Lessons with Dr.J: July 22 Closure

This is more like 'closure' post.

Whenever I would encounter something, I would write on a scrap piece of paper thinking that it would be good to review and make post out of.
However, this practice was lost in between my procrastination and laziness.

Today as I witnessed tarsorrhaphy (sewing eye lids shut) for the first time, and then I realized I must write about this. After all, my time at the clinic was ending and perhaps this would serve as a good reminder when I have to study ophthalmology.


The patient was a frail woman, octogenarian.

The procedure done was very similar to this, except both medial and lateral corners were done so that there was a 'tiny peep hole' in case something happened to her good eye.

The reason why the mucous membrane is shaved is because cells adhere better.
Sort of like debridement in a way, it just heals better.
The healing was especially important part as the woman had shingles and therefore had lost all her sensation.

"No sensation, No healing"

The reason why tarsorrhaphy is done can be divided to 4 main reasons:

1. Neuroparalytic :Neuroparalytic keratitis is inflammation of the cornea as a sequel to interruption of sensory impulses over the fifth (trigeminal) cranial nerve. The cornea’s loss of sensitivity leaves it much more subject to injury, exposure, and infection.
2. Neurotrophic
3. Corneal disease
4. Decrease exposure.



HERPES ZOSTER --> SHINGLES --> CN 7/ CN 5 damage --> ECTROPION/KERATITIS --> ECTROPION REPAIR/ worst case: TARSORRHAPHY

and as you might have guessed, the woman suffered from shingles and suffered terrible keratitis.
HM (Hand Movement) and LP (Light Perception) was the only vision she had left.
She hardly felt anything was the local anesthetic was given to her (usually "for 7 seconds it hurts like hell!" but "hurts going in but not coming out").


Indeed the surgery was done accordingly and smoothly.


I hope her quick recovery.

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When CO2 laser is used it can blow 'air' in and can result in subcutaneous emphysema (I google it and it says sometimes referred to Sub Q Air).

Emphysema means 'trapped air' 

Usually this can also happen if someone gets DCR (dacrocystorhinostomy)  because some bone is removed and so when a person blows his/her nose really hard, it can happen.

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It is always so difficult to leave the 'position' because you become familiar with it and you identify yourself with the position.

I've had in total about 4 different position here and each leave was 1) Silent (Mutual?) 2)Lots of Yelling P/O 3) Voluntary half fired half? 4) Voluntary

I was given exit review.

1. What did you enjoy the most while working here?

Learning. To be able to witness and participate in all aspect of patient care including reception to screening and assisting was an amazing experience! The sense of fulfillment and really feeling like a part of a team working efficiently together for excellent patient care was another part I enjoyed thoroughly. 

2. What did you find the most frustrating?

I don't think I was ever frustrated with anything. 

3. Did you feel that management supported you?

Definitely, I was grateful for management's understanding with my volunteer and family commitment. 

4. Were you given appropriate training?

Yes, while the course from SAIT provided me with academic guidance on-the-job training and guidance provided by all the other staffs (Olga, Teresa, Cheryl, Angela and Mary) helped me enormously and gave me practical understanding. 

5. Were you fairly treated? were your accomplishments acknowledged?

I believe so. Yes, staffs were very appreciative and I was always so flattered.

6. Was your salary reasonable and appropriate

It was discussed.

7. Were your working condition satisfactory?

Sometimes long hours were exhausting (10 hours) but I have no complaints because I enjoyed the OR time 

8. What are our office's strengths?

Strong team work, staffs' dedication to excellent patient care, professionalism, efficient staffs, caring environment, friendliness to mention few.

9. What are our office's Weaknesses?

Can't think of any

10. What would you like to see change at the office?

I would not change much, because I considered the office the most ideal in terms of how the clinic should be run. However, I wish sometimes people could be more courteous to one another if they are having a bad day because it is really infectious. 

11. Are there any other areas you'd like to discuss?

Thank you very much for everything. I feel so lucky to have worked at this office and feels sorry for leaving, because I can't imagine a better office environment to work.

May 9, 2013 - Lessons with Dr. J

These days either I'm forgetful or there has not been any new significant 'lessons' for me to post in this blog.
Perhaps, it could be that I have been preoccupied.






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Dr.J makes a very careful approach in treating his patients.
He is polite but says things that are appropriate in bull's eye manner. I would think it would take me forever to say things in that kind of manner or comes up with the vocabulary that can adequately leaves both the patient and myself perfectly content in communicating the patient's problem. Not exaggerating, but also not undermining - making my observation know if the patient shows discontent know when to move on or 'release the patient'.


The tone, the hand gesture, body language and words he choose seems to be all carefully planned.
I wonder how long and how many times you have to say it that way consciously in order to make it completely yours, which is more automatic, second-nature in a sense. Having the 'right' manner seems to be so difficult.




I have been told I think too much and over-analyze. I do, especially when it concerns what I say or do to people around me. I try to analyze how this person might have perceived me, did I creep that person out? I wonder what our next encounter will be alike? I hope this person doesn't talk about me... along that line almost obsessively. It goes both ways actually. Certain vocabs, words or things that a person says I take it as a hint.




Anyway, back to the lesson. On Thursday -  my late night, we had  one patient over who used own grocery store in a small town. The grocery store has been in family for 3 generations and he has sold it because such good offer came through. However, due to the effect of giant corporation, a la costco, a la walmart, a la target and etc, the new owners also had 2 other grocery stores but had to close those stores and was struggling with the store this patient sold to them.
Dr.J was more lively when he was talking to the patient during the surgery.
I was thinking that they must have lot of common because Dr.J and patient seemed to find each other pretty engaging when it came to certain topic.




However at the end of the day, Dr.J told me the reason why he kept the conversation going. The patient was on anxiety pill and that the local-anesthetic was not only the mixture of xylocaine and marcaine (6:4) but also the conversation.






I kept thinking I wonder how much Dr.J knows about me, how much he has analyzed me and etc.

Conversation in OR - May 1 2013

Gag order.

Whenever I see this word, I think about media - when socially outrageous, high-profile case takes place in a court house, judge typically "gag order" which  bans journalists, juries or anyone associated with the case to not to speak a word of it outside the court.

Would you believe it if there is a similar thing in a contract that your physician signs when they sign with a big hospital ( such as hospital privileges)?
I didn't know about this until today and I also learned that you are not to divulge anything that will harm the hospital's image or which taints the institution, or it's leader's competence or reputation.
You are not allow to criticize for some of the obvious dumb things that executives do and you are not to voice any opinion if something is not working out (ie.// new policy, hospital culture) or mistakes made (non-negligence or honest mistakes due to communication error) or...
The list would be endless because you are simply not allowed to discuss anything.

This seemed counter-intuitive to me, especially because hospital is publicly-funded and thus it should be more transparent than private.
It should be more progressive because it is publicly-funded.

And then, I thought about common sense (who can criticize the system best other than ones who are directly involved with it - on front-line) and I also thought about big-brother, an Orwellian society.

I live in Canada and Canada treasures its 'Charter of Right and Freedom'. It's a fundamental rights and freedom and we as a Canadian have, respect and extend to others.

So, why is it that freedom of speech should be banned when you are a consultant working for the hospital or directly involved with the care for patients, who are Canadians, who pays tax which pays for the service?

If there is inefficiency in the system, it should be voiced and fixed.
If something should be reported, it should be made known to all and fixed.
Why can't we think about fundamentals? Why does the hospital exist in the first place? Who actually does the work at the hospital? Why can we think about the common sense?

There is a really easy-going doctor from South Africa.
He is a practicing physician here and he once said, "South Africa is a 3rd world country with 1st class medical care and Canada is a first class country with 3rd world medical care."








To make things more grim, apparently when you go to a meeting at the teaching hospital, the most discussed subject is Research. That's good... step for innovation and all... and second, which is very, seldom, discussed is teaching....ok....hmmm...skepticism here. Then, what's the third and last thing that is NEVER discussed during these meetings? patient.









I just can't understand the logic...
it seems so blatantly obvious to me that people at that stage should be able to differentiate priorities and discuss about it.
You should save, be efficient and innovate like a private company. There is an absence of any 'push' to get things done in a public system, because after all there's no fiscal year report that sets out the profits or loss, you will forever be paid the salary which increase with every year you are with the government and get pensions and health care. You don't work on holidays, oh wait bank holidays and holidays that are not quite 'red colour' yet. Sounds like a dream job, but at the same time, a leech.

Best of all, the people who are at the management level at the hospital has nothing to do with health or medicine. They have not been fully exposed to front-line work.
They are oblivious about what works and what does not  and what leads to inefficiency, and they are controlled by politicians who are then controlled by big companies, who are subsidized by the governments.
This is a loop but for some reason majority of number lose out, sort of like a lottery.



I end my thoughts and discovery I made with this video.

And then just because of the way I am (...) and because I just found this...critique of the above video

... but I realized about half in, he was nit-picky about things that were not so critical and completely missed the point... saying that even if we seize all assets of top 1% it will still not be enough to cover the deficit and so on when Anne was clearly talking about principle, how the subsidy has contributed to the deficit.
Thus, I decided to unpost the critique video because it did not have a nutritious value in my opinion.

Gallery a la Mari 2: Hieronymus Bosch

Hieronymus Bosch, born Jheronimus van Aken was a Dutch Painter from 1500. Moral and Religious concepts and narratives.

Most well known art work: Garden of Earthly Delights.

Retinoschisis, ARMD

Retinoschisis (RS): Disease of the nerve tissue  in the eye - affecting retinal cells in the macula
It is a form of a macular degeneration but many people with macular degeneration does not have retinoschisis.
Genetic eye disease; male

****- schisis: splitting; breaking up of attachement or adhesion***

Symptoms

• Decreased vision (central vision can be affected)
• Loss of peripheral vision

Different from retinal detachment.

Retinal detachments can occur if the anchoring of the outer layer of the retina to the eye wall is impaired (bubble inside the wall paper)

Macular degeneration: breakdown or damage to the macula
1) Dry type: Common +++  - tissue becomes thinned and cease to function properly
2) Wet type: damaging +++ caused by the growth of abnormal bv behind the macula. The bv hemorrhage or leak and scar tissue forms if left untreated. Dry type can turn to wet type.

Symptoms

• The loss of the ability to see objects clearly
• Vision that is noticeably distorted
• Straight lines appear wavy
• Objects may appear as the wrong shape or size
• The loss of clear, correct colors
• Difficulty reading or seeing objects up close
• A dark, empty area in the center of vision 

Syndrome

Ramsay-Hunt Syndrome

Shingles infection (Herpes zoster) affects CN7 (facial nerve) near your ear.
Main symptoms: painful red rash with fluid-filled blisters on, in and around one ear; facial weakness
Results in: painful shingles rash, facial paralysis and hearing loss.
Treatments: high dose anti-viral treatment and corticosteroids


OCP (Ocular cicatrical pemphigoid)

OCP - stage 2

Subset of the mucous membrane pemphigoid (MMP);
Autoimmune disease characterized by T-lymphocyte dysregulation - the production of circulating autoantibodies directed against a variety of adhesion molecules in the hemidesmosome-epithelial membrane complex --> can affect the skin and other mucous membranes (oral, pharynx, larynx, trachea, esophagus, vagina, urethra, anus); chronic cicatrizing conjunctivities.
Characteristic: Slowly progressive and bilateral blinding
Average age of onset: 50-60 y.o



Aarskog syndrome

Heritable disease (x-linked), distinctive facial feature 
Facial feature: such as widely spaced eyes (hypertelorism), a small nose, a long area between the nose and mouth (philtrum), and a widow's peak hairline. They frequently have mild to moderate short stature during childhood, but their growth usually catches up during puberty. Hand abnormalities are common in this syndrome and include 

Some people with Aarskog-Scott syndrome are born with more serious abnormalities, such as heart defects or a cleft lip with or without an opening in the roof of the mouth (cleft palate)

Hand abnormalities are common in this syndrome and include Short fingers (brachydactyly), curved pinky fingers (fifth finger clinodactyly), webbing of the skin between some fingers (syndactyly), and a single crease across the palm

 .
Affects development of many parts of the body.

Just 10.

Just 10 companies in the world making pretty much every day essential items that EVERYONE eats and uses.

Just 10.