Ouch

So today i had my first PT session.  It overall wasn't too bad, mostly a lot of information-gathering on the therapist's part with some exercises thrown in for good measure.  The worst part was when "massaged" my left calf using a treatment called Astym.

That treatment is borderline horrendous - at least for me.  It essentially consists of mashing plastic implements deep enough into your skin to hit whatever's underneath, and then pushing said plastic implements along the direction of the muscle fibers.  As explained to me, the underlying principle is to stimulate the body's inflammatory response, hopefully promoting healing of the deeper tissues.

As far as stimulating an inflammatory response, i can attest to it somewhat because at times it truly felt like my leg was on fire.  I half-expected to find my calf skinned, raw, and bleeding at the end of the session.  Surprisingly, my Achilles was fine - it was every other nerve ending that was screaming out in pain.

Hopefully it gets better and i don't feel like i'm getting flayed the next time.  And even if i do - i'm willing to tough it out if the end justifies the means.  My therapist seems optimistic though, and thinks he can get me to finish a turkey trot next month.  We'll see.

The Source

In all honesty, things have not been right since the marathon.  Little aches and pains have been popping up here and there with annoying regularity.  But the worst has been my left Achilles tendon.  It first hit me in May, a little before the Riverbank Run.  Since then i've tried NSAIDs, ice, and prolonged (up to two weeks) rest, all to no avail.  Two weeks ago i finally relented and went back to see the Orthopedic surgeon.  He set me up for an MRI, and finally found Achilles tendinosis.

Not being an orthopod myself, i had to go look it up (do not click this link if you're squeamish, as it contains pictures of someone's ankle being dissected).  Apparently it's a chronic condition associated with gradual degeneration of the Achilles tendon, resulting from microtears related to overuse.  

It's more than a little disappointing to me, as i've previously speculated that i may just not be built for the activity that i've come to love - running.  Well, at least i don't have to have surgery (yet)... for now i'll be going to physical therapy, hopefully to rehab the injury away and get me back up and running (pun intended).  Maybe, just maybe - i'll be able to do the 25k in the spring before we move to Pittsburgh.  I'm keeping my fingers crossed. 

Awesome (C. Diff, Part 2 of 2)

The "alternative treatment" is actually fairly simple and one that homeopaths would probably appreciate.

Since the problem is caused by a dearth of normal gut flora (bacteria), the solution would naturally be to re-populate the colon with good germs.  And where else to get the good germs that normally reside in your colon but... in somebody else's healthy feces.

The procedure is as follows*: take a little over an ounce of a healthy person's poop (about half the size of a large Snickers bar), mix with two ounces of normal saline, and blend on high until nice and smooth.  Run the mixture through a coffee filter twice, and administer the elixir through a nasogastric tube (i've heard of it instilled via colonsocopy as well).  The recipient must have prepped beforehand with a few days worth of vancomycin and a few doses of omeprazole (very important steps, as you don't want to have to do it again because you forgot to prep the poor patient!).

I've never had the privilege of doing this procedure, but i believe some of the Infectious Disease doctors in our institution have had success with it.  Due to the "ick" factor, it's often a treatment of last resort - prior to calling a surgeon and taking the whole diseased colon out.

This is extremely is fascinating to me, as it illustrates important dichotomies in medicine: antibiotics, powerful drugs that can save lives, can also cause horrible disease and death.  And feces, shunned as disgusting and a vector of disease, can actually promote health and life.  Truly, in many things, there are both awful and awesome sides that need to be respected and understood.

Anyway, the mere mention of Snickers has made me hungry enough for a snack...

After a hard day's work of curing disease and saving lives, one has to unwind with a nice snack.

Mmmm, Snickers (a full two ounces worth).

Chocolate milk to wash it down.  

Got milk? 

*Source: Aas, et al. Recurrent Clostridium difficile Colitis: Case Series Involving 18 Patients Treated with Donor Stool Administered via a Nasogastric Tube. Clin Infect Dis. (2003) 36 (5):580-585.  Link to the article.

Awful (C. Diff, Part 1 of 2)

Antibiotics are not harmless.  

This may come as a shock to some people.  After all, antibiotics kill germs, and germs cause disease. So what's wrong with that?  

A lot, actually.  

For one, the antibiotic you're given may not kill all of your bad germs.  The ones that are left can develop drug resistance (essentially, immunity to the antibiotic) and/or cause an even nastier infection.  

One of the bad infections i've come across is from an organism called Clostridium difficile, which is somewhat affectionately referred to as "C. Diff."  In short, if you've used antibiotics recently and have killed enough good germs in your gut, C. Diff can gleefully step in, take over your colon, and obliterate it.  

One of the hallmark symptoms is diarrhea.  Not just in the soft-and-could-use-a-little-more-bulk-poop kind of way, but in the belly-hurting, toe-curling, run-to-the-bathroom, explosive-and-sometimes-bloody kind of way.  Imagine doing that once after an ill-advised trip to the Chinese buffet.  Then imagine doing it fifteen times in one night.  See what i mean by "obliterate?"  

(Interestingly, when i was in the RP, C. Diff struck me as kind of a semi-mythical beast, like PE (pulmonary embolism), which was only typically talked about in CPCs (clinico-pathologic conferences).  Or maybe i just wasn't exposed enough.)  

Left unchecked, this type of infection can kill not just your social life, but YOU.  So it's always important to talk to your healthcare provider about whether or not antibiotics are really needed for your current illness, or if you can fix it with just rest and fluids.  It's not advisable to press him or her for them "just in case it helps."  

Thankfully, there is a treatment for C. Diff, if not a guaranteed cure.  But ironically, it mostly consists of... more antibiotics.  If however this treatment didn't work (or if you just flat-out refused to take any more antibiotics - which i'm certainly not advocating, since they do have their place), there is another way that is near and dear to my heart.  

TO BE CONCLUDED

A Big Milk Letdown

Although i'm not a fan of sweets, one of the things i absolutely cannot resist is good pastillas de leche (literally - "pills of milk").  Done well, it can be exceptionally rewarding: a delicate interplay of creaminess and sweetness one one's tongue that can bring tears to anyone's eyes.  I recently had the privilege of tasting such divine creations at a friend's birthday party (i literally gorged myself on the wonderful stuff), but i digress.

During this year's annual trip to the Philippines, while deciding what pasalubong (homecoming gifts) to bring people back to the US, we happened upon a stall in Greenhills selling local "delicacies."  Among its stock were boxes of pastillas de leche, just begging to be bought in bulk and carted off overseas.  It looked more than decent, with a tasteful picture on the outside showing off the candy in all its glory.  So we bought a box to sample...

And were underwhelmed.   

Don't get me wrong - it tasted just as wonderful as i expected it to, but all the milk and sugar in the world can't make up for the bad taste in the mouth caused by deceptive packaging.  

The piece of candy on the lower right hand corner (did you miss it?) is the ACTUAL SIZE!
Don't buy from these dishonest A-holes!

Oh well, at least it only cost me PhP70.  But despite my disappointment, i'm still better off than this little girl: 

There should be a law against this sort of thing... or if there already is, they should enforce it better.  

Bad Memories

PREFACE: Early last month i received an email from the Educational Commission for Foreign Medical Graduates (ECFMG) soliciting narrative contributions for their Acculturation Program.  As a self-identified victim of a "clash of cultures" early on, i thought my input might be valuable.  I banged this piece out this afternoon and immediately sent it in.  I don't know if it'll actually be accepted (i'm suspicious that it won't - it's mostly storytelling with little in the way of advice), but i thought i'd post it here anyway.

-------------

“Lost” is an understatement for the way I felt during my first month of Internship. 

Having come into the US only a week before, I was quite literally a stranger in a strange land.  True, I was already a practicing GP in the Philippines, spoke English fairly well, and had been in the US twice before (for my CSA and Residency interviews), but the shock of starting on my floor rotation with just a half-day orientation was like being thrown into the deep end of the pool with a guidebook on swimming tossed in as an afterthought. 

It wasn’t the Medicine itself that was the issue – but rather everything else.  My previous exposure had only been to third-world medicine: unquestioning allegiance to consultants (even when wrong), minimal charting, no EMR, TB as a differential for everything, diagnostic studies not done due to expense, suboptimal therapy given for financial considerations, and NO DISCUSSION OF CODE STATUS.  But here, everything was evidence-based, no stone was left unturned, money was almost inconsequential, and code status was always, ALWAYS addressed on admission. 

Unfortunately, my senior Resident – who I looked up to as God, was no help.  Queried about the basics, such as “Why are all these people on subcutaneous heparin?” he would look at me disgustedly and say “Just do it!”  Between my sheer bewilderment and lack of strong supervision, I consider it a minor miracle that I didn’t kill anyone. 

And that was just in the hospital.  After work, I still had to stress over getting my social security number, fixing my immigration papers (my DS-2019 had mysteriously vanished), stocking my apartment, and buying a car – with only a barely-functional social support system, as my blushing bride was on the other side of the globe working on her own immigration stuff and my closest relative lived four hours away.  Getting around was in itself a challenge; I didn't know how to get anywhere and didn't even understand how to get through a four-way stop.  

Thankfully, it all worked out in the end.  With time and voracious reading, my knowledge bubbled to the surface and my synapses made the connection between third- and first-world (read: uninhibited by poverty) medicine.  I got my social security card.  USCIS issued a new DS-2019.  I bought a “new” used car.  Before the end of the month, my wife arrived and made me whole again.  And then we went shopping and stocked the apartment. 

Although I never considered self-mutilation, there were times that month that I felt my mind teetering dangerously close to depression.  Whenever that happened, I just doubled-down and worked harder – another legacy of third-world medicine.  But I wonder how much of my stress could have been alleviated by a simple helping hand. 

I’m happy to report that in the seven years since I arrived in the US, our Residency program has made a better effort to reach out to new Interns, reducing their workload and assigning “guardian angels” to help out in their first week.  There is now also a longer orientation.  Because of my own experience, I try to be more attuned to the Interns’ stress levels and try to actively mentor them early on.  I hope other programs out there also appreciate how starting Residency can radically change an IMG's entire world, and show appropriate understanding and sensitivity.  

Hello to Buyer's Remorse

Many moons ago, i talked about the PS3 being money well-spent.  It's taken me almost a year, but i realize now that it is in actuality a "poison pill."

My problem is that the damned machine does its job too well.  It truly does everything, which translates into a huge time-suck away from active productive pursuits (e.g. blogging) into passive consumption of entertainment (e.g. Netlifx, BD, and games).  I blamed my mental constipation (read: lack of interest in blogging) solely on the "great weight" that was my fellowship application, completely ignoring the fact that my creative juices had almost completely dried up from playing God of War, watching back episodes of No Reservations, and enjoying masterpieces like The Human Centipede (First Sequence).  It's not the machine's fault, of course; the predicament is my own doing.

Bah, never again.  Now that i've identified the problem, i can direct my attention to it (or, in this particular circumstance, AWAY from it).

Enema administered, let the diarrhea begin.

Silently it waits, with the single red light staring at me like the unblinking Eye of Sauron.