Odysseys of George

I just received a call from my very hard working medical officer, who is doing his ENT masters training, who has just completed his surgical rotations with me.

“Mr. George, are you free to talk?”

“Yes”

“I just witnessed a very bad accident, head on collision, one died on the spot. The was another four. One had difficulty breathing and was bleeding profusely, another has serious limb injuries. The other two was ok.”

“You were there at the scene”

“Yes, the ambulance that arrived did not have a doctor. So, I introduced myself. I had to do CPR in the ambulance. We reached the Hospital but the ED doctor was not around, so I intubated the patient and continued CPR. She lost a lot of blood. The ED doctor came and took over. I am very happy I was able to save two lives today. I managed to use my surgical training and the CPR course I recently attended fully. Thank you!.”

“Good! Excellent! Not many will have this opportunity and many will refrain from getting involved. Good!”

“Will there be any problems?”

“No, don’t worry!”

“I will call Serdang tomorrow to see how the patient is getting along!”

“I am happy for you! Good job! Good!”

“Thanks, Mr George. Bye”

Bravo, Soma. I am so proud of you!

A young lady in her 30s was referred to me for having serous mixed with blood(haemoserous) discharge from her previous abdominal incision. This discharge increased during her menses and with the same consistency. She had an emergency surgery a year ago for a ruptured uterus from pyometra (pus within the uterus) She was found to have a congenital (from birth) anomaly. This is her hysterogram

and fistulogram from the skin discharge.

Any guesses?

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What is pain? This was the question directed to me by our very first and own pain management expert, Dr Mary Suma Cardosa. I enjoy talking to her. She talks about her field of interest with much passion and commitment. So, what is pain? There I stood dumbfounded, as the last time anybody ask me this was when I was a medical student.

Pain, the word “pain” comes from the Latin: poena meaning punishment, a fine, a penalty. It is a sensation, a feeling of discomfort. But what does it really mean? Actually, pain is a protective mechanism of our body when we are injured in one way or another. In other words, when one feels pain, one has sustained some form of injury. But pondering it for a moment tells us this is not necessarily true in all instance.

I once met a young girl, she had lots of deformity as a result of a genetic fault making her unable to perceive or feel pain. Therefore, she often hurts herself by accident as she feels no pain. So, to feel pain is important and possibly a good thing.

When pain occurs acutely, then most often than not it means one has sustained some form of bodily inury. This is different in those who suffer from chronic pain, where though often the injury has healed but the tissue continues to defectively trigger or fire pain impulses causing pain. Chronic pain is a whole lot of a different scenario and involves behaviour modification and gradual tolerance and counselling with minimal dependence on medication.

Acute pain for instance after a surgery or trauma is a totally different ball game. Many physicians and nurses have under-recognised its importance causing in prolonged hospital stay and increased in post-trauma or post-surgery complications.

All this while, to assess for patients health status, the nurses would record a few vital signs to enable us to intepret and assess patient improvements or deterioration. These vitals that were taken mainly by the nurses included the blood pressure, pulses, respiratory rate and the body temperature. Pain has always been the neglected sign and has caused much confusion and fear among some regarding the usage of pain-killers and disregard from health care workers.

To ensure proper management of pain and reduction of usage of unnecessary painkillers(analgesia), the Veterans Health Administration (VHA) has introduce a directive to enable pain be assessed objectively and treated promptly and thus increase patient comfort and compliance to their chest and limb physiotheraphy. In Malaysia, Selayang Hospital is pioneering this before implementing all over the country and as you have guessed, my ward and the neighbouring male surgical ward have started treating pain as the fifth vital sign.

Assessment of pain is made objectively by combining :

1. Wong-Baker Faces Pain Rating Scale

2. Numerical Pain Scale

The numerical pain scale, uses a scale from 0 to 10; where 0 represents no pain and 10 represents the worst pain imaginable.

3. functional ability

* Where is the pain?
* When did it start?
* What makes it worse?
* What helps to ease it?
* Is it sharp, dull, aching, throbbing, shooting, burning?

It is important to understand that medications will not cure your pain or eliminate it. Medications work in many ways to help ease your pain such as by changing how your brain perceives the pain, by improving your flexibility, by treating underlying factors causing your pain, or by reducing inflammation or swelling.

Hopefully, pain as the fifth vital sign would stay as an assessment tool. It would also bring physicians back closer to their patients as this assessment though mainly done by nurses would require verification by the doctors and therefore cultivate the need to talk and touch your patients which in this modern age is very much lacking. Are we then making all these assessment as a result of us health care providers both doctors and nurses are slowly losing that human touch and connection with their patients? Maybe that is for another post to blog.

The medical blogosphere grandrounds is up at Medical Humanities Blog

Go check it out!

Up to 5% of patients with recurrent gastrointestinal (GI) bleeding will remain undiagnosed by standard gastroscopy and colonoscopy. In these patients, the small intestine is often suspected as the potential site of bleeding. During the past two decades push enteroscopy has become an important investigation in the evaluation of patients with obscure GI bleeding, with diagnostic yields varying from 38% to 80%. However, studies on the impact of push enteroscopy on the clinical outcome of these patients are lacking. Two retrospective studies have suggested that push enteroscopy may influence management decisions in 40% of patients.

Well, I had such a patient. He was an elderly gentleman who presented to us with a diagnosis of Upper GI bleed. I proceeded to do an OGDS which did not reveal any source of bleeding. So, I proceeded with colonoscopy and apart from an unhealthy colonic wall, diverticuli and some angiodysplasia, there were no reall source of bleed and no evidence of any recent bleed. As I was about to withdraw the scope, my intuition attracted me to the opening into the terminal ileum (the end of the small bowel). I manouvered my scope into it and wallah — there was a rare diverticula of the terminal ileum and evidence of fresh blood within the small bowel.

I decided to proceed for a push enteroscopy.

These scopes have a working length 210-cm or more and have standard and therapeutic sized biopsy channels that will accommodate a full range of accessories. They are similar to standard upper endoscopes in that they have up/down and right/left angulation along with a field of view of 120° or greater.

To aid in achieving the greatest possible depth of advancement, an overtube is usually placed over the endoscope prior to its insertion. The overtube reduces looping of the scope within the stomach or colon. Gradual insertion and withdrawal movements of the enteroscope help to pleat as much small intestine onto the scope and improve the depth of insertion. Using these techniques it is possible to examine 100 cm of small intestine beyond the ligament of Trietz in the majority of patients. Complications from push enteroscopy appear to be more frequent than for standard upper endoscopy. Perforation, possibly related to the use of an overtube, has been reported.

Using a standard colonoscope to examine the small bowel, a diagnostic yield of 38% has been reported.5,6 Whereas the use of a small bowel enteroscope resulted in diagnostic yield rates of 52% to 80%.

Well, this is what I managed to see about 200cm proximal to the ileocaecal valve(terminal ileum) — multiple large ulcers and one of them had a visible pulsating vessel waiting to rupture.

He was started on treatment and was discharged well yesterday.

Grandrounds is up at The Blog That Ate Manhattan

Check it out!