Chronicles of Ellery Ivan MD

While researching on Diabetes and deaths related with it, I stumbled upon an updated resource on mortality in the Philippines. Great information worth sharing.

According to the Philippine Statistics Authority, the reported deaths in 2019 reached 620,414. This is an increase of 5.0 percent from the 590,709 registered deaths in 2018. This is equivalent to a crude death rate of 5.8, or about six (6) deaths per thousand population in 2019. This corresponds to an average of 1,700 deaths per day, which translates to 71 deaths per hour or one (1) death per minute in 2019. This report was released last January 5, 2021.

How does the Philippine Statistics Authority (PSA) obtain the data for processing?

Data on deaths presented in this release were obtained from the Certificates of Death (Municipal Form No. 103) that were registered at the Office of the City/Municipal Civil Registrars all throughout the country and forwarded to the Philippine Statistics Authority. Information presented includes registered deaths which occurred from January to December 2019. Cumulative figures for 2019 reflect updated data which excludes fetal deaths present in the processing of regular deaths and may differ from preliminary counts previously published. Fetal deaths as well as deaths of Filipinos that occurred abroad which were reported to the Philippine Foreign Service Posts are presented in a separate report.

What are the top 10 causes of deaths in the Philippines?

Source: https://psa.gov.ph/content/registered-deaths-philippines-2019

The above figure shows the ten leading causes of death in 2019. Among the total deaths, ischaemic heart diseases were the leading causes of death with 97,475 or 15.7 percent of the total registered deaths. Neoplasms, commonly known as “cancer”, were the second leading causes of death with 68,657 (11.1%), followed by cerebrovascular diseases also commonly known strokes with 63,548 (10.2%).

Some thoughts though, I assume that deaths due to myocardial infarction are clumped or group in the ischaemic heart diseases. Not all diagnosed ischaemic (ischemic) heart disease die upon diagnosis although this is a serious medical condition. It would also be interesting to find out the different cancers that make up the deaths under the neoplasm category. I also would like to know what conditions are classified under the chronic lower respiratory tract infections. Lastly, the classification of “other heart diseases” is also confusing. Maybe they also clamp together all other heart diseases not under ischemic heart disease. What could be the top 1 disease under the other heart diseases? Is it congenital heart disease or maybe cardiomyopathy or even pericarditis or maybe even something else?

How about the deaths for 2020?

We will probably know more later this year or early next year.

Reference:

https://psa.gov.ph/content/registered-deaths-philippines-2019

Day 14 of #100DaysToOffload. Find out more about it here.

A moment of relief was felt yesterday. It would mark the end of my presenting, at least for a while until my next one. I've been presenting since December 2020 for my grand rounds presentation and my inter-hospital presentation. I was supposed to present the census for the months of October and November 2020 but this was further moved to January 2021. Due to work-related scheduling problems, my presentation was further split into two parts, the census for the previous months and a presentation on the mortality report. It was very taxing but nevertheless it afforded me more time to prepare my presentation.

What a welcomed relief! This one is for the books … just another chapter in the chronicles of residency.

Day 13 of #100DaysToOffload. Find out more about it here.

Ascites is a common complication of chronic liver diseases and is related to the extent of portal hypertension.

Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. Ascitic fluid may be used to help determine the etiology of ascites, as well as to evaluate for infection or presence of cancer.

I had little knowledge of the procedure prior to my residency. During my internship days at the Zamboanga City Medical Center, I was not able to observe the said procedure. I only have the faintest academic idea of what it was and its purpose.

Thankfully, the through the patience and dedication of my consultant, I was able to do the procedure through his proper guidance. I also had to read up on the procedure to familiar myself with the procedure. There are a lot of literature available in the internet to gain proper knowledge, however since paracentesis is a skill we also need experiential knowledge.

As a resident I learned about the purpose of SAAG. The serum-ascites albumin gradient or gap is a calculation used in medicine to help determine the cause of ascites. A simple calculation that can help determine what caused the ascites, subtracting the albumin concentration of ascitic fluid from the albumin concentration of serum obtained on the same day.

Below is the algorithm that I came across in my readings.

A SAAG of >1.1 g/dL is 97% accurate in detecting portal hypertension.

In the future, I should order the serum albumin at almost the same time the procedure is done. Moreover, I should be able to order the materials needed for the procedure more efficiently without consulting the ever trusty IM platinum often.

The procedure may be the first of many in my residency training and I should develop the habit and the skill in doing this simple yet important procedure for my future patients.

Day 12 of #100DaysToOffload. Find out more about it here.

I'm not going to pretend that I understand the complexities of molecular bioengineering. But here's a great summary that delivers great information on the vaccine.

Accessed: December 27, 2020 in https://www.bbc.com/news/health-55040635.

Thank you BBC news.

Day 11 of #100DaysToOffload. Find out more about it here.

Imagine you are a healthcare worker. Imagine further that we are in a pandemic.

What mindset should he or she have?

Wouldn't it or shouldn't it be the interest of all, the interest of the most?

I'd like to discuss on two commonly used principles in medical ethics. The principle of Beneficence and Non-Maleficence. All healthcare providers must strive to improve their patient’s health and avoid in every situation causing harm to their patients. In basic terms, it means to do good and do no harm. Simple to say but never easy to execute in health care because there can be gray areas.

Today, I learned that a medical practitioner who reported for duty, for work, not feeling too good and under the weather, was tested positive for SARS-COV2. Certainly, I can commiserate with his/her predicament. No one wants to be tested positive. There is not one health worker who wants to be positive.

And then, there's the rub.

A medical practitioner, deemed a front-liner, deemed the most knowledgeable and expert in the science of the transmission and infectiousness of SARS-COV2 decided to go to work. In doing so, inevitably exposing other members of the healthcare team and will be compounded when each member goes home to their family and love ones.

The end.

---

Some key lessons learned:

1. Protect yourself always. When you let your guard down, that's the time when you will be reminded of Murphy's law. 2. Trust no one. Even your family, loved ones and friends. It is your inner circle that has the highest probability of infecting you more than a random stranger in a grocery store. 3. Worrying over being infected is stressful.

Day 10 of #100DaysToOffload. Find out more about it here.

Day 2 of the 50th Philippine College of Physicians Virtual Annual Convention.

Today, I learned about the Declaration of Geneva. No, the declaration and the Geneva Conventions are not the same. The former document is not about the humane treatment of prisoners of war and the humanitarian conduct during armed conflicts. This is another document and it is a modern form of the Hippocratic Oath. The Declaration of Geneva is one of the World Medical Association’s (WMA) oldest policies adopted by the 2nd General Assembly in Geneva in 1947. Currently, it is on its 7th version and was amended last 2017.

There was a line that was purposely pointed out during the PCP Annual Convention. It states:

“I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;”

People tend to forget that health practitioners and medical professionals are people that can get tired and stressed out. But what I realized more is that, it is also incumbent upon the health care worker to attend to his personal needs. This exact line was also missing from the previous iterations of the document. It most probably reflects on the attitude of the health professionals as well.

Don't quit. Rest if we must. For if we are in our best state, we are able to help treat and/or cure the patient.

Do you want to read the complete WMA Declaration of Geneva? You can find it here.

Day 9 of #100DaysToOffload. Find out more about it here.

A little over a year ago, while I was doing my usual rounds in the hospital, a surgical consultant approached me and asked why I was wearing a facemask while I was in the ward. He even remarked that I looked silly and that instead I looked like I was harboring a respiratory infection with my facemask on.

I smiled and answered, I wear these masks so that I protect myself and my patients from the possibility of respiratory infections. He laughed rather heartily. Like I was such a joke.

I remember this incident because I saw him a few days ago. He was with his facemask and heavy duty faceshield. I'm sure he does not recall me or that conversation with him. This time, I thought to myself, “Where is your machismo now? I thought we don't have to protect ourselves from possible infections.”

Day 8 of #100DaysToOffload. Find out more about it here.

How can a consultant (boss) bully a resident in training?

There are probably a number of ways to bully a resident in training. But I think the brilliant once disguised themselves in “learning atmospheres”. Ahh, yes, the ones were you (the resident) is asked to present a case with less than 24 hours to prepare. It makes you feel that the objective really is to deprive you of valuable resource – sleeping time. Time that is scarce in the profession of medicine. She was probably having her bad hair days.

If the objective is truly a learning experience, then ample preparation should be given to the learner.

But what can a resident do, but to shut up and do or comply with what she asked. This way the problem goes away and hopefully her mood improves. Every resident must cope up and survive. Hoping for better days then...

P.S.

I was able to comply with her “request”. But I just need to vent for sanity's sake.

Day 7 of #100DaysToOffload. Find out more about it here.

Yesterday, one of my consultants asked a question about sensitivity and specificity, “Mathematically, how can you illustrate or formulate and explain sensitivity and specificity?”.

This is also in principle connected with a previous post about diagnostic tests on covid. But in this write-up, we will delve more into how a clinician puts weight or value on diagnostic tests.

Day 6 of #100DaysToOffload. Find out more about it here.

Currently, no SARS-COV2 test gives a 100% accurate result. Ideally, these tests need to be evaluated to determine their sensitivity and specificity, by comparison with a “gold standard.” The absence of a gold standard for the disease makes the evaluation of test accuracy challenging.

Diagnostic tests (typically involving a nasopharyngeal swab) can be inaccurate in two ways. A false positive result erroneously labels a person infected, with consequences including unnecessary quarantine and contact tracing. False negative results are more consequential, because infected persons — who might be asymptomatic — may not be isolated and can infect others. [1]

Previously, test availability has been a concern here in the Philippines especially on RT-PCR, but test accuracy may prove a larger long-term problem. Another concern is the high number of rapid IgM IgG test available in the market yet it's sensitivity and specificity of COVID-19 remains problematic.

Interpreting the result of a test for COVID-19 depends on two things: the accuracy of the test, and the pre-test probability or estimated risk of disease before testing. [2]

To understand accuracy of the exam, concepts on sensitivity and specificity must be first understood. Sensitivity is the proportion of patients with disease who have a positive test, or the true positive rate. Specificity is the proportion of patients without disease who have a negative test, or true negative rate. These terms describe the operating characteristics of a test and can be used to gauge the credibility of a test result.[2]

Two studies from Wuhan, China, arouse concern about false negative RT-PCR tests in patients with apparent Covid-19 illness. The studies suggest that 70% is probably a reasonable estimate for sensitivity of the nasal swab of RT-PCR. At this sensitivity level, with a pretest probability of 50%, the post-test probability with a negative test would be 23% — far too high to safely assume someone is uninfected. [2]

In summary, a positive RT-PCR test for covid-19 test has more weight than a negative test because of the test’s high specificity but moderate sensitivity. A single negative covid-19 test should not be used as a rule-out in patients with strongly suggestive symptoms. What this highlights is that we are still on our infancy stage in detecting SARS-COV2 and diagnosing COVID-19.

In a perfect world, designing a reference standard for measuring the sensitivity of SARS-CoV-2 tests in asymptomatic people is optimal. Simply following people for the subsequent development of symptoms may be inadequate, tiresome and dangerous as they may remain asymptomatic yet be infectious.

References:

[1] Watson Jessica, Whiting Penny F, Brush John E. Interpreting a covid-19 test result. https://www.bmj.com/content/369/bmj.m1808.long

[2] Steven Woloshin, Neeraj Patel, Aaron S Kesselheim. False Negative Tests for SARS-CoV-2 Infection — Challenges and Implications. https://www.nejm.org/doi/abs/10.1056/NEJMp2015897

Day 5 of #100DaysToOffload. Find out more about it here.