Trust your doctors: ethical dilemmas in remote medical consults

A 35 year-old female came in at Afable Medical Center, with severe 10/10 (NAS) hypogastric pain of sudden duration. Palpation revealed a tender abdomen to deep palapation at the left lower quadrant. There was no fever and no relief to Mefenamic Acid, an over the counter analgesic.

Initial Assesment was a possible Nephrolithiasis. CBC and Urinalysis were normal except for 2-4 WBC on the urine sample. No crystals were seen. Tramadol and Buscopan per IV were given to the patient with substantial relief. Admission was offered for observation and to prep for an ultrasound. A referral to a urologist was recommended.

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The patient agreed and was admitted.

It was a Sunday and, since Olongapo City was short of medical practitioners, I had to wait for an available urologist to examine my patient. For temporizing measure, I gave Tramadol and Cefuroxime (a broad spectrum antibiotic). I also have to wait until a sonologist would have to be available for an ultrasound.

All my management was sound and under protocol.

After a few hours, she bursts out in anger.

“Uuwi na po ako; wala daw po ako sakit. [Trans. I’m going home, they told me I have no illness]

“Who told you?” I asked.

She gave me her cellphone and I talked to a Dermatologist who was very angry that I admitted her sister-in-law with 2-4 WBC.

I told her that I saw the patient in severe pain and that she had to undertake more tests.

She told me that I was an ingrate and that I know nothing about her sister-in-law’s condition.

She dropped the phone. I asked my patient for the doctor’s name and she refused. She paid for the bill after signing a HAMA agreement.

This was four years ago and I regret I did not sue. The attending physician, or the one that is actually present, has precedence over a medical case. Medical opinions outside of the case are just that, medical opinions. Having a board certified specialty training in Dermatology doesn’t make you an expert over matters you cannot see. You can have a triple specialty or subspecialty but if you do not oversee the case, you shouldn’t make inferences that can damage the reputation of the attending.

The dermatologist violated the PMA Code of Ethics and is liable for slander. My story is one of many I have encountered in clinical practice. I have met patients time after time asking for a second opinion hoping to discredit the previous doctor in their care. I always tell the patients about differences in practices and that their previous doctor was doing the best he can. I do not wish to stain anybody’s reputation but time after time, I hear my own patients telling me that some specialty consultant said something bad about me, or that another patient I knew, is spreading a nasty rumor after his/her kid is not feeling well despite the meds I gave. Each of us doctors graduated with a degree of Medicine and sworn to uphold an oath. Each one had a different set of teachers and a different set of values. In a time when teamwork is needed, I see a crab-mentality issue going on.

“Hindi yan magaling… [Trans. That doctor is no good…]

I actually heard this comment coming from another doctor. The doctor he was referring to was a specialist that has serviced the community for more than 20 years and has done a ton of charity work. I actually found out that the commenter had a daughter who has graduated with the same specialty as the victim and needed a recommendation of patients to see.

This has got to stop! This is bad practice. This is unethical practice. Medical Doctors are becoming scarce and the remaining Filipino doctors are discriminating each other.

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Filipino Medical Myth: Bawal Tumalon Pagkatapos Kumain

Get a free preview hereSupport independent publishing: Buy this e-book on Lulu.

Filipino mothers keep this epic advice to their kids — “Bawal tumalon pagkatapus kumain at magkaka-appendicitis ka!” [Translation: Stop jumping after you eat; you’ll get appendicitis] I actually grew up hearing this advice over and over. The funny thing is I kept jumping just to piss my mom off.

This was awfully popular in the 90’s and I have noted various spinoffs. Some were “your stomach will explode” or “worms will come out of your butt.” These and other more ridiculous variations did not last long enough because they cannot carry their own weight. Only the appendicitis myth survived.

I discuss its perverted origins in my book and provide a real-life celebrity example. There have been at least 1 doctor that lectured impaction of feces when jumping as a cause of appendicitis. No scientific paper nor any experiment holds this to be true. There is no predisposition to appendicitis.

Anybody can have appendicitis.

Surgeons know this as this is their bread and butter. So if you’re Filipino, stop blaming your brethren who is going to have his appendectomy. His jumping or doing any vigorous activity did not cause this disease.

Find out more from this and other medical myths from Dr. Zero Mella’s book at Lulu Publishing here.

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Book Review: Diablo 3 The Book of Cain

Olongapo City, Philippines —The much anticipated release of the sequel to the Diablo PC game series gave me quite an excitement. As an avid fan for more than 10 years, I have been enjoying much of the literature Blizzard has been putting up the internet. The game’s storyline is solid. It transports you to a world of demons and angels and their eternal struggle. And you play a character in the middle of it. It’s a beautiful saga and finally I was able to piece it all together with this book:

Diablo III: Book of Cain

This is a wonderful read. It starts with the will of Deckard Cain addressed to his niece. It narrates the events even before Diablo I. It soughts to explain the questions left by two preceding games. The book starts with a narrative about Anu and the Dragon; how they were both destroyed in the initial conflict creating the universe as we know it. Anu’s remains became the Worldstone and the Dragon’s, the seven evils as we now know it. The seven evils are Diablo, Baal, Mephisto, Andariel, Duriel (this 5 are the ones we met in the previous 2 games), Belial, and Azmodan. The mention of the latter 2 is a premonition of what we could be expecting at the 3rd installment of the game.

The story continues to tell of the story of King Leoric and his sons Prince Albrecht and Aidan. This narrative is about the initial story of the game as the heroes proceed to venture into the catacombs to seek and slay Diablo, the Lord of Terror. Aidan, the hero of the story is possessed and becomes the Dark Wanderer in Diablo II. The story tells of the slaying of Andariel and Duriel, the two big foes met in Diablo II’s first stages of the game.

Details about the Zakarum, the Vizjerei Mages, the Horadrim and Tal Rasha explain the details behind the main storyline. The archangels, of whom we have only met Tyrael, were also discussed. He happens to be a part of the Council of Angiris at the High Heavens. He was instrumental in saving the human race when a vote came to the council as to the eradication of humans.

The book ends in the last parts of the Diablo II Exapansion storyline. This is where Tyrael destroys the corrupted Worldstone. It explodes and lays waste to the Deadlands of Mount Arreat. New civilizations were mentioned in the last part of the book which could be instrumental in Diablo 3’s storyline like Westmarch, Skovos Isles, Kehjistan and the Torajan Jungles. A new brand of mercenary was also mentioned and they were called demon hunters. Repetition of Azmodan and Belial’s important parts in the future were signs that they will be minor antagonist in the story. Diablo was told to have been banished in the abyss but since he is the main antagonist, we will expect the game to shift a deus ex machina to summon Diablo back into the mortal realm.

The book is available in hardcover by Insight Editions. The interior is filled with monochrome yellow images and penciled artwork from great artists. It looks like an oversize tome that came straight from the game. It’s a great add to fans of the Diablo game out there. Most of whom are already in the working class like me who would also like to pay for kick-ass items like these!

Buy it now from Amazon!

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Zero MD Recommends Elisha Collections!

Since its inception, I’ve been a part of Elisha Collections. Now, I am partly responsible fro spreading the word. I have only a basic understanding of IT but so far it pays to know even a little. It’s a fast paced world. Not keeping up is almost the same as financial suicide. Now I take helm as Elisha Collections’ social media manager. This is one of the hardest task ever. I’m a full-time rural health doctor, sidelining as an ER physician, a husband, father, and now this?? I must be crazy. But hey I am taking steps not to bury myself in work. Every now and then, I have 5 minutes of silence while I’m awake. Just kidding.

The idea is to find a way to work less and earn more. To be able to make that even a tiny bit feasible, you have to work hard. Stocks and Money market are not good for me right now because the market is full of greedy people overpricing the market. The best is to go into business. My wife and I started Elisha Collections actually out of curiosity. We couldn’t get products we like in the net to the Philippine market. We started to find out that the same raw materials in Quiapo, Marikina, and Pandacan are being sold in major Philippine branded clothing stores. They are just marketed differently and priced ridiculously. So we opted to find our own niche. And we found it by importing.

Elisha Collections is now the best distributor of China-made fashion jewelry in Olongapo City. We are now constantly supplying budding retail fashion stores. It’s one of the best things that the global recession taught most of us. It taught us to endure and have an optimistic entrepreneurial spirit. Most of those affected by this paradigm shift are women, including my wife of course. They feel empowered and that is what we provide as a vision for our company. To empower women entreprenuers by giving them a source of income, and a support system to maintain that income. With only 2 employees, my wife and I have to settle to sacrifice a lot with this goal in mind.

Our product line includes bags; fashion jewelry (cheap but of good quality and design) such as necklaces, bracelets, earrings and rings; clothing; belt, watches, and shoes! We have them all listed in! It features 10,000 items that are up for grabs. However due to increase demand, our suppliers find it hard to stock most of them. So you can expect a delay as we negotiate your orders with our suppliers.

As social media manager, I’ve started a new blog which will be our online fashion magazine. Aptly named: 

This will feature detail product previews of our products. Bloggers who like surfing picture blogs will definitely love them. We are currently processing articles regarding women’s health, exercise and nutrition to add to the blog. Nowadays, it’s very easy to be labeled a plagiarist. So I am trying to avoid that pitall. I’m currently editing and giving it second and third looks before giving it a thumbs up. I am also talking to a few local actors if they can give their views. We are doing a major upgrade of Elisha Collections in terms of social media marketing. And it is very hard with limited resources and time. Someday, I’ll be delegating all this to some department but since that department hasn’t existed yet… Well, I’m it.

We got Youtube, Facebook, Google Plus, Tumblr, Multiply, and Twitter. I don’t use as much exposure on myself though. Not yet anyway… wink wink. Elisha Collections will be my masterpiece, my soon to be crowning glory of  basic IT-ness. Amidst the polyphasic sleep patterns and a lot of carpal tunnel spasms from too much typing is probably glory on the other side. This company will define us one day. And I’m glad I’m in it from the beginning.

Watch out for many exciting changes in Elisha Collections! Even if you don’t purchase, spreading the word can help us a lot. I love you guys.

Why (we) Doctors don’t usually give out personal phone numbers: The dangers of mobile consulting

Olongapo City – Personal experience has taught me that giving out your personal numbers to patients is really a bit of a nuisance. Patients will try to seek consult for free by texting/emailing you and refusing to be seen at the clinic for further work-up. Other patients will text/email you symptoms that a companion has so that they too can sort of get a free consult. Most of the time, they get angered when I do not give them that priviledge especially when they text me at 3 in the morning. This is not because I want to charge a Professional Fee. Trust me, I usually give out clinic consults for free. I don’t give out consults online or via mobile because it’s dangerous.

Few months ago, an OB-GYNE was enjoying a meal with friends. She got a text from an unregistered number. The sender identified herself as her patient and that she is experiencing abdominal pain. The doctor is nowhere near her clinic and has (of course) no copy of the patient’s medical records nor any way to access it. She texted back instead, “TAKE BUSCOPAN 10mg/tab 3x a day.” She did as the doctor ordered. After 2 months, the OB-GYNE received a subpoena.

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The sender happens to be pregnant at the time and she was experiencing premature labor. Hyoscine (Buscopan) hastened the process and she delivered a premature baby, who died a few minutes later. She consulted another doctor (not me, promise!) who told a lot of things to incriminate the OB-GYNE. The court case is still ongoing.

Mobile consults are not something you will see in the future. It is happening now. For mobile consults to happen, a system must be set in place to prevent incidences like this. Higher charges should be imposed on mobile consults because the risks for malpractice are greater.

For now, I do give out my personal cellphone number but I do not give out consults via text or online methods. I simply request my patients to see me at the clinic or if the case is urgent, be seen at the emergency room. It is important to me that I see the patient personally before I prescribe a medication. The patient may be an old friend but every new symptom must be treated with a fresh eye. Complacency can kill patients.

If you are a patient (whether mine or somebody else’s), please bear in mind that we have every duty to put you first but you must understand that we need to see you, feel you, and hear you. We do not care about financial compensation. We do care about your safety. Please refrain from asking what is the best medicine for a certain ailment. We can answer you, but the answer may not be the best medication for you.

The art of medicine is the art of when to give and when not to give a certain medication.