How to Use the Verbal Pain Scale or VNRS-11

Hi guys! It has been a while since I posted on my blog and here’s the first one for 2015! Fresh from the hospital, I got myself to record a Vlog for my YouTube One Channel.

I got to diagnose myself as having an appendicitis. Of course, I couldn’t operate on myself so I got a friend, Dr. Arnildo Tamayo to do it for me. It just so happens that he is a very good surgeon and he follows the Philippine College of Surgeons policy of No Antibiotics, No Analgesics policy prior to my emergency appendectomy. So I felt the pain all the way right up to the Operating Room.

In this video I discuss how the resident doctors and nurses made mistakes in asking for my pain grade. I show you guys tips on how to do it better. Also I provided a link for the best way or method in providing a good pain scale:

Also I offered my viewers a simple question:

What do you think about the current practice of Filipino surgeons in maintaining the No Analgesics, No Antibiotics policy prior to an emergency appendectomy?

I know some of you would say that the PCS has changed the policy into giving Amoxicillin-Clavunalic Acid 1.2 grams single dose pre-op and opting for Tramadol as a good pain reliever. It’s in their website.

However, most of the surgeons do not practice this, whether they are public hospital physicians or private practioners. They often cite that they are not yet that 100% certain which is why they don’t follow the guideline.

What degree of certainty is needed before they give pain relievers?

Write down what you think below and I’ll put your comments up for review with guest surgeons in a future episode or post.

Take care guys! Happy blogging!

Happy 100th Post to Public Health Resources!

For the past 6 months, I have been busy producing a new blog called Public Health Resources. It has received some 7,000 views over the course of its creation and today, I have just finished publishing the 100th post entitled: “Calculation for Normal Maintenance of Intravenous Fluid Infusion.”

The Need

The blog was made under the precept: “I hate the DOH Philippines website.” Ever since 2006, I have had difficulty surfing the website and it really really sucked. For the design, it has improved over the  years. True, but the content didn’t. I am a self-taught IT expert with no diplomas and certification. But even with that handicap, I know that the website has big problems on its architecture.

It has been a grueling 7 years of frustration. I needed data coming from the Department of Health (DOH) since majority of my patients are FIlipino (10-20% per month are from other countries). I need data that are specific to Filipino patients with management that can cater perfectly to them. It will take you an hour to browse through the DOH website to find out a specific government program and learn about it and another half an hour to find out that it doesn’t exist anymore.

Majority of the important articles are not on the webpages themselves. Trust me. You can get to the webpages through Google and be disappointed to find out that the one paragraph information contains none of what you are looking for. Most of the data are in a database of memorandums and administrative orders coming from the Department Health Secretary. That’s where you’ll find all the patient treatment standards approved by the Department of Health and its branches.

The main problem is that the important data is not Search Engine Optimized. It’s not even Website optimized. The memorandums are in PDF’s and they are a bunch of scans that cannot be read by Google. Some scans are so bad, my eyes have trouble deciphering them. They are even advertising Health Beat magazines that cannot be downloaded properly from their servers.

And how about the techie doctor who can afford great bandwidth in their cellphones. He’d be frustrated like me to find out that the website is not even optimized for mobile.

The  news clippings from the Department of Health is nice but that’s just all there is to it.

The Site

I do not want to create another DOH webiste, God forbid. But rather I want a website that can decipher all that information from the DOH website and bring all the data to those who need it in a form that can be understood by a similar public health practitioner. The future has a great potential. Pretty soon Cable TV’s will die and the flow of information will be seamless in bytes. Content like those in Public Health Resources and in my YouTube Channel will be viewed easily on TV screens and those that really need it quick must get the information in a form that is not hard to navigate or much less needed to be downloaded.

So I made the site. I used a blogging platform to have seamless CSS mobile integration. Also, the SEO optimization is easy after the Panda update on Google. I just need it to rank and be seen along a lot of social channels. Formulating the navigation would be easy for me since I have familiarity over blogging platforms. The only downside is the domain name. I still have no cash to feed this baby because my credit card hasn’t been resurrected yet. So I have to stick with blogspot.

The Content

Even though I have enjoyed some SEO induced traffic, my content remains to be dull. If you have visited the website just now from the links I have provided above, you’ll see why I call it dull. It’s an information website and I have to be as accurate as possible with as little side notes as possible. The evolution of the website has been planned out. The first 200 or so posts will be information rich data that are needed by my target demographic: doctors, nurses, midwives, and health workers with or without mobile internet access.

The rest of the posts will be clinical practice suggestions linking to the proper reference embedded in the website. It’s a daunting task that’s why it took me 7 years to convince myself. Now that it’s live, it has taken a life of its own. So feel free and enjoy the website. More content to follow Public Health Resources.

Top 5 Things Your Doctor Forgot to Tell You About Amoxicillin

General Practitioners and Family Doctors lead a busy schedule. We have to see our patients fast because there’s a really long line. And we always want what is best for our patients, no matter how busy we get. Amoxicillin is one of the most prescribed of the antibiotics depending on where you are in the world.

In order to make up for time, some stuffs about Amoxicillin may not have been discussed with you. Here are 5 things he/she may not have explained fully:

Continue reading

Remember Zinc: the gut vitamin for diarrhea

Since the consensus was published in 2005, a lot of doctors forget zinc supplementation as part of the treatment algorithm for diarrhea. Some pediatricians argue that most of their patients were already prescribed multivitamins that contain adequate zinc content that further supplementation may not be necessary. But how sure are they that the mother is giving the multivitamins to their sick child?

In my rural health primary practice, many mothers are surprised that I recommend zinc or other vitamins during illness. Further probing told me that they stop all vitamins once they have a sick child. It was an old practice that was passed down but is now obsolete.

Related Story: Gatorade in Diarrhea: not First Line therapy

The following is WHO’s recommendations regarding zinc:

Zinc can be given as a syrup or as dispersible tablets, whichever formulation is available and affordable. By giving zinc as soon as diarrhoea starts, the duration and severity of the episode as well as the risk of dehydration will be reduced. By continuing zinc supplementation for 10 to 14 days, the zinc lost during diarrhoea is fully replaced and the risk of the child having new episodes of diarrhoea in the following 2 to 3 months is reduced.

This was taken from Treatment of Diarrhea 2005.

Remember to supplement zinc during diarrhea and if you are a mother reading this article, ask your pediatrician if you can switch to better forms of zinc than your plain old multivitamins. Also, stress to the caregiver it’s importance so as to greatly increase compliance.

Zinc sulfate drops and syrup are available for free in barangay health centers. We are only one of the 46 countries that have a national policy on this.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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Gatorade in Diarrhea: not First Line therapy

Gatorade, a popular sports drink, is continually being used by some pediatricians despite the fact that it is not a first line therapy for acute diarrhea or vomiting. It is marketed as a sports drink and should only be used as such.

Gatorade is a fluid high in sugars and low in salts. It is preferred by most infants and toddlers due to the taste but the risk of osmotic diarrhea prevents me from recommending it. Its use can only be recommended if there is no suitable replacement for plain ORS but the quantity required to treat some signs of dehydration is still dependent on the salt content. Compared to ORS, you will need twice the amount of Gatorade to replenish the same amount of fluid deficit. ORS is therefore cheaper and far more effective. If the patient may exhibit NO signs of dehydration, Gatorade can be actually be used. However, there lies no consensus among concerned medical parties and is therefore not recommended. Start oral rehydration salts early to prevent further dehydration instead.

Related Story: What Your Doctor Wants To Know About Your Diarrhea: Quality and Quantity

Other common fluids also exist that are used by Filipina mothers that may be harmful include coffee, carbonated drinks and carbonated juices. I have met many mothers who have given coffee to a sick infant, further increasing the dehydration and the diarrhea. These are mothers who are usually reluctant to seek consult and are the ones that bring their child to attention only when severe dehydration and malnutrition is observed.

Salt is the primary method of treating diarrhea. Rice washings could be salted to provide a better alternative but the WHO recommends early access to ORS since the recipe is often forgotten.

ORS is provided free in barangay health centers and, if there is shortage, is inexpensive when bought in a local drug store. Gatorade and other fluids are far more expensive, less efficacious, and could be harmful to the child.

Dr. Mella is currently the head of the Committee on Diarrheal Diseases in Olongapo City. This is part of an education campaign to combat diarrhea.

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“Q-tingin:” Estimating Fluid Deficit by Physical Examination

Olongapo City – In the published manual of the WHO entitled “Treatment of Diarrhea” (2005), fluid deficits in dehydration and response to therapy need not be calculated using laboratory values but rather by straightforward physical examination.

Diarrhea with NO SIGNS of dehydration can have a fluid deficit of no greater than 5% or 50 ml per kg body weight. Thus a 15 kg child with diarrhea who is alert, drinks normally, and has normal physical exam is estimated to have at most 750ml of fluid deficit and correction of that deficit by increased oral fluid intake or ORS can be beneficial.

Diarrhea with SOME SIGNS of dehydration can have a fluid deficit of 5-10% or 50-100 ml per kilogram of body weight. For a 15 kg child with diarrhea who is restless/irritable, has sunken eyes, thirsty/drinks eagerly, and/or skin pinch that goes back slowly, his fluid deficit is estimated to be in the 750-1500 ml range. The patient should be weighed to detect clinical response as most patients begin to lose weight at this stage of dehydration. ORS, continued feeding, and zinc supplementation is recommended.

Related Story: Mom’s Best Arsenal Against Diarrhea: Oral Rehydration Salts!

Diarrhea with SEVERE SIGNS of dehydration can have a fluid deficit of more than 10% or greater than 100 ml per kilogram body weight. Thus the same 15 kg child above, should he become lethargic or unconscious, have sunken eyeballs, drinks poorly or not able to drink, and/or with a very slow (>2 sec) skin pinch over the abdomen, is likely to have a deficit of more than 1500 ml! This patient should be admitted. IV fluids and ORS are an emergency measure. Death follows if there is no immediate fluid replacement in 24 hours.

These fluid deficit estimation can be used in many etiologies of dehydration such as hyperemesis and severe exercise. Reference used in this article was provided by WHO and can be downloaded from this link:

Treatment of Diarrhea.Manual for Health Workers

Dr. Mella is currently the head of the Committee on Diarrheal Diseases, Olongapo City Health Office

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Oral Rehydration Therapy Should be Taught in Schools

Afable Medical Center – I became flustered as I heard one of the mothers say “No” when asked whether she gave Oresol (an old brand and short name for Oral Rehydrating Salts) to her child who had 3 days of watery diarrhea. I really tought they teach this at the grade school level as I was taught in Las Pinas about Oresol during grade 2. I poked around the history and found that the mother received primary education but was never taught how to prepare ORS. I apologized for my behavior and realized that I was lucky enough that I knew how to prepare ORS at a young age. Most people aren’t and I shouldn’t be judgemental.

I didn’t grow up rich but I did attend a private school. It was the cheapest private school at that time. My mother had to make ends meet just to pay the tuition and I had to be a good student just to stay at that school. I think I taught my mother ORS. It was simple. Just drop the tablet, shake it, drink it and you’ll feel better. No dosing, just drink when you have diarrhea or vomiting. I learned it can be bought without a prescription since our Home Economics teacher made us buy one as an assignment.

Related Story: Mom’s Best Arsenal Against Diarrhea: Oral Rehydration Salts!

It’s a simple remedy that stays in the mind once taught and sticks once practiced. Although as a doctor, I prescribe it with more on dosage control to effectively put out dehydration but as an educator, I think what my school has done for me during grade school should be practiced in all private and public K-12 schools. The information can help save lives since Oral rehydration solutions should be administered promptly especially to kids less than five years of age to prevent death.

Fact: In the Philippines, most teenagers who became pregnant early are grade-school or high school drop outs. Due to poverty, dropping out can’t be helped especially in urban areas. Poverty in rural areas is different in highly urbanized cities. Cost of living is higher in urban areas and places strain on both parents and students. If health maintenance education like Oral Rehydration Therapy can be taught early in school, we can target this population effectively and prevent more under-five deaths.

But this grade-schoolers aren’t five years old or below, you might ask. Yup, but they are future parents.

Related Story: Gatorade in Diarrhea: not First Line therapy

Fact: ORS overdose especially in diarrhea is rare or probably nonexistent. I haven’t encountered one and I would be able to spot it since I’m a doctor. Free and cheap ORS (even the flavored ones) are hard to swallow because of the taste. Glucose found in ORS isn’t sweet. As an experiment, I have attempted to swallow 500ml of it as fast as I could and ended up vomiting it. We can only take a few amounts of it at one time. Letting the child sip it, placing it in droppers, or using teaspoons to administer it is safe. It only takes a little to create clinical improvement. It is safe in all situations.

Theoretically, an overdose can only happen if the child suffers different morbidities. At that time, the child would probably have been admitted for other reasons that would not preclude the use of ORS.
Teaching a child how to treat himself/herself using ORS is as easy as drop, shake, and sip. No need for a thorough explanation.

If symptoms persist, consult your doctor. We can then give more thorough instructions depending on weight and dehydration severity. Other measures can then be initiated but we can be assured that once ORS was started at home, the patient is likely to be away from danger.

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