Sunday, April 7, 2013

Putting back your Bones, Putting back your Life!

Basketball fans, not only in America, but throughout the world, witnessed the “gruesome” injury of Louisville guard Kevin Ware last week.  

  And since this kind of injury is one of the common injuries orthopedic surgeons deal with, allow me to discuss a few things about this.

Reports showed how the player came down wrong on his leg as he tried to block the shot of an opponent player. His right tibia, or shinbone, broke through the skin in what is called an open or compound fracture.  This caused fans and players alike to shut their eyes in horror and disbelief.  Some nearly hurled.  (Just look at the reaction of the bench of Ware’s team in the above YouTube clip.  (Napaiktad sa gulat!)
So what happens in open fractures?

Not only does the bone get broken, open fractures often cause damage to the surrounding muscles, tendons, ligaments, and more importantly, blood vessels.  The usual concern here is infection because once the skin is broken, harmful germs or bacteria may prevent the wound and the bone to heal.

I am not privy to the exact treatment that the player got, but the typical procedure for this kind of injury, is that the patient will be immediately brought to the hospital. After thoroughly cleaning the broken soft tissues (muscles, ligaments, etc), the bone will be reset and a metal rod will be inserted into the shin bone. That’s either a stainless steel or titanium placed inside the hollow leg bone to reconnect it where it broke.  After surgery, we place patients on antibiotics to lower the risk of infection.

  Although the fracture looked gruesome and extraordinary, orthopedic surgeons like me see this often, especially if you trained in a major government  hospital like PGH (Philippine General Hospital) or POC (Philippine Orthopedic Center).

     The thing here is that open fractures are usually the result of a "high-energy" trauma, such as a vehicular accident or a fall from a height. The injury was extremely unusual given the circumstance (jumping in basketball). The player may have twisted his leg as he landed, causing the bone to snap. It's possible Ware had a “stress” fracture or benign bone tumor that weakened the tibia before his fall.  This is called a ”pathologic fracture.  As I’ve mentioned, I am not involved in his care so I am just stating my own personal opinion here.

Can the player go back to playing basketball again?

A good friend of mine from High School asked me this.

My answer?

Ware’s doctors probably got him up and moving the day after surgery. And with intensive daily physical therapy, he could be back on the basketball court in six months to a year, barring any complications. In a "best-case scenario," Ware would begin to show signs of healing within 8-12 weeks. In other words, the injury is not likely a career-ending one.

However, the three most common complications for open fractures are infection, difficulty healing and a condition called acute compartment syndrome. That develops when pressure builds in the muscles surrounding the injury. This very painful and can cause tissue death if the pressure is not relieved.

If Ware's leg doesn't heal properly, he may need more surgery.

Should we be more concerned now and discourage our children from playing basketball since these injuries occur?

Before leaving the court on that fateful day, Ware reportedly told his teammates to focus on winning the game.  “Win the game.  Just win the game!”.

The gruesome injury and words apparently left his teammates in tears, and they went on to win the game.

A photo posted on the Internet shows his jubilant teammates holding up Ware's jersey as they celebrated their win. Another showed Ware in his hospital bed, holding the trophy his teammates brought to him.

So my answer to the question is NO. We should not get disheartened when injuries like these happen. Because we all know that everything happens for a reason.

Kevin Ware himself was not disheartened. Remember he was more concerned for his team to win. It can serve as an inspiration to any injured player. As a good friend of mine from Medical school commented, “If you'll pardon the expression, Ware has balls of titanium and now a leg to match”. 

      And besides, you can always call your friendly and well-trained orthopedic surgeon to put back your bones (and possibly your life) together again. 

Sunday, March 10, 2013

Four Orthopedic Tests that might be Unnecessary but are Routinely Ordered

Some patients, especially those with HMO insurance, adopt a more-is-better approach to medical care, and this goes for doctors and patients alike. Armed with information from “Dr.” Google, and “Dr.” Wikipedia, or just plainly because they have medical insurance, some patients often demand tests that might not be necessary at all.

Sometimes, doctors are often all too willing to oblige.  While there is no doubt we, doctors, genuinely want to help our patients stay healthy, sometimes, we may also be motivated by malpractice fears. “What if she really had a tumor and I didn’t get an MRI?” Or they may have thought that ordering a test is quicker and easier to convince patient of his or her diagnosis, than sitting down with the patient and discussing the risks and benefits of his/her health situation.

The consequence of all this, of course, is that patients or insurance, may spend way too much on unnecessary tests. Unnecessary tests aren’t just costly. They take away the “clinical eye” of the doctor that really separates the great doctors from mediocre ones. In addition, some tests can also do real harm to patients. Although rarely, the procedure can be a physically invasive measure that can go wrong; other times, it exposes a patient to a potentially harmful substance, like radiation. In addition, a false positive can lead to anxiety and a cascade of unnecessary follow-up tests.

I recently had a patient who brought her MRI results showing me a full paragraph of the results.  She was anxious, of course, because she couldn’t understand the medical jargon. In her opinion, it was good she told her doctor to have the MRI right away because the MRI reading was so long and sounds scary. So what did I say about the results, as expected?

” Nothing.  Don’t mind that. It just means you are not a teenager anymore….”

The list below contains four screening tests that are commonly performed on orthopedic patients. These are tests or procedures whose necessity should be questioned and discussed thoroughly with your doctor before proceeding.

If your doctor recommends that you get one of the tests below, ask some questions to help you weigh the risks and benefits. I offer some suggested questions. Instead of asking “Doc, is that really necessary?”, ask instead “How would the results of this test change the management of my case, Doc?”; “Can we get this information by history and physical examination only?”; and perhaps the most versatile question of all: “Can this wait for a while or should it be done ASAP?”

1. X-rays
Some doctors, especially non-orthopedic surgeons, order x-rays left and right, as long as the chief complaint is pain.  Not all orthopedic patients need x-rays. There are cases wherein whether we see specific findings in the x-rays or not, the management won’t change. It may, however, help us rule out or exclude other causes of the pain. Remember that x-rays will mainly show us bone abnormalities.  And a thorough history and physical examination usually can get the diagnosis correct, without the need for x-rays.

2. MRI  
   A lot of patients or doctors insist on getting MRI if their clinical diagnosis is slipped disc.  But it is necessary to remind everyone that if you perhaps do an MRI on all people in the world, 20% might show slipped disc in the MRI, even if they have no symptoms. Unless you are planning to undergo surgery, MRI is usually not needed for diagnosis.

3. Uric acid test – A lot of patients come to orthopedic surgeons with uric acid results already, most of the time with normal results. Apparently, this has been ordered by their primary physician beforehand.  If the clinical suspicion is not gout, it is unnecessary.

4.       Peripheral bone-density scans for low-risk women –A lot of osteoporosis screening tests are just a pitch for leading anti-osteoporosis drugs, and orthopedic doctors wanting to get more patients.  If this is offered free, then you may want to undergo. But unless a woman has risk factors for osteoporosis, women shouldn’t get a baseline bone density test until at least age 65. (Risk factors for osteoporosis include having a family history or previous history of fractures, small bone structure, early surgical menopause, etc.) Too often, however, women without any risk factors get this test. Many are then diagnosed with osteopenia, a diagnosis that refers to low bone density. This condition may never develop into osteoporosis, but women with the diagnosis can find themselves undergoing a lifelong regimen of costly drugs that carry side effects, from gastrointestinal distress to the rare jawbone problem or even “atypical” thigh fractures.

Women who are found to have osteopenia but don’t want to take medications, can talk to their doctors about taking calcium supplements and doing more weight-bearing exercise.

Deciding when to do a procedure or screening test can involve as much art as science, because behind those illnesses and scientific evidences are real patients with real feelings and demands. There are few hard and fast rules, and medicine is not an exact science. Much of the necessity of the tests depends on the risk profile of the patient. Doctors and patients should work together to find the right balance. “Otherwise, there’s no end to the tests we can do, the harm we can cause, and the money we can spend. “

The tendency to over-diagnose and over-treat is often a result of doing unnecessary tests. Giving financial incentives to doctors to deliver more efficient and cost-effective care, is probably a step in the right direction.

What do you think?

Tuesday, February 26, 2013

Lose Weight to Improve Bone Health

     Recently, I had an animated conversation with one of my patients. She was a funny, middle-aged lady, overweight, or probably obese is the better term. She told me he has been having back pains.

     After examining her and discovered no real bone or nerve problem, I told her the solution: lose weight.

  “Ma’am, sorry don’t ask me how. I am an orthopedic surgeon, not a weight management specialist. I can refer you to a colleague of mine who specializes in that if you want.  I just know you have to lose weight. And you have to start exercising. Try walking at least 30 minutes per day“ I said.

    She looked at me as if I was a creepy alien with pointed head. Obviously, my patient wasn’t really the athletic type.  So walking is already considered a death-defying, dangerous, and extreme sport for her.

    “What do you do everyday, Ma’am? Like, what’s your work?” I asked.

     “I am a manager, doing desk job 8 hours a day.  No exercise at all.” She said. “Do you really I think I can still lose weight?”

     I said “Well, strange things can happen in this world. After all, there have been sightings of UFO’s, monsters, Big Foot, etc..  Of course I am just joking.  But I really suggest you start exercising.  Get out and walk. And then maybe, you can start joining Marathons later.” I said with a smile.

       “Marathons?  I will die if I join Marathons.”

        I rolled my eyes towards the ceiling.

       “Speaking of Marathons, I really can’t understand why people join them.  What will they get out of that?  Only muscle pains all over!” she said.

      “Well, you can get a shirt if you finish the race.” I smiled again.

      “Shirt, what kind of shirt? The expensive, branded ones with a crocodile with gingivitis, or the weird man riding a horse with a stick pointing to the ground?”

     “Haha. You make me laugh. Hay, naku. Just do any physical activity.  Walk, bike, swim. Whatever. When you come back to me, I want to see your waistline down to 32”.  You can do it!”

    “Thanks a lot, Doc.  I really appreciate your advice. I am just joking. I just feel depressed sometimes. But promise, I will lose weight, and you won’t recognize me when I follow up.”  She said.

  “Sounds good to me.  I’d love to see that. Goodluck!”

    As she left my consultation table and approached the door, I witnessed the “ruffles” on her waistline going up and down.  “Geeesh, how can one really get rid of those cellulite deposits,” I muttered to myself.   Perhaps, the answer will be in an esoteric code handed down by aliens in Atlantis.

Take Home Message

  Friends, a lot of the orthopedic problems that patients encounter, are just because of being overweight. Not only back pains. Knee pains, hip pains, ankle pains, etc are mostly due to increased loads on these joints which bear the most weight in our bodies.  We really have to live a healthy and active lifestyle and maintain our ideal body weight.  This will not only prevent joint and bone problems, it can help your heart, lungs, prevent or control diabetes, and improve overall well-being.   You’ll feel better and more confident about yourself, too, as you can look svelte in your jeans :)

Wednesday, December 19, 2012

5 Reminders Surgeons Should Not Forget

           Just a few more days to go before Christmas. So to those who are reading my blog, Merry Christmas to you, all!  To those  who  are  not  reading  this, please greet    them    for   me,   too.  And  just  in  case  the doomsayers  are  correct in  predicting  the end of the world  tomorrow, I  might  as  well  greet  you   Happy New Year too! Kaboom!

Christmas time for me is really an anticipated season.  Besides the partying left and right, my birthday also falls a few days after Christmas Day. Wow, I can’t believe I’ll be turning 38 years old by then. My older relatives used to call me, “Doctor or Doc Raldy, the young doctor”. Slowly, the word “young” is being dropped and am now just plainly called “Doc Raldy”.  When I was a kid as young as my daughter Raya (She is 7 years old), I used to think that people near or in their 40s are “Jurrasic”.  So that means I will be a mere 2 years away from being “Jurassic”!  (If you don’t know the meaning of the word Jurassic, you’re not my age.)

Anyway, for this blog post, I decided to put some reminders that I would like to share to my fellow surgeons.  I did not learn this in medical school, nor during my residency training. I haven’t read this in any medical textbook. I have come to realize these things only after 4 years of being in private practice.

1.       Start each surgery with a prayer, and an empty bladder.
          For the first part of the sentence, people may be shocked.  Me? Say a prayer? Well, believe it or not, I do, silently in the locker room, where only God can see me.  I realize that my most potent weapon as a surgeon is not the scalpel, but God guiding my hands.  In private practice, you are on your own. No consultants to defend you. No training institution to say you are still a “trainee”. Humble yourself and realize that God is the Greatest Surgeon Mentor. For the second part of the sentence, this is self-explanatory. It is not good “dancing around” Gangnam style while the surgery is on-going.

2.       We should not discourage our patients from seeking second opinion. It is their right, and it is our responsibility to give them choices, with the risks and benefits of each choice explained in terms they can clearly understand.  
        I have mentioned this before.  I still believe it’s true.  The decision whether to undergo surgery or not, is not for us surgeons to make, unless it is a life and death situation. When patients and their families fully understand the risks and benefits, they will make better judgement, and will love us surgeons, whether the outcome was good or bad.

3.       When doing your rounds of patients, always greet them and the family first, before discussing the case.  And talk to them as if we have all the time in the world, even if we obviously don’t. They will appreciate that. And in fact, they will be the first one to say “Doc, baka may gagawin pa kayo.  Nakakahiya naman tagal nyo na sa amin.”  End the conversation with a firm handshake if they have no more questions.
4.       If you are not comfortable doing a surgery on your own, you can always “Call a friend”. Even though we are “competitors” in terms of patients, most of us fellow suregons are willing to help each other out during surgeries. Only very few are arrogant enough not to share their expertise.  And these people don’t deserve to be our colleagues.

5.       Everyday in my private practice, there is something new to learn.
      The day you stop learning is the day you will die. Medicine is a very dynamic field, especially orthopedic surgery.  We learn not only from our more senior consultants, but also from our more junior consultants, and most especially, from our patients.  Patients teach us that we are only humans.  We sometimes cure, oftentimes heal, but can always comfort. And whether we like it or not, we also have to learn the business and politics side of medicine, too (unfortunately).

I still have a lot of things in my mind that I have learned through practicing medicine, orthopedic surgery in particular. But I can’t put the right words for now.  In the meantime, until, the next blog post, I want to greet everybody again a Merry Christmas and a Prosperous 2013!

How about you, my dear colleagues in medicine, do you have any reminders you can share us that you have learned during private practice?

Wednesday, November 28, 2012

4 Things HMO Insurance Won’t Say

It feels weird making a new blog post after almost three months of not writing one. Sorry, but my mind sometimes short circuits and does not come up with any useful information. As you know, this is not my job and I just do this during my free time.  But I still hope you can get something from this little blog of mine. So before you yawn and hit the delete button, those of you with HMO insurance might want to know some things these HMOs won’t tell you.

  I recently had a patient who came in with her family. They reminded me of Goldilocks and the Three Bears where one was too large, one was too small, and one was just right. The Goldilocks look-alike was the mother.  The father and kids all look like bears.  (I pity the kids. Hehe. JokeJ). Anyway, the mother needed an operation for a torn knee ligament. She told me they got a Health Maintenance Organization (HMO) insurance and this will take care of her operation. At first, she was smiling and ready to schedule the surgery.  But when she realized that there were things that she didn’t expect from the HMO insurance, her face suddenly changed like that of a child whose lollipop was taken by another person.

    From experience, here are some things your HMO won’t tell you when you avail of the HMO insurance, so take note and be prepared to ask so you won’t feel disappointed.

          1.      They will not tell you that your medical insurance is not always enough for your surgery.

HMOs usually have a maximum benefit limit (MBL) for each disease and if you have used any of these benefits before, such as consultations or lab exams, there will be deductions from your total benefit. Also, implants are usually not covered. So if you need surgery for a fractured hip and you were advised by your orthopedic doctor that you need implants to fix or replace them, chances are, you need to churn out money for the implants. In some cases, these implants are not cheap at all.

This particular patient of mine even had a heated argument with the insurance agent because she felt that the amount being deducted from her salary was big enough to cover her surgery.
       2.       They will not tell you that your preferred doctor and hospital are not always accredited with your HMO insurance.

 There are even instances that your favorite doctor may be accredited in his or her clinic, but not accredited in the hospital.  So be sure to inquire about this. 

          3.       They will not tell you that they will pay your doctor with a discounted or “negotiated” rate after 3 months, 6 months, 1 year, or worse, never at all. Then, they will make all sort of excuses such as documents not signed, lost documents, etc, despite having a contract with us, doctors, stating that they will pay within 30 days.  The problem with us, doctors, is that we are generally poor negotiators since most of us are not businessmen, and we end up providing quality health services without being paid or paid on time, while making you, the patient, believe otherwise. 

For most patients, this does not really concern you, as long as you get the appropriate treatment.  That’s all right. But I just want to inform you why some doctors do not accept or ask you the option of paying more than what the insurance company is willing to pay us, before we agree to operate on you.  “Tinitipid nila kami, sobra.”

          4.       They will not tell you that you need to have Philhealth coverage, or else, you will need to pay the amount what Philhealth normally pays for.  From what I know, Philhealth pays 20-30% of the total hospital costs.

For employed individuals, this is usually not a problem since Philhealth contributions are mandatory by law when you’re employed, this being automatically deducted from your salary. You just need to bring the proof of contributions prior to surgery, either from Philhealth office or from your HR department. So make sure you or your employer is up-to-date with your Philhealth contribution, and that you have clearly stated in your Philhealth Membership form, who your dependents are.  For self-employed individuals, you have to make sure you pay the Philhealth contributions yourself, or ask someone to do it for you if you don’t have the time. The last time I checked, you should have contributed at least 6 months prior to your scheduled surgery to avail of Philhealth benefits.

When I was just starting my private practice a few years ago, my daughter was confined in the hospital. I thought I can use my Philhealth. But it turned out I had missed contributions the past months before her confinement because I was abroad undergoing fellowship training.  So too bad I wasn’t able to get my Philhealth benefits then. 

It is also good to ask your surgeon if the medical facility where you will have your surgery is Philhealth-accredited.  With the popularity of outpatient or ambulatory surgery centers, like those in the malls, some may or are not yet Philhealth-accredited.  In such cases, you will not be able to avail of your Philhealth benefits.

It is imperative that you read and understand your medical coverage and benefits, and have the surgery or procedure approved first by your HMO, especially for elective or non-emergency cases, before you decide to get admitted and go under the knife. You may end up paying more than what you expected and feel unprepared financially just like what happened to my patient.

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