This report is also available at Lancet Student. The content is the same, other than the fact that mine has one more picture, and many more links! Lancet Student Editors decided that providing links will distract readers from actually reading the article, which to a certain extent is true. For seasoned blog readers, they do know it can be an issue and text links tend to be images only. Many internet users use tab windows; personally i check the link at the bottom of my firefox before clicking on it to get a brief clue abt what it might be about. I do hope you will continue to read this article in its entirety though! 
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The last time i participated in a mission trip was back in Jan 2008 in Cambodia. That was part of my church’s 14-day evangelical and medical outreach.
This time round, the medical trip had no religious component, it was organised by a student-run organisation – Singapore Medical Society of Victoria (SMSV). SMSV aims to bridge the gap between medical students in Victoria and the healthcare industry in Singapore. They had previously organised a trip to Hainan Island, China. Past participants have commented they were able to step above and beyond their usual shoes as a medical student and do ’so much more’, e.g. perform a lipoma excision. As such, when I heard about an upcoming trip to India, I did not pass up the opportunity.
Vellore is a city in the state of Tamil Nadu, India. The name, Vellore, is derived from the Tamil words : Vel (spear – வேல்) + uur (ஊர் – city), means city of spears. Ancient history shows that Vellore was basically a battle field, where the warriors used to fight. As of the 2001 India census, Vellore City had a population of above 900,000. Vellore has an average literacy rate of 74%, higher than the national average of 59.5%: male literacy is 80%, and female literacy is 68%. In Vellore, 11% of the population is under 6 years of age.
About 15 students (all from Melbourne) were accompanied by a team of doctors and nurses from Singapore, lead by Prof Fong Poh Him, a renowned plastic surgeon from Tan Tock Seng Hospital. The aims of the trip were two-fold. Firstly, a surgical team performed surgery at the Sri Narayani Hospital & Research Center to supplement the services available there. Whilst the hospital is multi-specialty, they do not have what they call super-specialties like plastic and reconstructive surgery. A couple of ‘cleft palate’ cases were thus arranged beforehand for Prof Fong to operate on. In line with one of the mission’s objective of capacity building, a local ENT surgeon also scrubbed in to learn the procedure from Prof Fong. Secondly, we ventured out into a preselected village in Tamil Nadu, where we set up a makeshift clinic to provide locals with primary health screening, antenatal screening for pregnant women and basic dispensing services. There were several healthcare professionals including a gynaecologist, general practitioners, and surgical nurses. We had some basic operating sets to do simple local-anaesthesia based procedures if necessary.
Primary healthcare in rural Vellore
The village center which we visited was more than 50 kilometres away from Vellore city centre. The estimated village size was about 150. The makeshift clinic was situated amongst a local primary school. We know that because during break time, tons of curious little ones pour out to the clinic area, eager to see who these foreigners are and what they were doing.
When it comes to the spectrum of diseases that the medical team come across here in rural Vellore, one might expect late presentation of illnesses and exotic infections only mentioned in the fineprint of general medical texts like the handy Oxford Handbook of Clinical Medicine. For the large part this was not so. The same chronic diseases that afflict any developed population also apply here: heart disease, diabetes, osteoarthritis, etc. Many did present with polyarthritis and a preceding viral illness. Only after 30 or so patients did someone with better English told us he was diagnosed with chikungunya, a type of alpha-viral arthropathy, at the hospital. Chikungunya (CHIK) is a mosquito-borne viral illness which manifests itself with an acute febrile phase lasting only two to five days, followed by a prolonged arthralgic disease affecting the joints of the extremities. The pain associated with CHIKV infection of the joints persists for weeks or months, or in some cases years. When I hear some of them make a living as farmers, and bemoan in Tamil their plight, I cannot help but fill with heartfelt sympathy.
I was told universal healthcare exists in India, and these villagers get their usual primary care from a similar mobile clinic, staffed by only a local doctor and several nurses/students from the College of Nursing. When necessary, a referral is made to the Sri Narayani Hospital or the larger tertiary referral center at Vellore Christian Medical Centre. Also, when something emergent or troubling occurs, the locals do know how to seek help at the hospital. Access to healthcare is limited but not totally absent.
Our involvement here however, was not entirely superfluous. For these 2 sessions of clinics (9am to 1pm), the medical team saw over 250 patients. Patients were first pre-clerked by senior medical students (years 3 and 4) to quickly obtain a history of presenting complaint. I was stationed here. I spent no more than 3 minutes on each. This also took into account the time taken for translation from the local language Tamil to English and vice versa. They were then directed to a blood pressure Time-permitting, we got the junior medical students (years 1 and 2) to listen to their chest and lungs. Our team also brought glucometers, so all had their random blood glucose tested. Next, there were 3 doctors who each had the final say in diagnosis and management. Finally, a local nurse was in charge of dispensing any prescribed medication.
An acute case lit up the 2nd day we were there. A 4-year-old boy presented with an infected burn over his left axillary region. Thankfully Prof Fong was around so we promptly referred it over to him. Oh, did I mention there was a Channel News Asia video crew here? They zoomed in all their attention on that poor little boy. Essentially they cleaned up the wound (read “ouch” x 10 for the boy) and dressed it. At the same time, the nurses were educating the parents about the importance of keeping the wound clean and teaching them how to dress it.
Sri Narayani Hospital
After a sumptuous Indian-inspired vegetarian lunch, I spent some time in the hospital. I wandered into the General Surgical Outpatient Clinic (unfortunately their operating list was over) and joined the consultant. This was familiar territory once again – tertiary level care, general surgery, outpatient clinics. Almost everything was similar, other than the language.
One interesting thing I saw was this elderly gentleman who presented with some GIT complaint and yet he was walking around with this external fixator with no qualms whatsoever. If I am not mistaken, he had a fractured tibia in an accident several months back. I would have thought someone like this would be one some sort of bed rest. Perhaps his abdominal complaints were too much.
Future mission trips and educational opportunities
This operation is projected to span five years, with 1 to 2 trips made per year. Throughout our involvement, the team hopes to share our clinical expertise and practices with the local healthcare providers (especially in the subspecialties), and also provide primary health services and advice to selected villages which do not readily have access to health services otherwise. Talks were held to discuss the possibility of CME sessions like conferences or seminars conducted by specialists from Singapore. The Director of Sri Narayani Hospital also welcomed medical students to spend a longer period of time (2-3 weeks) at the hospital to experience the pathology unique to India. Through SMSV, future students might be able to do so A big plus for student opportunities is that S.N. Hospital is private and only staffs consultants. This means that there are no other medical students, interns or residents roaming the hospital.
Vellore CMC – world-class hospital
Perhaps the most famous thing that comes to mind when one speaks of Vellore to a health professional will be a Vellore Christian Medical Center (popularly known as CMC). Vellore CMC is a referral tertiary hospital and one of the largest and most renowened hospitals in India. It attracts a floating population of at least 5000 persons every day. The hospital was founded in the early part of the 20th century by a Cornell-educated medical missionary Dr. Ida S. Scudder. It is a very popular elective location for medical students from all over the world because one can experience unique Indian pathology being tended to by world-class medical and surgical teams. Since I was there, I did not pass up the opportunity to at least pay a visit.
India is a fascinating tourist destination but also a great place to see the stark contrasts between health outcomes of the poor and underserved and the rich who can afford private healthcare or health insurance. I would recommend either of the above 2 hospitals for your elective. I, for one, will surely be back for more.
Most readers here would have had enjoyed numerous festive seasons. For me, the Christmas season is most meaningful of all festivities, perhaps by virtue of my Christian faith. It is a timely reminder of why Christmas existed in the first place and the implications the birth of Jesus Christ, His life and the reason why He died on the cross, have for the entire human race. A.D. 2009 will be over in a few days. It might even be over by the time you chance upon my humble little blog. A.D. is medieval Latin for Anno Domini and can be translated as In the year of (the/Our) Lord.
For medical professionals, the duty of care to patients does not cease just because of a festive season. Patients do not cease to require medical attention just because everyone is enjoying their holiday. In fact, according to a South African study by Meel,
Most of the pediatric deaths occurred during the festive months of December, January, and April; the death toll during these months was three to four times higher than in the rest of the year. [1]
This year, South African authorities also urge the public “not to put added strain on the health system during the festive season by putting oneself at unnecessary risk of injury or even death.” It is clear why MVCs or RTAs occur more frequently during festive seasons – they drink. Some people tend to do stupid regrettable things when they are drunk. “Blood alcohol levels were particularly elevated in firearm and sharp instrument homicides and among the pedestrians and drivers who die in motor vehicle crashes.” (emphasis mine) The National Injury Mortality Surveillance System (NIMSS) also revealed that fatal injuries, especially as a consequence of violence and motor vehicle collisions, have been identified as a top South African public health priority. [2]
Venezeulan student Jacqueline Saburido was hit by hit by a drunk driver in Austin, Texas. She was pinned inside the vehicle as it caught on fire, leaving her with severe burns over 60 percent of her body. She lost her hair, her nose, her ears, he left eyelid and much of her vision. Her fingers were amputated. She’s become a spokesperson against drunk driving. (source)
Dedication
I would not imagine this to be much different anywhere else where alcohol is interweaved into the society’s fabric. As such, this edition is specially dedicated to the many people who, in one way or another, help to clean up the mess that drunkards cause on the roads, or anywhere else – paramedics, road traffic controllers, ED staff, and, since this is a surgical blog carnival, for patients who are stable and alive enough for some surgical therapy, theatre staff and trauma/general surgeons. Last but not least, because all our hearts are probably still wrenched by the story above, to the victims (dead or alive) of drunk driving.
Clinical Case 1 – Jane
First up, we have a clinical case. 21 year old Jane presents in the ED after a major motor vehicle accident. She was riding home from a party. Both her and the pillion rider were flung off across the tar road after colliding with an oncoming Prius. She suffered third-degree ‘friction’ burns (which looked similar to this one).
How would you manage Jane?
[Answer: Ask the Burn Surgeon. Online. For free. Yes. Let him tell you how he would treat Jane]
Featured
UnDead Doctor, who recently started blogging in October, describes himself as a “Surgeon by day. Anaesthetist by night. Not enough spare time in between.” In his first ever post, he introduces himself:
I am a medical doctor, with experience in the state and private sectors in South Africa, and more recently in the first world… … At this hospital, I spent my time split almost equally between surgery (daytime hours), and anaesthetics (after hours). I am currently looking for a post to begin specialising in surgery. I will let you know what happens in this regard in due course..
With such an introduction, it begets one to question his impetus behind starting blogging. What are his aims and hopes? All these are clearly addressed in the aforementioned intro post, of which this one captured my attention the most:
This sparked a thought – how can we effect change in our health care system through blogging if there are so few here! I decided I needed to start writing, so that maybe, on the off chance that someone of any importance stumbled across these pages, they might be enlightened to the plight of a South African doctor and his patients.
There are currently a total of 9 posts he has penned since October, a healthy 3 per month. All are great. I feel i might do him injustice if i feature one article over another, so kindly head on over to his blog to check out all 9.
Without going too much into patient details, we find out that this next patient of Dr Alice, who blogs at Cut on a Dotted Line, was actually not a candidate for surgery, or so the textbooks say. She describes her experience flying solo on a colectomy which was performed for this patient.
… He discussed the next steps with me as though I had any idea or say in the matter, and then let me do virtually every bit of the work, for the next several hours. And it was work. I had thought holding a retractor for hours at a time was hard work. Not much, compared to …
You absolutely have to read this excellent piece documented free for us here online about the transition from a surgical assistant to a REAL surgeon, which Alice aptly titled “in the deep end”.
The joy of a positive outcome for a patient, on which an invasive intervention has been performed, cannot be understated. A pathologist who blogs at Methodical Madness relays a lesson learnt from a patient encounter who had a FNA biopsy performed for a slow-growing parotid mass:
I won’t be so quick to pacify a patient, in the future. My idea of “no big deal,” isn’t every one’s. I’m not the one going under the knife – this week, anyway.
Speaking about learning lessons, Dr Alice rants about a recent referral to the surgical team about a young college-aged sexually active female with ?appendicitis but has had no WCC nor pelvic exam nor CT performed. She wonders if “they’re teaching me how to be polite to frustrating referring physicians”
Technology
Dr Bates from Suture for a Living kindly provides a constructive review on the only iPhone app for surgeons – i-Surgery Notebook. Rightly so, a reader (TBTAM) raised issues about patient data being stored locally on an insecure platform and suggests logging onto a secure server to protect patients’ privacy. However, this has to be balanced against the inconvenience of requiring 3G or wifi access to edit or enter new information. Perhaps a secure ‘local’ solution can be sought for this app and the iPhone in general.
Surgery never fails to fascinate any onlookers. They can range from the circulating nurse, to the curious medical student, to the rep who just turned up to introduce some products to the orthopods. Even surgeons in training are interested to learn the best technique to do a particular thing. As such, it is not unusual for surgery to be properly videographed. Veteran medblogger KevinMD notifies us of several issues surrounding videotaping surgeries in the operating room.
There can oft be more than 1 way to do a certain procedure. After reading an article from the British Journal of Surgery which compares two techniques of portacath insertion; the Seldinger technique vs. the venous cutdown, Buckeye Surgeon wonders aloud if ’science’ can/should change one’s surgical practice.
Clinical Case 1b – Jane 4 years later
Four years later, Jane presents with acute onset of unrelenting abdominal pain and vomiting four years after a major motor vehicle accident. Link on to check out the CXR ordered and test yourself with a series of Q&As. Courtesy of Life in the Fast Lane.
The author behind Reflections of a Head Mirror, Dr Bruce Campbell, an otolaryngologist from MCW, shares with us the myriad of emotions his patients and himself experiences during his Cancer Center clinic day.
Over the course of the day, about 20 people will pass through the office. Their medical problems will vary but each one hopes to hear good news.
Benedict Carey from the NYTimes penned a great article about Henry Molaison — known during his lifetime only as H.M., to protect his privacy — who lost the ability to form new memories after a brain operation in 1953. Over the next half century he became the most studied patient in brain science. Now after his death, his brain is being studied, dissected and digitally mapped thoroughly. The findings could well change our current understanding of neuroscience.
Finito
This is a relatively short and belated edition of SurgeXperiences. The brevity is deliberate to help the reader focus on each quality article. The tardiness can be partly ascribed to my sister’s recent solemnisation; i am so delighted for her and my new brother-in-law. I was the cue master during the ceremony and all went well with military precision.
Meanwhile, should you desire more surgical blog reading over the holidays, kindly avail yourself to he archives of SurgeXperiences, stored here (Season 2) and here (Season 1), along with the latest schedule of dates and host sites. You can also subscribe via RSS or email to SurgeXperiences over at this link. And of course, you can submit your best VIA THIS FORM.
If you are interested in hosting SurgeXperiences, please contact me.
Merry Christmas and have a meaningful New Year ahead.
References:
- Meel BL. Mortality of children in the Transkei region of South Africa. The American journal of forensic medicine and pathology : official publication of the National Association of Medical Examiners (2003) vol. 24 (2) pp. 141-7
- allAfrica.com. South Africa: Extra Care called for during festive season. Dec 2009. Available at: http://allafrica.com/stories/200912080487.html
… before graduation from med school.
went to tasmania for 3 days. freycinet national park was awesome, so was wineglass bay. “bay of fires” – one of the top 10 lonely planet places to travel to before dying.
got an unexpected gift from Dr Coppola. pictures here. will def do a review.
http://www.facebook.com/album.php?aid=358250&id=850900513
off to chennai, vellore, and bangalore over next 10 days for a medical mission trip / holiday. in fact its 70% touring and 30% mission stuff. til then, ciao
Surgeons have to be quick and decisive. Surgeons have to hurt you first so that they can heal you. Surgeons heal with cold steel.
Thank you for dropping by this latest edition of SurgeXperiences, your one and only online Surgical Grand Rounds. Each fortnight, a different host take turns to host and present a digest of the best surgical related posts or articles he/she thinks its worthy for others to spend time reading.Today, it is my turn, and I shall do so in “bullet” style. Enjoy.
Featured
A newly discovered surgical blogs – Dr. D J’s Surgical Adventures. Dr. D J is a surgeon from Mumbai, India. This is how he introduces himself”
“A surgeon with a penchant for writing and a passion for revealing the truth behind the farce that is the Indian Medical Industry.”
He treats us with an account of his living nightmare on a Monday when he started work at 8am and finished on Tuesday 8pm.
“We started laparoscopically, found the rent in the oesophagus, tried to get at it, tried and tried. The liver was getting in our way, the spleen was oozing blood because its capsule was stretched to tearing, the camera kept fogging up, the omentum was playing policeman in the abdomen sealing everything off.” [READ HERE]
He then updates us about that patient whom he spent 12 hours operating on. [READ HERE]
Just to feature another of his not-so-recent post, Dr D J has a M&M incident to tell involving a NG tube and abdominal drain got muddled up. [READ HERE] (P.S. interesting intra-operative picture)
Regulars
We have a triad of posts from the great bongi who blogs at “other things amanzi”. First up, he bemoans the poor state of the state constructed hospitals and the almost funny situation that creates in an emergency:
“to get a patient to theater from casualties therefore you needed to take the lifts…. but, as is typical of the maintenance ethic in south african state hospitals, only one lift worked at any given time. this added a unique aspect to an already high stress resus effort in casualties” [READ HERE]
While we are still on lifts, he has another story of funny times squeezing too many people in the small lift with an intern who has claustrophobia.
“his face was in my face and his eyes glazed over with hatred. i prepared to defend myself, but almost expected a phagocytotic attack” [READ HERE]
Bongi finally shares a little story on why he chose to specialise in Surgery. [READ HERE]
Ramona, a plastic surgeon in Little Rock, Arkansas, reviews 2 journal articles – 1 about peristomal skin complications and management [READ HERE] and the other about abdominal wall reconstruction [READ HERE].
Øystein, a Norwegian surgical videographer, shares with us a new procedure he has developed – “framectomy”. It involves a scapel, artery forceps, and some old photos [READ HERE].
Alice, a surgical resident, who regularly chronicles her ‘quest to become a Christian surgeon’ at Cut on a Dotted Line , tells us how life has been for us recently with night floats. [READ HERE]
Yours truly wrote a little post about surgical extended matching questions and how the options given in exams may not always reflect what one will do in real life. [READ HERE]
Surgical – opinion
Recently, the U.S Preventive Services Task Force issued new guidelines for breast cancer screening. It was met with criticism from the surgical community. Here are some of them:
A practicing breast surgeon, Alison Goldfarb, MD FACS, comments on the latest breast cancer screening guidelines laid out by the U.S Preventive Services Task Force [READ HERE].
Another breast cancer surgeon, Dr Megan Baker, answers a Q&A in this video exclusive. [SEE HERE]
The Swedish are saying “No Surgery” unless you quit smoking. Is this a good policy? Secondhand Smoke gives his reaction on this. [READ HERE]
Cool stuff
Ooh… Books! has an exclusive interview with Dr Chris Coppola, whom we all know from his previous blog at “Made a Difference for That One“. He was featured for his recent book “Coppola: A Pediatric Surgeon in Iraq“. [READ HERE]
Not Yet Published has a spiel on the distinction between physicians and surgeons, going into a little history about the term “mister” [READ HERE]. (P.S. a cool picture of a historic amputation kit awaits)
Has minimally invasive surgery hit the domain of breast surgery as well? [READ HERE]
Or even thyroid surgery? Apparently, a surgeon at Tulane has done the first scarless thyroid surgery. [READ HERE]
Next edition
To be hosted by Steve, an adult congenital health defect survivor! Read more about him here. He blogs over at Adventures of a Funky Heart, definitely worth checking out. You can submit your best surgical posts VIA THIS FORM.
The archives of SurgeXperiences are stored here (Season 2) and here (Season 1).
Subscribe via RSS or email to SurgeXperiences over at this link.
Clinical knowledge exams, at my medical school at least, tends to be not so clinical. For example:
Choose the most appropriate investigation to be performed next.
- A 59 year old male present with severe central abdominal pain radiating through to the back. His bp is 90/70 and a tender pulsatile central abdominal mass is palpable.
- A 29 year old male presents with 1 day history of periumbilical pain that has migrated to the right iliac fossa. Examination reveals local tenderness in the RIF and raised WCC.
In question 1, the diagnosis is no doubt a ruptured AAA given the hypotension and central abdo pain radiating to the back. What i understand is that you do not waste time with imaging (which under exam situations, i would clearly put CT abdomen) and you take the patient to the theatre for a laparotomy. This is supported by Case Files : Surgery, and the relevant case was written by Henry Veldenz, Chief of Surgery at Hardin Memorial Hospital, Kentucky. I quote:
“For a patient presenting with AAA rupture (back pain, hypotension, and a pulsatile epigastric mass), operative open repair is the most available and most potentially life-saving therapy. If AAA rupture is clinically suspected, the patient should undergo emergent operative repair. There is no role for radiologic imaging if clinical impression is a rAAA – the delay involved in obtaining imaging is too risky for the patient compared to a potentially negative exploration”
Going off on a tangent, for rAAA, if this patient presents to a hospital which has no vascular surgical cover, you would no doubt if a transfer to a nearby hospital which has a vascular surgeon on cover is better for the patient’s outcome. Would this delay in transportation make a difference? This is a question we tried to answer with this paper.
68 patients presented to the hospital with an onsite vascular service (group A) and 33 presented at sites without a vascular service (Group B)… the significant difference in time to operation between the two groups did not influence patient outcome, nor did the lack of an “on-site” vascular service lead to selective intervention….
The conclusion we drew has workforce planning implications, e.g. if the administration wishes to extend vascular surgeon service to a peripheral hospital in a particular health network.
An image you wish you wouldn’t have to see on a computer monitor. (image credit: learning radiology)
In question 2, classic appendicitis. We recently had such a question in our GP written exam, and one of the options was “no further investigation required”. Other options relevant include abdo U/S and abdo CT. I chose the first one. When the diagnosis is clear, there is no need to waste unnecessary resources. I raised this point with Dr Alice, a surgical resident in USA, who blogs at “Cut on the dotted line”. I did learn something from her comment. I love how she described it as “fun” to convince her attending to operate without a CT in a ?appendicitis.
Alright, rant over. Cheers
Thank you for chancing upon my blog somehow. Whether you are some SEO person assigned to increase your client’s visibility in this increasingly cluttered WWW, or a bored somebody perusing medical blogs, or a fellow medical student, or better yet, a doctor who is actually spending time reading the ramblings of “that blogging medical student”, i welcome you humbly to my blog.
so what’s been happening in my life so far? well, i just finished my Family Medicine rotation. 9 weeks just zoomed past like that. in your mind, perhaps family medicine is all about coughs, cold, routine blood pressure check ups. for some part that is true. there is a lot of preventative health stuff going on – BP control, diabetic screening, colon/cervical/breast/prostate cancer screening, vaccinations, diet, lifestyle. if you enjoy explaining such stuff to your patients, then great, do Fam Med. otherwise, u might, just like me, find it a ‘tad boring. GP-land is not as exciting as they make it out to be, at least at Monash. see, we get this Professor of General Practice, who incidentally wrote THE bible for general practice. his name is john murtagh, and mention this name, most if not all australian trained doctors will know him. he is synonymous with excellent general practice teaching and care throughout his career. “General Practice” is in its 4th edition, and prof murtagh has written numerous other books to aid GPs all over the world. how is GP different from internal medicine then? shouldn’t we stick to Harrison’s Principles of Internal Medicine? oh yea, to me, i still value american medicine higher, and harrison’s is the gold standard of internal medicine for me. CMDT 2010 is also something i use frequently. however, GP texts tend to focus on primary presentations, e.g. murtagh’s book has a section with many many chapters on first presentations, e.g. cough, back pain, chest pain, headaches, etc. the symptom is the topic of the chapter, not a particular disease. patients don’t present with a left bundle branch block, they present with syncope and lethargy.
anyway, its all part of training to be a doctor. most avid readers know i want to be a surgeon. however, i dont want to be a cut em and dice em brainless surgeon, if that even exists. probably exists in the preconceived notions of unlearned individuals who probably never had the honor of working or learning under surgeons. or in comedies like scrubs. nonetheless, i want to have a broad base of medical knowledge to back up my future practice, which is why im studying so hard now. more than ever. partly because of exams, but also for the future. 4th yr is the yr of our big MBBS exams at Monash. 5th yr we’re pretty much on our own, trying to get good letters of recommendation from various consultants so we land an intern job in a hospital of our choice.
so yea, im preparing for it US-style. im working my way through lange step 2 CK Q&A, and Kaplan Step 2 CK Qbook. they shd put me in good stead with int med, surgery, psych, obgyn and pediatric clinical knowledge. lets hope monash exams ask stuff similar to step 2ck standard! otherwise its still good prep for step 2ck which ill take next yr
kudos, thats enough for an update in the midst of exam prep!! take care now, thanks for dropping by, and i promise more frequent posts after exams.
oh and if u want to host SurgeXperiences, let me know! gimme a yell. the only online surgical grand rounds needs you!
a 75yo icteric woman noted to have multiple lesions in her liver that on CT imaging are suspicious for metastatic CA. which of the following is the most likely source of the PRIMARY cancer?
(a) stomach (b) lung (c) colon (d) cervix (e) pancreas (f) gallbladder (g) eye
ANSWER:
traditionally i think i would answer (c) – colon. it is the most relevant answer to surgeons because of the possibility of resecting the mets and 5yr survival rates are about 50% even with met colon ca.
however, against my better judgement, a friend who responded to this facebook post, answered EYE. at first i thought it was ridiculous, but further pursuit revealed an emedicine article that suggests otherwise: http://emedicine.medscape.com/article/369936-overview
a 1982 study quoted
Analyzing the data from 9700 consecutive autopsies in patients with 10,736 primary cancers, Pickren et al found that liver metastases were present in 41%.[1,2] They found that the primary sites most commonly metastasizing to the liver are the eye (77.8%), pancreas (75.1%), breast (60.6%), gallbladder and extrahepatic bile ducts (60.5%), colon or rectum (56.8%), and stomach (48.9%).
- Pickren JW, Tsukada Y, Lane WW. Liver metastases. In: Weiss L, Gilbert HA. Liver Metastasis. Boston, Mass: GK Hall Medical Publishers; 1982:2-18.
- Pickren JW, Tsukada Y, Lane WW. Liver metastasis. In: Weiss L, Gilbert HA, eds. Analysis of Autopsy Data. Boston, Mass: GK Hall and Company;. 1982: 2-18.
Welcome to this fortnight’s SurgeXperiences. This is edition 308.
Without further ado, let’s check out the best in surgical blogging!
Regulars
Buckeye Surgeon take a (painful) trip down memory lane as he came across some survey published in the Archives of Surgery talking about public vs health professionals’ viewpoints on end-of-life interventions. [READ HERE]
Dr Chris Oliver, a UK orthopod, who chronicles his amazing journey from obesity to trialthons, shares 2 articles on his blog about lap-band and battling the obesity epidemic. [READ HERE] [AND HERE]
Marianas Eye, an ophthalmologist working in Saipan, shares his column contribution to the Saipan Tribune about healthcare reform. [READ HERE]
Dr Bruce Campbell shares another piece of his great literary writing in “The Save”. [READ HERE]
Just so we don’t forget, even though he’s been off the radar a bit, Surgeonsblog still has many fantastic posts worth reading. [READ HERE]
The Independent Urologist has some tips on how to quickly capture a patient encounter in the EMR within 5 minutes. [READ HERE]
IntraopOrate replies to an email from a “surgery addict” and sheds some light on how to get to be in the OR more often! [READ HERE]
Aggravated DocSurg rants about how doctors (really) think. [READ HERE]
Blogging about research
This is gaining popularity at the moment all over the medical blogosphere. I guess medical bloggers are realising it is much easier to provide an opinion via a blog than to write a letter to the editor or comment about it formally in the journals.
Are mastectomies overly used for breast cancer treatment? The latest JAMA issue, which focuses on surgical care, has a study that reports otherwise.. [READ HERE]
Plastic Surgery 101, penned by Dr Rob Oliver a board certified plastic surgeon, shares his thoughts on this as well [READ HERE]
In the same JAMA issue, comparison is made between prostate cancer surgeries done the old fashioned way, or the new sexy way with minimally invasive techniques – often with the assistance of Da Vinci robotic system. WSJ Blogs give you the low-down. [READ HERE]
Military-related
The work which supports the healthcare of the military or those hurt in war zones are indeed commendable.
Military pediatric surgeon Dr Coppola has recently published his 2nd book about this time in Iraq. His book is now available for pre-order. Reviews from many notable authors have been fantastic! [READ HERE]
Dr. Donn Chatham, who heads the American Academy of Facial, Plastic, and Reconstructive Surgery, has announced a new program to help soldiers who sustain serious facial wounds. The program, called Faces of Honor, aims to provide more expert care in surgically repairing soldiers and veterans who may not have access to cutting edge treatments in their veterans administration hospitals. [READ HERE]
Professional misconduct
It is sad that increasingly surgeons are dominating the medico-legal scene.
2 plastic surgeons in Singapore are fined S$2000 and S$5000 by the Singapore Medical Council for professional misconduct: one failed to provide supervision for a laser lipolysis procedure performed by a nurse, one performed cell therapy involving the injection of animal foetal cells into patients for anti—ageing and rejuvenation purposes. [READ HERE]
A Pennsylvania plastic surgeon is being investigated for possible bribery. [READ HERE]
Special events
Over at the Clinical Congress of the American College of Surgeons, a trauma surgeon paints a bleak picture of the U.S. trauma system — 38% of the U.S. population may not be covered by a statewide trauma system. [READ HERE]
Many bloggers were off this weekend to the BlogWorld Expo at Las Vegas, including Bongi all the way from South Africa. Ramona who blogs at Suture for a Living, shares a little poem about her trip and provide links to all other similar posts about the great time they had. [READ HERE]
NEXT
Sorry no announcement about next host yet. But meanwhile, you can still submit your best surgical posts VIA THIS FORM.
The archives of SurgeXperiences are stored here (Season 2) and here (Season 1).
Subscribe via RSS or email to SurgeXperiences over at this link.
See you in 2 weeks!
I haven’t been posting much… So what’s been happening?
Well, i’m currently doing my 9-week Family Medicine posting. We get attached out to the General Practice once a week. On Mondays, Wednesdays and Fridays, we go to a central teaching location at the Department of GP where we get didactic lectures and clinical skills tutorials, where they hire simulated patients for us to practise our history taking/management. The focus is now less on history taking, and more on using the 10-step management plan devised by Professor John Murtagh, a guru of family medicine and author of a textbook called General Practice.
Anyway, i’ve also been doing some of the assignments that come along with this GP rotation, which i shall not bore you with.
What else? I completed editing of the SIHS newsletter for Summer 2009. You can download it from Adam’s website here (pdf file). The feedback has been positive.
Another thing i was busy about was finding out about General Surgical Residencies in the USA and about electives during my final year, in SDN forums and such.. I changed my mind from doing the Mobile Surgical one in Ecuador with Cinterandes, to doing as many rotations in USA as possible to get more letters of recommendation from US faculty to boost chances of residency application success. So i hope that comes to light. Also spent quite a bit of time deciding which USMLE Step 1 materials to get and finally got down to it. The SDN people really got great results, at least those that post on the forum! Most have >230/99. I do hope i will be one of those posting such great scores in the future. Probably gonna take it in 5th year between Apr – June 2010.
Other than that, my girlfriend is coming to Melbourne for a visit, so that should be awesome. It’s been a long time since we first started dating; i ought to close the deal sometime soon! Probably at the end of internship or something.
Also been helping out a friend to train for the Melbourne Marathon. we are taking part in the half event. what is cool is that next year, my brother, the legendary ultra marathoner in Singapore ( i say this because he has been getting quite a bit of media for his crazy running enthusiasm) will be taking part in the Mind Alpine Challenge with me. its a 100km event that scales 5-6 peaks in the alpine region in Victoria. will be gawdfully tough and i have some events lined up to help me prepare for them!
- 24 Jan: Mansfield to Buller – 50km (http://www.aura.asn.au/MansfieldToBuller.html)
- 6 Feb: Cradle Mountain – 82km (http://www.cradlemtnrun.asn.au/index.php?option=com_frontpage&Itemid=1) only 60 allowed, first come first served.
- 20-22 Mar: Mind Alpine Challenge - 100km (with my bro d’ man!) (http://www.rfv.org.au/Alpine%20Challenge%202010/home)
Medical practice is not knitting and weaving and the labour of the hands, but it must be inspired with soul and be filled with understanding and equipped with the gift of keen observation; these together with accurate scientific knowledge are the indispensable requisites for proficient medical practice.
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 4)
… this is a continued series of my reflection of my 9-week psychiatry rotation. read the 1st part, 2nd part, 3rd part. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
Aged Psychiatry
How apt for my 9-week Psychiatry term to come to an end with patients in their twilight years. I spent 2 weeks at an aged care centre consisting of a rehab, geriatric and aged psychiatry facility. There were 3 components of our stint here – aged psych ward, behavioural support team (BST) , and intensive care team (ICT). The aged psych ward consisted of mostly demented and depressed patients. There were the odd schizophrenic ones. A patient i saw from CL psych the previous week was here as well. I went out on a visit with the BST once, and that was to an elderly man who kept turning on the taps in the nursing home where he was residing. ICT tends to the patients who had just been discharged from the aged psych ward. I also went out on a visit with them once.
After getting a feel of how to interview demented and depressed patients, i sought to do other more “exciting” activities. They do some ECT sessions here, so i attended one. “Shock therapy”, as it was commonly called, isn’t as bad as it sounds, or popularly portrayed in mainstream media. Apparently it has had quite a bit of bad press. With pictures like these, who could blame them.
ECT has advanced quite a lot and now, patients only received 3 seconds of electrical voltage placed strategically on their foreheads (some unilaterally, some bilaterally). After which, they sustain a 20-second or so brief period of seizure activity. Usually ECT comes in packages of 6. They have no idea how it works, but it does. Majorly depressed patients with melancholia have reported feeling much better after. Schizophrenic symptoms can go into remission. It works wonders.
Some other thoughts
Finally, we recently had a tutorial on chronic mental illness. During the tutorial, several issues came up. We were given a brief overview of the Community Care Units that the Psychiatrist was heading. A multi-faceted approach including neuropsych, occupational therapy, family intervention, psycho-education, social support for carers, dual diagnosis management, social skills development, vocational rehab, is emphasised. Then we started talking about institutions and asylums. Australia was de-institutionalised some decades ago. Unfortunately, some patients fall between the cracks and not suited for CCU care or residential services. The psychiatrist herself was reflecting as she told us, was she chemically restraining patients (E.g. those with chronic schizophrenia) just so their psychotic symptoms are controlled well enough to fit into society just because we cannot provide adequate services for them?
On that note, it brings me to wonder about allocating funding for a healthcare system. Who should decide these allocations? Just to state a common example: should we continue to pump money into neonatal intensive care units to sustain the lives of these little ones? Some of them are born very prematurely (e.g. under 24 weeks) and not many can survive. Round-the-clock NICU care is expensive and there is no guarantee of their survival. Even then, their young lives will be troubled with numerous complications, e.g. bronchopulmonary dysplasia. Should the money then be spent on the elderly in geriatric wards, aged care facilities and nursing homes? After all, these people have worked hard their whole life, contributed to the society and economy and now it should be society’s turn to look after them… Are we then forced to make a decision as to which life is valued more? Should we?
Concluding thoughts
I first started Psychiatry with a negative preconceived notion. I exit having enjoyed some of it, especially so after writing this long reflective piece on what i thought about this entire 9-week sojourn. I doubt i’ll pursue a career in Psychiatry, but at least i had a taste of it to confidently i wouldn’t want to do it for the rest of my life. I’m encouraged by the fact i attained a Distinction for my 5000-word Psychiatry Case Report, but i received some help from tutors. All in all, I’m certain I’m to face some psychiatric conditions further down in my career, and I hope these 9 weeks can adequately equip me to deal safely with them. Besides, it also helps me to understand the mystery of the human mind much better. I remember keenly a tutorial on Personality Disorders. The tutor commented, “Who are we to judge and segregate how one acts into various sets of conditions known as Personality Disorders?” Of course, he did go on to explore how some of these conditions like OCDs can significantly impair one’s daily functioning and that is when these people seek the help of psychiatrists or psychologists. I’m glad that now i can vaguely make out different personality traits in people i come across and friends as well through conversations. And surely, you would have derived my obsessive-compulsive trait (apparently quite common in medical students) in trying to finish this entire reflective piece in one sitting. I hope you enjoyed reading about my experiences, and i look forward to hearing your comments.
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 3)
… this is a continued series of my reflection of my 9-week psychiatry rotation. read the 1st part, and the 2nd part. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
Child and Adolescent Psychiatry
Persons under the age of 16 afflicted with mental illnesses can be a sensitive and heart-wrenching situation. I was attached to Child and Adolescent Mental Health Service (CAMHS) community clinic. I sat in consultations with a Paediatrician who has a special interest in Autistic-Spectrum Disorders. She was clearly very enthusiastic about this, and displayed it by providing with numerous education articles she wrote. She asked me to spend some time to read them all, and provide a summary to her. Remembering some of these online quacks i’ve come across while blogging, especially the passionate blog articles by Orac regarding anti-vaccination, i asked her take on all these. This was replied by her printing off a lengthy book review of Paul Offit’s “Autism’s False Propets: Bad science, risky medicine and the search of a cure”. I appreciate her keen efforts to quench my thirst for knowledge.
Of course, Child and Adolescent Mental Health isn’t all about Autism. I sat in some consultations with some of the Psychiatry Registrars and we saw patients with conduct disorders, learning difficulties, and notably one with significant substance use. The polysubstance abuse was causing him to have disturbing visual hallucinations of himself getting killed in various graphic ways. A few others i remembered were teenage girls with eating disorders. What is sad about some of these cases is a consistent pattern surrounding an unstable family environment – mum divorced and recently remarried, dad and mum are separated and had previous histories of heroin abuse, etc. I feel a surge of melancholy as i wonder about their future. They will be the next person committing suicide from the Westgate Bridge, or the next up-and-rising drug dealer in town, or more scary yet, the next patient i see in the Emergency Department as an intern, treating them from paracetemol overdose or multiple lacerations on their forearms.
Consultation Liaison Psychiatry
This week prove to provide a more acute perspective to Psychiatry. Medical patients in the main hospital who develop or have a psychiatric condition may require some form of psychiatric care. This is when the CL team is called. At where i rotated, owing to the vast numbers of inappropriate referrals, the CL team necessitated a referral form faxed to their office, with a full MSE completed. No other requests would be entertained. The acutely delirious granny in the geriatric ward who was suffering from a UTI, or the aged grandpa, admitted for treatment of his pneumonia, who was found attempting suicide for the 2nd time on the ward. A most memorable patient was a 68-year-old lady who presented with weight loss, malaise and lethargy. CT scans revealed multiple mets and the primary tumour was not found yet. Prognosis is poor and she was receiving chemotherapy. Understandably, she displayed signs of major depression. When the CL reg was notified, he told me that sometimes there is more to Psychiatry than to just start the patient on some medications, like in this case, a tricyclic antidepressant. “Sometimes they just want to talk. Let them whine to you. They just want someone to listen to them.” And so we did, for nearly 2 hours we listened intently to this woman’s story, and found out her depression did not just start after the discovery of her cancer, but years before after she broke off with her ex-neighbour. This affair was undiscovered, but culminated in her selling her property via him (he was a property agent) and him dying suddenly of prostate cancer. She was filled with remorse and regret. I certainly hoped the time we spent helped her a little, even just a little.
This CL week gave me an insight into some of the common problems i might face as a medical or surgical intern on the wards. What makes a good referral, when should i refer, what expectations do i have for the CL psych team.
(to be continued…)
Of shock therapy, schizophrenics, and the obssessive-compulsive medical student (part 1)
My 9-week psychiatry rotation is about to come to an end, and i thought i’ll continue my reflections on this year’s rotations. I have previously written about my Paediatrics rotation, and most recently my Obstetrics and Gynaecology rotation.
I must admit i first approached Psychiatry as a specialty in a reserved and guarded fashion. We were first exposed to snippets of it in 1st and 2nd year, where we were taught components of a Mental State Examination, including cognitive assessment via the Mini-Mental State Exam. A memorable moment was our Clinical Skills exam (OSCE), where we had a simulated patient suffering from acute psychosis. We were just several months into our medical training, and as infants, were expected to conduct and sustain an interview with a hugely uncooperative patient, and thereafter report back on our MSE findings. I swore I hate psychiatry from then on.
My preconceived negative sentiments toward Psychiatry as a specialty did not improve when in the first week, we had observed interview sessions in front of our group of 10 or so students. The clinician selected a patient unknown to us and himself and with proper consent, brought this patient into the room full of students. My colleague and I set off to interview her. She was extremely guarded, and constantly stared me down. There was certainly a lot of transference and counter-transference going on and i had to be careful not to project her hostile feelings back onto her. She was, for the most part, unwilling to engage and did not give us a good sense of why she presented. Halfway during the interview, she stood up and surrendered. “Stop trying to get into my head! I don’t want to do this anymore!!” She promptly exited the room, and we were all quite taken aback. Thankfully, this was not met with any major clinical sequalae and she settled without chemical restraint after a while.
Community Psychiatry
My 2nd and 3rd weeks took place in a community clinic where patients were case managed. The case manager is often a social worker or a registered psychiatric nurse. They have clinical reviews by registrars or consultants periodically. I found these incredibly boring, to be honest. They were mostly well managed and their psychotic symptoms (most had some type of schizophrenia) were under control. There were also dedicated sessions of “Clozapine reviews”, where treatment resistant schizophrenic patients are reviewed medically after being commenced on the atypical anti-psychotic. They require weekly FBEs because of the rare but serious complication of agranulocytosis. Weight gain can sometimes a problem as well.
My fortnight there was also highlighted by some outreach trips to a certain undisclosed rural location, about an hour’s drive away. I was fortunate to have a registrar who liked to teach and also delighted in imparting his perspectives into psychiatry. He particularly emphasised things like being able to work in a team with other health professionals. The psych nurses seem to like him a lot. I hope i can be one such doctor in the future, with great rapport with the nurses.
A memorable patient was one who was suffering from major depression with melancholia. Everything about her looked depressed – she wore dark clothing, looked dishevelled and unkempt, walked and talked slowly, loses concentration from time to time, lost weight, reports insomnia and her affect was blunted and restricted in range and reactivity. That is not one i will forget for a while.
My fortnight ended off with a bam when we saw a very angry patient who received some electroconvulsive therapy (ECT) some months ago. She suffered from retrograde amnesia, a common self-resolving complication and was very cross about it. She claimed the doctors treating her did not explain to her properly these matters and treated her without her consent. To complicate things, she had a history of paranoid schizophrenia characterised by delusions of religious grandeur. ECT is not usually indicated for schizophrenia.
What I felt to be a confronting issue was Christian patients suffering from mental illness. At what point do you acknowledge that there is a mental illness stemming from chemical imbalanced in your neurological pathways, and at what point do you say that you need to rely more on God to overcome depression, for example. I still do not have the definitive answers, but i am keen to put forth an explanation that certain people are indeed more prone to mental illnesses genetically or chemically and the beauty of it is that God has granted wisdom to researchers and doctors to invent and use psychiatric drugs to successfully help these people cope better.
(to be continued….)
“A boy of about five walked towards me, his hand held open, asking for food. I felt nausea as he appraoched. “He is cursed,” Hurzi cautioned. “There are more like him coming from the villages.” At first I thought the boy had been shot in the face. He had a gaping hole eight inches in diameter just below his right cheekbone. The jawbone was exposed, and the flesh around the opening was rotting black. Through the hole I could see his tongue moving as he tried to talk to me. He was suffering from cancrum oris, a very rare effect of prolonged starvastion, where immunity is all but nil and the normal bacteria of the mouth proliferate and begin feeding on proximate flesh. I had only seen old pictures of it in tropical medicine textbooks. This was real, and for a moment I had to turn away. Disease follows hunger and will likely kill before the body expires from starvation.”
- James Orbinski, when he was serving as a medical coordinator in Baidoa, Somalia, with “Doctors without Borders”
Picture of a boy suffering from “cancrum oris”. Deliberately shrunk. Click to enlarge.
An Imperfect Offering is a good book. I definitely recommend it to any health professional or anyone interested in Humanitarian Work or International Health.
Dr Vijay, a practising radiologist from India, has just hosted SurgeXperiences for the 2nd time at his blog “scan man’s notes”. SurgeXperiences 226, is the 50th edition and the final one of SurgeXperiences season 2.
Official SurgeXperiences logo, courtesy of Vitum Medicinus.
SurgeXperiences was set up to be the definitive Surgical Grand Rounds in the medical blogosphere. A surgically focused blog carnival featuring all the best posts related in anyway to the diverse field of Surgery.
SurgeXperiences was first started 1 July 2007. It is hosted by various hosts ranging from surgeons to anaesthesists to radiologists to students! It is on every fortnight and each season lasts approximately a year.
- Season 1 [Jul 2007 - Jun 2008] had 24 editions. An archive can be found here.
- Season 2 [Jul 2008 - Jun 2009] had 26 editions. An archive can be found here.
A big and special thank you to all previous hosts. Your time and efforts do not go unnoticed and i hope the traffic this carnival brings you is sufficient of a motivation to host another time!
Here’s to all 50 and 50 more!
