Drastic and devastating

Drastic and devastating

The title of this post presents two important words from the medical dictionary. “drastic” can be first seen in the homeostasis introduction to medical physiology course. It emphasizes the lack of adaptive and accommodative responses to sudden and strong changes in the environment. In such conditions the outcome can be quite damaging or even fatal. The word “devastating” can be found in the pathology essays such as those changes due to severe infections and it usually concerns a local pathological change, e.g. necrosis. Though the two words may originally concern natural events in the environment, they may provide clues to medical care and case evaluation.

In medical practice the care-giver should avoid harsh interventions in terms of course and dose. The treatment may be better doing when it is decent and incremental (opposite to drastic). That view in the medical care – in some situations – entails ‘partial correction’ of the concerned disorder as”rapid*” ‘full correction’ may bring about quite unwanted or even fatal hazard. It is always wise to have an overall vision of the medical case with top-to-bottom estimate so that such extreme flip-flops can be better appreciated and avoided. The treatment should be both problem- and patient-tailored. As the body’s reserves to accommodate changes (temperature, water, food, etc.) is limited and varying from time to time one should be careful not to be too rush or too slow.

By the way, the medical opposite of devastating can be ‘mild’ or ‘trivial’.

Take-home massage:

1- Be decent, systematic, and incremental.

2- Observe well.

3- Be open-minded, generous and evolution-ready.

4- Make your expectations as modest and small as you can.


* Suggested steps of management could be:

1- Reverse the current event.

2- Restore/establish base line.

3- Treat residual illness.


Orthotherapia (orthocura) – an interview –

orthotherapia (orthocura)

Interviewer: Hallo, everybody! Welcome to this episode of “medical views”. Today, we have another very exciting view of medical care, namely “orthotherapia or orthocura”. Let’s greet our guest; Mr. Physician 21, welcome back to our program!

Physician 21: Thank you. I am very happy to be with you today.

Interviewer: Would you explain the core concept of your orthotherapy?

Physician 21: Well. To start with, the idea is not by any means very novel but more it gathers and harmonizes some basic medical principles in a well structured and meaningful medical philosophy.

Interviewer: So, what are the main pillars of your idea?

Physician 21: Orthotherpia or orthocura claims that among all possible medical care regimens there could be only one that best suits a given medical case. While in this regard the conception of a presumed bodily functional hierarchy would be in the centre, some medical peculiarities are also much concerned including patient type, medical remedy type and mode of application.

Interviewer: Very fine Mr. Physician 21. Now, we are about to get that well structured and meaningful medical philosophy of orthotherapy. Would you bring us closer to those very interesting medical presumptions; first, what do you mean by bodily functional hierarchy?

Physician 21: The bodily functional hierarchy would mean that the various physiological functions and their body organs may be ordered in such hierarchical manner so that one function would be prioritized in respect to another. An example could be: lung > stomach > heart > liver and spleen > muscle and bone > gonad and kidney > brain. Such conception of possible hierarchically ordered body organs would help appreciate disease evolution from one side and disease management order from the other side.

Interviewer: How nice! We would perceive a glimpse of ‘alternative medicine’ in that presumption of bodily functional hierarchy, would you say that?

Physician 21: Well, I should say that I am not an expert in alternative medical methods. Anyhow, as I already said in the beginning the idea may not be very novel and it should make use of much of the well known medical arts.

Interviewer: Would you give practical examples to further explain that?

Physician 21: Well. Let’s consider a case of fever with signs of dehydration. The dehydration may be first corrected by giving appropriate fluids and then the body temperature could be assessed and managed accordingly. In such case, prioritizing fever to dehydration would be inappropriate and cost-ineffective. Another example could be the improvement of anxiety which reflects neurologic stress on practicing some suitable kind of sports. Again, in that case over consumption of anxiolytics may be cost-ineffective.

Interviewer: you mean that in handling diseases it makes great sense which disease or organ function to consider first to achieve a rather smooth and nature-coping healing process.

Physician 21: That is it. Thank you.

Interviewer: To summarize, “orthotherpy” or “orthocura” would emphasize the significance of choosing the management regimen with the presumption of natural hierarchical order of body functions and systems. Thank you very much. Mr. Physician 21 for this very interesting information.

Physician 21: Thank you too.

The clinical session algorithm

The clinical session algorithm

The excitement and challenge of the medical session are not to overlook especially for newly practicing physicians. Red cheeks, heart knocking, hand sweating and even head whirl may be typically experienced by many doctors even by quite experienced ones. The reason for such clinical session tension could be overestimation of the job and/ or lack of the successful scheme (algorithm) for medical management.

In this essay, I wish to emphasize that the tactful handling of medical care including clinical session is a matter of training and learning where the inherent talent influences the length of time necessary for such clinical mastering. About clinical session or examination questions regarding its duration, steps and order plus precautions and ethics are indeed worth noting. These together will shape out what is known as ‘the clinical sense’.

1- Context: what is the context of the clinical session?

By clinical session context I mean the time-place frame of the patient’s presentation. These circumstantial provisions may have influence on the clinical session as for professional progress and patient-doctor expectations. Besides care about medical perfection and contentedness the question whether a medical fee could or could not be considered can be quite sensible.

2-Patient type:  what kind of patient is this?

Broadly speaking patients may be seen as either chattering or serious. Because in some cases such definition and judgment of the patient may take time for the sake of fairness and respect to all patients, this question should be considered from the beginning and throughout the clinical session.

3- Presentation: what level of urgency does this case have?

The level of urgency may be graded in 4 levels: 1) life threatening problem, 2) potentially ailing problem, 3) naturally resolving problem and 4) intervention sparing problem.

In order to adequately define the level of urgency good knowledge and appreciation of the possible presentations (complaints) in the different diseases is required. For example, headache can be a symptom of different diseases like stress, constipation, muscle inflammation due to cold for example, fever, sinusitis, high blood pressure, etc. The level of urgency and, hence, appropriate management will vary for the same complaint from one disease to another.

4- Management plan: what to do for this case?

This question is answered at 3 levels: 1) immediate plan, 2) remote plan, and 3) Follow up plan.

The immediate plan is instituted for either therapeutic or prophylactic aspects. It can be omitted when there is no need for it or when the case cannot be yet well judged. Referral of the patient to a more experienced colleague and/ or medical care center is also possible option for immediate management plan. The remote plan may form a further management step or follow certain preparation with or without medications. The follow up plan can be needed for life long or relatively time lasting cases.

5- Clinical session closure:  what to do when you are done?

Considering the appropriate ethics, time and progress of the clinical session, the closure of the session should be smooth and well prepared ensuring that all the medical instructions and treatment plan given to the patient in writing and having the required and ‘allowable’ contact information taken by both physician and patient.

The physician’s guide

the physician's guide

The physician’s guide is an indispensible tool to summarize basic medical and clinical knowledge and experiences. It should be concise, easily demonstrable, regularly updated and greatly physician-specified (self made).

Here is a personal view of such important medical tool.

The Hippocratic Oath

Section 1: normal values (pediatrics: growth milestones or curves, caloric and fluid requirements and calculations; CBC; hemoglobin electrophoresis; plasma electrophoresis; liver function; kidney function; urine; stools; semen; hormones; electrolytes; arterial boold gases; and ECG findings).

Section 2: preparation-oriented drug index (topical formulas: skin, eye, ear, and nose; tonics and food supplements; antimicrobials: antiseptic, antibiotic, antifungal, antiprotozoal, and antihelimenthics; analgesics and antipyretics; antihistaminics; corticosteroids; skeletal muscle relaxants; antispasmodics; antihypertensives and cardiac agents; hemostatics, hypoglycemics; neuropsychiatric agents (sedatives and hypnotics, anticonvulsants, brain stimulants, antidepressants, antiparkinsonians); and beauty preparations (shampoos, cosmetics, soaps, etc.).

Sections 3: natural foods and herbs – sorted alphabetically – and their uses (basilica, chamomile, garlic, green tea, onion, thyme, etc.).

Section 4: medicines’ doses and instructions tables (neonate, child, and adult).

Section 5: crude models of medical prescriptions (orthopedic, eye, ear, nasopharyngeal, dermal, gynecologic, oral, cardiac, digestive, liver, renal, respiratory, and neuropsychiatry).

Section 6: medical algorithms (pediatrics: infant of diabetic mother, muconial aspiration, low birth weight, prematurity, neonatal jaundice, respiratory distress, etc.; adults: HTN, DM, bronchial asthma, cardiac asthma, DVT, diabetic ketoacidosis, hypoglycemia, stroke, etc.).

The physician’s bag

the physician's bag

In alignment with the order needed for a well resolved physician a competent and feasible preparation of the physician’s bag should be realized. This process entails a thorough understanding and mastering of the commonest medical problems that may be a matter of urgency or emergency. Here are some of these cases arranged according to their relative frequency rather than their emergency level:

  1. Fainting or syncope: – let the person feel that he/she is attended, e.g. hold the arm and ask about how he/she is now, while feeling the radial pulse. – apply the ABC scheme (air way, breathing, and circulation). – notice the colors, odors, sweating, tremors or special positions, if any. And – take the vital data (pulse, blood pressure and temperature). Manage accordingly.
  2. Anxiety bouts (attacks): – reassure the person that he/she is attended, i.e. appropriate care can be available. – notice pulse rate, hand sweating and temperature. – try to encourage the person to talk about some topics like the type of food, sports, books he/she likes and if he/she have certain fears or current personal problems. – discuss the possibility of immediate treatment, e.g. with a beta blocker (nonselective), and outline a management plan that can multidimensional, e.g. physical, dietary and/or medical.
  3. Hammering headaches: – reassure the person that the case is not serious. – take the vital data (pulse, blood pressure and temperature). – ask the person if he/she is taking any medications or if there is (are) some chronic illness (es). – encourage the patient to drink normal water after making sure there would be no risks (e.g. the person can swallow normally, no intoxication by a corrosive substance for example, no water restriction, etc.). Manage accordingly.
  4. Fever: – reassure the person that the case is not serious. – ask about specific pain or other complaints, e.g. diarrhea or colic. – if this would seem conservative and neutral, encourage the person to drink normal water, fresh juice like lemonade and orange that have the same temperature as that of the environment. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. Manage accordingly.
  5. Renal colic: – reassure the person. – the typical renal colic follows the course of the renal system on either right or left side, i.e. the loin region, the ureter and the urethra. – ask for a precipitating factor, e.g. drinking water problem, unbalanced food intake, exposure to cold, or stress. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. Manage accordingly.
  6. Chemical intoxication: – reassure the person. – take the vital data and notice the colors, odors, sweating, tremors or special positions, if any. – after withdrawal or avoidance of the intoxicating agent the condition resolves gradually and steadily over time. Manage accordingly.
  7. Difficult breathing (asthma): – reassure the person. – ensure good ventilation of the room, e.g. open the windows. – notice the colors, odors, sweating, tremors or special positions, if any. – assess for ABC. – notice lower limb edema, abdominal enlargement and or tenderness, neck vein pulsations. – auscultate the chest for abnormal inspiratory or expiratory sounds. – consider possible heart and or lung diseases. Manage accordingly.
  8. Bleeding nose (epistaxis): – reassure the person. – let the person breath by his/her mouth and then compress the nasal cartilages against the nasal septum from outside. – ask the person to raise his/her head little up while still closing the nose. – after the condition has stabilized, the person is advised to avoid the precipitating factors, e.g. avoiding sun burns. – notice the colors, odors, sweating, tremors or special positions, if any. And – take the vital data (pulse, blood pressure and temperature). Manage accordingly.
  9. Cut wound: – control the bleeding site by compression with clean and sterile gauze. – special wound healing plaster and or surgical stitching may be used as required.
  10. Chest pain: – reassure the patient. – risk factors include family history of coronary heart disease, hypertension, diabetes and smoking. – under medical supervision , e.g. by an ambulance, and while explaining it as being absolutely precautionary, refer the person to the nearest hospital or an intensive care unit for best medical care.

The physician’s bag contents include:

  1. Physician’s guide.
  2. Physician’s stationary: a prescription or note-block, pen, plastic ruler (about 10 cm length).
  3. Medical disposables: 3- 5 plastic examination gloves, 2-5 sterile scalpels, 2-5 sterile plastic syringes (1, 3, and 5 ml), 1-3 i.v. canulas (small and medium), medical cotton and gauze, and 2-5 tongue depressors and sterile surgical needle.
  4. Medicines and medical stuffs: ampoules and tablets (atropine, theophylline, antihistamine, NSAID, corticosteroid, hyoscine, nonselective beta blocker), and surgical betadine.
  5. Apparatuses and instruments: stethoscope, sphygmomanometer, torch, thermometer,  needle holder and arm tourniquet.

Decision making

“Decision making is not easy”. I can remember very well the scene when this statement has once first knocked in my ears. She was a young lady anesthesiologist  wearing the surgical theatre suit. In that time, I was just a freshly graduated medical doctor who dared to enter the most horrible medical situations, namely the cardiothoracic surgical room, seeking for nobility, self and glory. Once the soft and serious voice touched my ears and my whole being, I felt again the difficulty of the duty that hangs on a word and a meaning I am apparently deficient in, decision. I was not really raised up to know what a decision could be. And now it might be the time to have it, inevitably, face to face. Was it really the time? – Maybe.

As a physician one has to train on decision making as precise and as time-fitting as possible. One time you decide to start a medical treatment, another time if to discharge a recovering patient, again whether to refer the case to another colleague, and so on. Simply, I would ask myself very curiously how many decisions I had to make this finished work day and how my score in terms of right and false ones was. Do medical decision making differ from that in the general life themes?

The process of decision making comprises 4 elements: 1) ‘resolved’ person, 2) ‘adequate and reliable’ information, 3) ‘proper’ scaling and interpretation and 4) ‘titratable’ stepping. An appreciable cost of time is needed for each of these elements. There could be an order for the functionality of decision making which includes: instinct → cognition → insight → intuition → inspiration → revelation → destiny and divine providence. The person is, thus, quite obviously the most important player in the right decision making. To be a ‘resolved one’ I would need to have: 1- things in a reasonable order and to 2- critically and objectively assess my own self-perception. A systematic way in decision making would help the person to sustain an ambitious and promising performance and to cope with the thus restrained and unlikely embarrassing incidents.

Inclination, decision and obligation are three words that would contrast the meaning of one another. Inclination might be a kind of default that could be good or bad. Obligation is a kind of constraint that would bear benefit as it is the case with medical recommendations. These two seem like simplest form of behavior. Decision, on the other hand, would imply a much longer and elaborate problem solving starting from ‘order’ passing through ‘information’ and ‘interpretation’ and effected in incremental or ‘titratable steps’.

Being person-dependent, decision making may vary considerably in form and utter. However, a preservation of consensus of ethics would greatly neaten such personal variations.

Disease characterization and classification


disease characterization

In the medical field, a disease may be regarded as any objectively addressable deviation from the abstract normal. That abstract normal would be assigned a “neutrum” of customarily and/ or scholarly defined state of equilibrium and perfection.

Very remarkable is that the human normal is not shaped, as may be noticed in the phrase above, only by physicians or medical professionals, but also by thinkers, philosophers, scientists, creative minds and the general lay people.

In order for such “disease” to be defined or characterized a few parameters should be fulfilled.

  1. Type of the person in whom this disease may be seen.
  2. Onset of the disease.
  3. Course of the disease.
  4. Associates of the disease.
  5. Common outcome of the disease.
  6. Name of the disease.

These are 6 parameters that would be quite sufficient to characterize a disease on gross and perceivable measures by scholars and the lay as well. The knowledge about the cause(s) and underlying micro changes and molecular mechanisms fall to the interest of a few people including the health care providers.

Let’s talk briefly about each of these disease parameters in hand of common examples.

Type of patient includes:

– Age (child, adolescent, adult, and elderly),

–  Sex (male and female),

– Stature (stunted, average, above average)

– Body shape (slim, average, obese),

– Race (Caucasian, Negroid, Mongolian),

– Personality (easy, strict),

– Acquaintance (poor, average, high).

The relevance of patient’s type to the disease is understood by the fact that some diseases are more common in some patient’s types than in other types.

Onset of the disease

This means how the disease was noticed by the patient or the relatives.

– Sudden onset: the disease has commenced very acutely. Example: a thrombus formation in the leg (deep venous thrombosis, DVT).

– Gradual onset: the disease commence over relatively long time. Example: weakness in the leg due to a disc hernia.

Course of the disease

This describes whether the disease tends to increase, decrease or fluctuate as time passes (over relatively long time) without any interference from the patient’s side.

– Progressive course: e.g. progressive decrease in visual acuity.

– Regressive: e.g. so-called self-limiting disease that resolves gradually by itself such as common cold or flu.

– Intermittent course: this describes a disease that tends to appear from time to time.

Associates of the disease

These imply the relation of the disease to other things like food, drinking, activity, stress, posture, etc. Among the associates of the disease we can consider risk factor(s), e.g. obesity is a risk factor for type 2 diabetes mellitus, and precipitating factor(s), e.g. water restriction is a precipitating factor for renal troubles.

Common outcome of the disease

This is how the disease would most probably set its end.

– Self-limiting, self-curable: usually no treatment is needed.

– Ailing and incapacitating: treatment is needed.

– Life threatening or fatal: treatment is needed.

Name of the disease

This is important because it helps in reliably and efficiently preserving and communicating knowledge about disease.

The terms: “natural history of the disease” and “the full blown picture of the disease”, are helpful in presenting the disease as well characterized entity with its unique components and behavior.

In the realm of disease a classification system may be very necessary in order for easy sorting and recall to be in hand. It is anyhow not an easy job to classify diseases at any known or unknown factor, e.g. their causes. As medical practitioners and students we used to have medical terms such as:

– Infectious diseases and noninfectious diseases

– Organic and psychological diseases

– Genetic and acquired diseases

In addition to other terms like trauma, congenital, psychosomatic and constitutional.

From a practical and treatment-wise approach, I would classify diseases into two main classes: biologic and nonbiologic. In the former class some living organism, e.g. a bacterium, a virus, a parasite such as E. histolytica or a worm, is almost certainly accused for making the disease. In such a case the effects of such biologic invasion must be well assessed and specific treatment may be given as appropriate. Such a microbe- or parasite-oriented treatment may be in some cases life saving as the timely diagnosis and treatment are crucial for favorable outcome. For the latter class of diseases, in which such accusation of an invading organism is quite unlikely to bring about the disease, the treatment will be chiefly concerned with combating the illness through general and/ or specific treatments.

Now,     I wish to present a master for patient’s diagnosis that would be comprehensive and elegant as well:

* Moderate jaundice in otherwise apparently normal 3 days female neonate of type 2 diabetic mother for general treatment and investigation.

* Renal colic in other wise apparently normal 6 years boy for general treatment and investigation.

* Moderate fever (38⁰C) in reportedly hypertensive obese; easy taker 49 male adult for specific antibiotic treatment and advisable investigation.

* Slight Albuminuria (+) in otherwise apparently normal; tense taker 19 weeks primigravida, 32 female adult for mandatory weekly-monthly follow up.

This 5-site patient’s diagnosis comprised: 1) patient’s most relevant complaint or finding, 2) patient’s look and/or medical history, 3) patient’s type, 4) suggested treatment, and 5) investigation.

With the expected advancement of disease characterization more molecular designations will be available for common use that would reflect an increasing awareness of molecularly-oriented medicine.