Cast & Curious

Tag: Medicine

  • Of headaches and coughs

    Once in a while I get a break from purely orthopedic stuff and wield a stethoscope as a “general practitioner”. I used to like the general medicine as a student but when clerkship bombarded me at least fifty patients a day giving nothing but prescriptions and prayers as “medicines”, I resigned myself to cutting it out in the surgical field.  In my place of practice though, there are times when you’re the only doctor within 1 kilometer of a medical emergency and every other medical practitioner is busy handling other medical emergencies somewhere else. God knows what happens if the patient’s relatives find out you don’t know what atrial fibrillation looks on ECG. So when push comes to shove,  I welcome instances where I can re-learn my rustic general medical skills. Or at least mount an attempt to re-learn.

    Two days ago I started seeing patients for routine medical physical examination. The sheer volume of patients made me think I’d get bored or get tired sooner. Surprisingly, I found myself enjoying the “routine” job simply because its something not routine for orthopods like me. “A break in the monotony of bone breaking, hammering and screwing..” perhaps.  The same fun feeling and excitement when you had your first few patients as a medical student. This routine physical examination also gives me the opportunity to look at the depth and effectiveness of my patient communication skills, especially in medical topics way beyond the orthopedic cram space.

    The sheer volume of patients also brought in funny experiences and encounters you’d probably die of laughing out loud in the washroom.

    Here are some of my (funny) encounters;

    Patients chart says: Chief complaint: “occasional headaches”.
    Me: “Masakit po ba ulo ninyo ngayun?” (Do you have a headache now?)
    Patient: “Wala po”. (None)
    Me to self: (Right, this encounter must not be an occasion for his headache to come out)

    Here’s another:

    Me: “May “cough” po ba kayo ngayon??” (Do you have coughs right now?)
    Patient: “Wala po. Ubo meron” (None, but coughs I have.)

    and another:

    Me:” Sino po ba nag bigay reseta ng “salbutamol” sa inyo?”(Who gave the prescription for your medicine, Salbutamol?)
    Patient: “Tatay ko po” (My dad.)
    Me: “Doctor po ba cya?”(Is he a doctor?)
    Patient: “Opo, doctor po apilyedo nya!” (Yes, this patient’s last name is “Doctor”)

    You couldn’t hide snickers whenever a patient answered like this:

    Me: “Kelan po ba sumasakit ulo nyo?” (When does your headache usually occur?)
    Patient: “Tuwing nag tatanggal kami ng damo sa school” (Everytime we’re tasked to weed out grass in the school grounds!)

    Believe me I couldn’t contain my heart laughing out loud during these light moments. I don’t know if its because of the many misunderstood and trivial complaints you get whenever its an ambulatory clinic you’re conducting (or that I was just too confined with more serious, trauma patients). One thing though,  we all needed the laugh just so we can finish some two hundred plus patients each day.

    Who said my specialist life is too constricted and boring? If there are instances like this where you can find time to re learn your medical skills as a general practitioner, why not? Especially, when there are plentiful of laughs you can make out of the “routine-ss” of the situation. I can surely wield some stethoscope.

  • 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.

  • Serving communities near one’s previous home…

    Two days ago I had this rare chance of visiting a community hospital near my birth place. I went to this “far flung” community to see patients admitted at an 18 bed primary  hospital, the only one within in a 20km radius in that area. Many had reservations going to this place. A few doctors were brave enough to serve this community despite constant threat of being abducted or god knows what.

    Anyhow this community is significant to me because of its proximity to where I was born and where my family previously lived. Just about a few kilometers from our previous, memorable home. My parents both worked at a big corporation previously operating north of this community. Both migrants to this place, this is where they met and fell in love with each. Three of my siblings were born here. I was born here. I grew most of my formative years in this relatively serene and laid back far flung community. My family built memories here. When my dad passed away and the company pulled out of the community because of the worsening peace and order, we left the place too and settled here in our present area. Since then I never had a chance of  coming back to this community, to even gaze at my birthplace, to even walk at the staircase of our former house, or maybe swim again at the duck pool, or climb that santol (tamarind) tree.

    Such a relaxing sight don't you think? (photo credits here)

    On our way to this community hospital, I rekindled familiarity with the road, of the lush green rice paddies alongside, those white herons on water buffaloes’ back, and that smiling townsfolk half submerged in mud paddies trying to catch some catfish. I saw all of them again and for a moment I am happy.  I wanted to take out my camera and take photos but I hesitated wanting to enjoy the moment rather than fiddle with a gadget. So close to home. So close.

    At the hospital I examined patients at the same time exchanged jokes and stories with some of them. I used to understand and speak their language but now, I can only understand common phrases and blabber “yes” and “no” in their dialect. One patient even joked “our doctor now is kind of a joker” in their dialect to which everyone in the ward was laughing.  Strange, but I felt a strong feeling of commonality with them.

    I went there as a physician more than an orthopedic specialist and I saw diseases that were epidemic in far flung communities – water and food borne disease as well as animal transmitted diseases. It reminded me of my community internship in one far flung province somewhere north. But this is close to home and admittingly, close to my heart. Many would find me reckless and bold to go there despite the risks, and even I was surprised It turned out to be a pleasant and heart warming visit, but some things are never meant to be understood or left to calculating risks. I cannot answer why I did it. I just felt doing it.

    Will I do it again? Who knows. Maybe in another opportune time. When I could go even closer to home…

  • Do we need a law that protect healthcare providers if they disclose or confess medical errors?

    Central to correcting medical errors is accepting one first, if it did happen. Improvement in healthcare delivery will only happen if we learn from our mistakes and make concrete, active steps to rectify it. This is what we actually do during mortality and morbidity conference- analyze medical events and cases to help improve delivery of healthcare services.

    The health care industry accepted the occurrence of medical errors decades ago. But disclosing medical errors publicly is unpopular even in countries where litigation is relatively not so common. Why? No one really knows. In our society however, publicly apologizing for one’s true medical mistakes is akin to killing your medical career. I guess it’s a bit easier to admit moral turpitude publicly than let’s say admitting you misdiagnosed a patient. The acceptance is just too low.

    But what can we do? First, we should create an environment of open-mindedness among medical peers and enact laws that will protect disclosures of medical errors publicly. That way, we can freely examine medical errors to institute appropriate corrective actions based on acceptable and evidenced based medical practice.

    This is what John Hopkins University Hospital is doing since 2001. Their  Disclosure Policy  protects and actually encourages employees to confess or report medical errors. This is partly the reason why JHUH  litigations have continually decreased ever since the policy has been implemented.  John Hopkins is the top ranked hospital in the US for 20 years already.

    Medical errors simply don’t surface over time. For us, providing a “medical whistle blower” law might just be the first step in improving delivery of healthcare services. Don’t you think so?