for 60 sec between sets. Stretching, calisthenics, abdominal and back strengthening exercises can be done daily.

    I also concentrate training on my lower extremity (thigh and leg muscles) and my upper torso, usually the back and stomach as this will help me carry my backpack. Strength motor training of upper and lower body should be done twice a week

    Warming up and cooling down is an important part of my fitness program. I warm up 10 minutes before any exercise, with jogging or skipping ropes and bring my heart rate to my training range.

    I do static stretching for 10-15 minutes before and after my fitness program workout. Stretching reduces muscular tension and prevents soreness after workouts and climbs. Any static stretching exercise should be held for 30 seconds.

    Weight training should be focused on correct form and technique to develop the essential large muscles first, like the shoulder, triceps, biceps, quads and calf muscles. Leg curls, calf raises and squats strengthen the lower body and extremities while some exercises should be aimed in developing the chest, shoulders of the torso. For abdominal exercise, cross training the abdomen is beneficial. I highly suggest you seek advise from your fitness instructor regarding these strength training exercises and the correct techniques needed to do it.

    I do one leg stand for my static balance exercise. This consist of standing on one leg holding the other leg’s foot then squatting and then returning to the standing one leg position. I do this two sets with 12 reps each.

    I benefit much from badminton for my dynamic balance exercise, since I do this as a sport also. Aside from dynamic balance, I also gained some sort of cardiovascular strength from badminton, although this is just on the subjective point of view.

    For most of my training regimens and physical conditioning, I try to keep a training record of my fitness program, more for discipline and assessing my improvements. I am certainly motivated and getting enthusiastic every time I see an improvement in my fitness status.

  • Bone MD blogging back in The Orthopedic Logbook

    After that scary Mt. Dulang-Dulang to Mt. Kitanglad traverse trek I joined 4 days ago (watch out for an upcoming post about this trek on my mountaineering blog, Talakudong Mountaineer at http://tacurongmountaineers.blogspot.com) , It’s nice to be back here, in the “comforts’ of my logbook. Dangling helplessly on those cliffs with just your bare hands holding on to a jutting tree root, I was praying I’m just blogging instead!

    The orthopod Bone MD on top of Mount Dulang-Dulang, the first stop of a 3 day D2-to K2 Traverse Climb he joined in Bukidnon

    But I couldn’t resist this scenic view on top of Mt. Dulang. I hope this is worth the risks of the grueling traverse and the unfinished tasks I left here in TBR and Logbook.

  • 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!

  • Filipino MDs in the blogosphere: "Duktor Ko"!

    These Filipino docs may have a very busy clinic or duty days, but blogging is part of their routines. Blogging may be after all, one of their stress reduction prescription- Pinoy style!

    Em Dy of Pulse have compiled blogs of Filipino MDs in the blogosphere including some (Martin B. of On My Way Home, Doc Emer of Parallel Universes, Prudence MD by Tess R. and yes Em Dy‘s Pulse ) of the well known personalities in the medical blogosphere, and some ‘Juan-came-lately” newbie blogger doc (like me).

    So perhaps, Pinoy MDs are taking more active “utilization” of this form of social media after all!Blogs may not be medically related, but they are as interesting as the docs themselves!

    Here is the list and the complete descriptions of the blogs by Em Dy of Pulse. I can’t think of better descriptions of the blogs than what Em Dy has wrote. So I’m lifting it here verbatim!

    • On My Way Home. This is the blog of Dr. Martin Bautista who is perhaps the most popular among the Filipino doctor bloggers. His fame is not so much due to his blogging but because of his attempt to run for a Senate seat. Although unsuccessful in his bid, the votes that he garnered is testament that the Filipinos are ready for change.
    • Prudence and Madness. Tess Termulo is a well-known figure in the Philippine blogosphere. She talks about medicine, personal and socially relevant issues and even shares her dreams.
    • Parallel Universes. Also well-known among Pinoy bloggers, Doc Emer writes mostly about medicine but occasionally ventures into posts very distinct from medicine.
    • Finestkind Clinic and Fish Market. Retired physician Dr. Nancy Reyes dispenses her thoughts on medicine, culture and the joys of cooking pancit.
    • No Special Effects. The doctor who runs this blog, Manggy, is addicted to dessert.
    • Feeding the Boys. A dermatologist now living in Canada, CTL shares her adventures in the kitchen.
    • My Little Space. This is Dr. Gita Asuncion’s home on the web. Here, she shares her life, what she’s seen, felt and heard, where she’s been and more.
    • Super Dok. Amelyn R. Rafael, MD wears many hats, those of a mom, practicing physician, teacher, wife, etc. With all that multi-tasking, she’s definitely super.
    • Shouting My Whispers to the Universe. This is the personal blog of a female Filipino doctor who calls herself Midnight Rainbow.
    • MegaLife. Written by MegaMom, this blog is a collection of posts about food, wine, coffee, books, music, art, movies, health, family, altruism, everything but bowling. Now blogging at Pinay MegaMom.
    • Notes of an Anesthesioboist. I found Dr. T. Legarda from a comment in MarketManila. She was born in Manila and now engages in anesthesiology (private practice) in Boston since the move to the US in 1981.
    • My Life and My Scrapbooking. Dr. Rita Marie S. Vergara is a pediatric pulmonologist and is a certified scrapaholic.
    • The Doctor is a Photographer. Dr. Antonio C. Comia shows us that his photographic eye is as good as his clinical eye.
    • Ripples from the River of my Thoughts. A physician from Cebu, JA also likes to dabble in creative writing.
    • Payb-Pifty Lang Po. This is Doc Broks’ funny blog.
    • Samu’t Sari. A personal blog with interesting takes on theater, dance and travel, Samu’t Sari is all that and much more.
    • Differentials. Another personal blog, this time by a female physician on her way to becoming an internist.
    • Sympathomimesis. Dr. Rosseau, another would be internist, channels his thoughts in this site.
    • Aloyloy. Probably, the strangest name among the blogs listed, this one focuses on politics and pop.
    • Lifeline. Reeza is a doctor from Lipa who has only recently started blogging.
    • So Far, So Good. Dr. Christian Gomez describes himself as multi-faceted. His blog is similarly so.
    • Life Journal of an Integrative Medical Doctor. A ger
      iatrician who calls himself XyberDoc talks about his life and medical practice.
    • Pepper Says. A newly licensed doctor in transition from school to work blogs about her universe.
    • It’s Me! Raphael. This doctor from Cebu talks about family, medicine, technology and religion.
    • Mah Lyf. Norwin Detalla is another doctor blogger from Cebu.
    • The Last Frontier. This is the blog of Raul Espinoza Ramos, a doctor who’s also a nurse.
    • Chronicles from the Middle of Nowhere. Dr. Clairebear describes herself as a young doctor in quarter-life crisis, wandering through life for the first time without a map.
    • My Sanctuary. Doc Mai is a Filipino doctor based in Mindanao who once dreamed of a Palance award. She rekindles her love for writing in this blog.
    • Merry Cherry. Merry Cherry is a doctor to the barrios who blog about her adventures both in the city and in the country.
    • Checking In. This is the blog of Dr. Geena Macalua, an internist-oncologist. Here she talks about medicine and life in general.
    • Sison of Love. It’s obvious that Doc Cristina loves two things: music and love.
    • www.thekid.tk. TK is an internist/medical officer whose mission in life is to make good memories with his children.
    • Doralicious. Another doctor who wears many hats, Dorothy is a psychologist turned physician turned public servant.
    • At Random Ness. Based in Dumaguete, Ness blogs about medicine, family and friends.
    • The Orthopedic Logbook. Bone MD writes about issues affecting his daily medical and orthopedic practice.
    • Okasaneko Chronicles. This is the blog of KittyMama, a doctor whose passions in life include autism and Hello Kitty.

    Thanks again Em Dy. And to those interested we can form a blog carnival of Filipino MDs. Please don’t hesitate to contact me (email) or leave a comment here!