Cast & Curious

Tag: Orthopedics Practice

  • The (high) cost of hospitalization in the Philippines

    I’m not talking about top quality health care that is available to those who can afford. I’m not even compounding the issue with other factors such as health insurance system and access to medical care. Not even the extensive use of public health facilities by the poorest 30% of the Filipino population.

    I’m talking about this patient’s words

    Doc, di nalang ako magpapaadmit sa ospital kahit kelangan. Di ko po kaya ang gastusin” (Doc, I don’t want to be admitted in the hospital  even if its needed. I can’t afford the expense)-Indang

    Her words not only rang the current “cost” of being a “poor” sick here in the Philippines but of frustration and disgust for having been a victim of a doubly whammy – that of being a poor and getting sick here in the Philippines.

    The findings of a study to assess the three year implementation of Health Sector Reform Agenda
    narrates a littany of negative factors that promotes this double whammy among the poorest of this country. One i could highlight is this:

    The average hospital bill is three times the average monthly income. Costs are so prohibitive so that a 10 percent increase in the price of private hospital services will reduce utilization by as much as 30 percent.

    Not only sounded true but also alarming. Compared to the Mayo Clinic which is among the highest-quality, lowest-cost health-care systems in America, ours pales on its reach and delivery. Philippine General hospital tries to deliver such high quality low cost health care system also but even such healthcare system hurdles not a few logistics problems.

    Here’s one good thing the guys at Mayo clinic are doing:

    …Mayo recognized that the first thing it needed to do was eliminate the financial barriers. It pooled all the money the doctors and the hospital system received and began paying everyone a salary, so that the doctors’ goal in patient care couldn’t be increasing their income. Mayo promoted leaders who focussed first on what was best for patients, and then on how to make this financially possible. No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But, almost by happenstance, the result has been lower costs. “When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,”

    I’d like to think this should be another thrust among health care reforms (among a plethora of other issues) be implemented. Maybe we should look at our health cost utilization and unnecessary diagnostic costs. Put patient first and then work on to minimize health financial expenses. Maybe its not who pays or how are we paid as physicians and how we can maximize health expenses. Lowering cost of expense is second only to quality life of patients.

    What do you think?
    (Photo taken from the Daily Herald, here)

  • What we do for living is "Heal"

    I found this amazing animation about what orthopods do when patients sustain multiple fractures. Aptly titled “heal” and produced by genius animators of Ghost Productions, this high definition video was presented during one American Academy of Orthopedic Association (AAOS) convention and it awed a lot of viewers.

    And even you tube visitors were equally amazed at the production. So go see for yourself!

    One short note though, we do all of these with patient anesthetized! Helps allay the gory innuendos some may think about this orthopedic procedures!

  • Bonesetters vs. Orthopods

    One post operative, open fracture patient I’ve been following for weeks came to my clinic today asking me if I could remove his leg external fixator now so he can go to a “neighbor-recommended” bone setter that will “fast tract” his bone healing. A bit amused by his persistent pleadings (despite numerous occasions of explaining the need to maintain the external fixator for now), I chose another uncanny method to dissuade him.

    I told him these:

    1. that my own neighbor actually recommended a butcher to cut of his left leg and free him from all his temporary worries now.
    2. a bone setter could not possibly do any bone setting at all because his once fractured bone, is aligned already and is showing signs of healing (2-3 cortices joined already). He cannot claim what nature does beautifully and without pain now.
    3. I also told him that if the bone setter can attend to him 24 hours a day, answer all his questions via text message or calls anytime, stand on trial testifying for his “serious physical injuries” charged against those who mauled him, and then take it on stride that his services may be for free, then he can go to that bone setter now.

    That bone setter lost one more patient today.

  • 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…

  • Some horrendous claims of herbal supplements may kill you…

    It’s not only irritating to hear horrendous “cure all” claims of some food supplements manufacturers and advertisers about their “drug” but the lack of advertisement control also nauseates me to no end. The sickening charade of food supplements jumping out of nowhere and claiming to heal all kinds of human afflictions thinkable (just so they can corner the poor man’s pocket) is staggering to say at least. Taking these supplements at advertisement value is already one big step to your sick bed. Deceiving someone with false hopes and killing the patient in the process is another “crime” worthy of harakiri.
    (Photo taken from Science Blogs.)

    In almost everyday that I listen to the radio, some airtime (at times lasting a full 15 minute!) is spent on miracle cure throttled by exaggerated personal testaments of complete strangers.

    What happened to “PANA: Truth in advertising?” or the KBP’s commitment to “Nothing but the truth, so help us GOD?”

    Here’s BFAD guides on how to spot false claims by these unscrupulous supplement manufacturers.

    1. The product is advertised as a quick and effective cure-all for a wide range of illness.
    2. Certain key words like “scientific breakthrough, miracle cure, all natural without side-effects or ancient remedy” are used.
    3. The promote claims that medical professionals and scientists have conspired to suppress the product.
    4. Adverts contain undocumented, anecdotal cases, but with amazing results. No science involved.
    5. These products sell falls hope for extreme physical attractiveness and shortcuts to weight loss. They will never emphasize the value of healthy lifestyles, like avoiding smoking, excess drinking of alcohol, eating appropriately, adequate rest and sleep, and regular exercise.
    6. Remember that legitimate health supplement products will never carry claims for quick cures; claims such as cancer prevention, good for arthritis, good for diabetes or good for hypertension, should be high suspect.
    7. The product is advertised as available from only one source.
    8. There is a money-back guarantee promise.

    The usual excuse laid for such drug supplements goes along the lines of herbal medicine being natural and hence, is the best form treatment. Another sad excuse propagated by these unscrupulous manufacturers and advertisers is the soaring prices of BFAD certified drugs. Both of these excuse “prompts” the ignorant listener to buy the cheaper, food supplements that claims healing every imaginable human disease yet lacking in rigorous scientific testing! It’s like jumping on a plane hoping your jacket will save you (it may even get tangled in the plane’s props) instead of your chutes. Stupidity does have its additive effect remember. It might not only rob you of your hard earned money but it may sometimes kill you or your patient!

    To argue that some drugs or supplements need not pass rigid testing to be effective is an outright lie. Often, these are Russian Rolette type solution to a worsening health economics. Licensing and BFAD approval of any drug aims at at least two basic goals. Rigid and scientific testing makes sure the quality and quantity of any drug is not only safe for human consumption but should also be effective against the illness(es) it claims to combat.

    At the very least, any drug must be tested for its safety profile and efficacy. Remove the first and your taking in a poison. Any dubious drug efficacy even in rigorous scientifically studied drugs, is nothing but pure waste of money. Take out both, and you make yourself poor on your way to your deathbed.

    One (or two) person’s testimony, no matter how famous that person, is not tantamount to a safe and effective medicine.Some physicians or physician’s name is even attached to these claims. In the current recommended evidence based approach to treatment and procedures, anecdotal testimonies ranks the lowest in the strength of evidence.

    Now would you want any food supplement giving you all these complications? Would you even dare to give food supplement to someone you love and risk losing his life base on false claims?

    Think again…