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Full interview Medical Journal: Chapter II

Well, this is the second and final installment of the answers to the questionnaire used for the interview published in the Medical Journal on 25 April.

How often do you update your blog?

I have no specific deadline I write as issues arise, some are current, others are part of the manual residents, or really the antimanual because treatment issues are not in any standard manual

I've also started two new chapters of entries: clinical cases power-point attempt in which to disseminate knowledge about surgery, and photos history is a section for the memory of some patients who have had powerful stories and also a new experience trying to humanize the image of surgery, usually perceived as unpleasant.

- Is it possible to know the number active fan having your blog?

E l number of followers is hard to know because many people read but is not a follower, so if you know the number of visits and which pages are the sources through which is traffic. Since I began to count the visits in April 2010 to 25000 pages were viewed approximately and received 140 comments and as many messages and queries. Keywords used were surgery, patient, MIR, surgeon, medical. Most traffic comes from blogspot , Directorioplus, wordpress, networkeblogs facebook and twitter (@ fjaviherrera).

most visited entries have been, you can see them in the right column, "popular entries

Choosing the wrong specialty ambulatory surgery.

health Hyperspace

medical Guards: a "slavery" of our time

My recipes to choose from the MIR space

The worst call of my life

For medical students and new MIR

MIR exam answers 2010 general surgery (complete)

- What is your specialty? What age?

was born and studied medicine at the Medical Faculty of the UPV in Bilbao I have 52 years and 28 professional. I'm the surgeon general and digestive system, I did the residency at the Hospital Puerta de Hierro in Madrid (1983-88) and work in liver transplantation to 93, since then I have worked in the Hospital de Navarra in Pamplona, \u200b\u200bI am currently Head of Hepatobiliopancreatic Surgery Unit of the Hospital de Navarra. My career has focused on Hepatobiliopancreatic Surgery and Oncology, did the thesis in 1988 at the end of the residence on liver transplantation.

Why did you become a doctor?

chose to be a physician and surgeon since childhood, I have no idea why, I had no family history, perhaps the number of doctor Ganon (Medical Center) marked me XD.

I do not regret the surgery is a very important part of my life and my passion but I never thought I would have to exercise a monopoly in the public health enterprise. In short I like what I do but not where I have to do-I mean the current public health-and what I do I can not do anywhere else.

have you thought about working abroad?

I have not raised to go abroad for family reasons.

for you What are the defects and virtues of the Public Health System?

major shortcomings from my point of view are:

absence -based career is done, as is done and how. Perhaps the one size fits all policy is the most destructive of the company.

-absence of incentives for innovation and quality at work but otherwise is preached.

-absence of clear objectives of the company off the lists waiting and numbers.

instruments, lack of teamwork.

-political leadership, unprofessional management, lack of clinical management.

purely assistance-Objectives teaching and research remain upset and "productivity."

Virtues:

-as a citizen I believe that health care coverage and are a great social achievement as indicated by the parameters public health.

-public health specialists is good but then mistreated.

Obviously I have no solution for these problems but some steps are:

-generalize the clinical management of multidisciplinary units targeted to address specific problems. Recognize the teams end up with the constant changes of personnel.

-procurement system and pay much more flexible.

-mobility, the fragmentation of regional ministries of health have ended with mobility. Premium in the oppositions are locals only 1 of every 10 seats out to regional transport. If you leave your community to internal, as I did, go back home is impossible or requires a long journey.

-integrate teaching and clinical research in everyday work. It is painful to the low scientific level of some services and how proud we are their managers because they have no waiting list.

-implanted quality programs led by doctors. If the politicians only care about the quality perceived by the patient, they call it customer, and where is the scientific-technical quality?. A patient with a good deal and a pat on the back is left happy but may not have done the right thing.

- provide digital tools including social networks to improve internal communication with patients. Hospitals are a breeding ground for gossip, jokes, gossip or slander: lack visibility, communication and plenty of gossip.

-participate in the design of strategic plans investment and health. The doctors are not consulted to design the health strategy, a seudogerentes the design and some have never seen a patient, that explains the medical-management disagreement.

-have a trade union dialogue own doctors and recruitment conditions specific to each job with productivity linked to results. In many communities and in Navarra our labor issues are negotiated at a table in the health sector that are numerically minority groups-all health of hospital doctors is the smallest.

What is the level of surgery in Spain?

The level of surgery is generally good but not consistent in all hospitals and autonomy. Reference should be improved to expert teams in cases of low frequency and high complexity. Complicating autonomy. Mobility should be improved to enhance learning and reduce the number of MIR to improve the quality of their training. It is difficult to maintain a system which makes more money with simple procedures in private practice with highly complex surgery that is done in public. The younger generations learn that the effort is not rewarded.

improvement of anesthetic and surgical technique has eliminated the contraindications for age and reduced comorbidity related, I've always been concerned about the sense of proportion when making a surgical indication transmit it to future generations. View the blog entries: common sense applied to medicine, less is more , primum non nocere .

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As a family facing troubled

Unfortunately it is increasingly common, especially resident, having to deal with patients' relatives conflict, assertive, rude, intrusive, violent, threatening or simply "tocapelotas" - or its female equivalent. To be sure, with most patients the treatment was correct but the situation is far from idyllic.

As in other aspects of this manual nobody tells you how to take on one aspect of our work that produces more frustration and impotence, making the brown to talk to a family conflict when the problem is company or other service or other medical or health: I feel that day has touched you.

Well the issue, try to tell you what I have learned based on years of conversations of this type. The most common scenarios are: emergency department, called the plant at night, go to visit the weekend or holiday. We're going to mess ...

Area emergency by far is where the resident is more exposed to the wrath family. The resident is vulnerable because he is alone, it looks like a girl and if it is woman, and as such, is considered by some men as a perfect target. How to avoid unpleasant situations, easy! prevention.

emergency preventive measures : prevents the examination room between more than one family, do not say never with a crowd, do not talk in the aisles with people around, if the patient is very complex for help before you speak, although the case-DESIGNED do not get caught in non-, do not talk of what could be and was not, no des explanations of care from physicians, non-judgmental about the actions of other professionals-remítelos to them for clarification, "in short, do not get in a garden or try to convince them, our job is to inform.

steer the conversation As : only two family members identified "best of the first order, friends or brothers etc ... are often the most impertinent", identify (name, specialty, year of residence), it is best to wear gown, avoid embarrassing mistakes, "the conversation should be short and clear.

never be heated, or raise his voice, or argue, or attempt to convince them they are wrong. Your mission is to inform with clarity and honesty, not convince them to have made things right, or justify what is wrong. If there has been some error or delay by poor organization first to disable the just anger of the family is apologize.

If you have completed all these steps the family insists on blaming, yelling, insults or put edge or irrelevant, it is best to terminate the conversation and leave, not without comment that when subside return to resume the conversation. If the second attempt can not take a polite conversation tell them to talk with them attached and terminates the conversation.

Night Calls : in these cases is added the night shift that alters patients, families and nurses. In this case the key is to see the patient before obtaining the maximum information from the story and nurses. If a chronic patient and the call is in despair, insomnia, fatigue for prolonged hospital stay, anxiety, the key is to quiet conversation with family members-usually relieve the pain and anxiety (see entry as attending a night-call guard). Never argue or issues of medical treatment, are those who know you best, if the patient is severe call your assistant, what are their complex patients negotiated.

visit passes weekends and holidays is typical that the family will spend the morning at the hospital Sunday or holiday. This situation, which everyone considers normal can have serious consequences for the doctor to check you have to swallow, usually after 24 hours. The fundamental cause is that the family has much time and want A summary of the patient's progress, and you just want to leave as soon as possible to your home. Also usually go the "smart guy" of the family who has read anything on the Internet or have a friend or seen any health television program that will magically become an expert. (See entry for enteraooos )

The weekend pass is to visit patients and see if there is any change to no diagnosis replated or making important decisions, except the patient has complications and required. These decisions are better than their doctors to take responsibility, guard making decisions about acute problems.

The family must inform in a concise and if you want further explanation refer to their physicians. never make summaries of developments or future decisions without consultation.

Chicken Pox Just On Limbs

New video section full interview

I could not resist putting the videos we've been recording over the years in our unit as we are dedicated to liver surgery, biliary and pancreatic will be the first video of a liver resection a bit special because it divides the liver into two parts left open like a book.

If anyone wants to share videos of surgery and has a platform to do so can upload to YouTube and send me the link or embed code and I will hang in the video section

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surgery Medical Journal: Chapter I

As you can understand the medical journal article is a summary of everything I wrote for the interview and as a review that serves to identify the reasons creation of its sections, and short stories, I have devoted publish it if anyone is interested. The responses to the questionnaire that I sent in two innings publish them not to become too heavy.

Since when have the Blog?

started in late 2009 but really until June 2010 I announced not in social networks because I was not sure if I would have continuity and follow-up.

Why did you decide to create it?

Had long been thinking of writing on topics related to surgery that is never spoken and which had been pondering for many years, read a blog to encourage me to try. I did not want a blog on surgical technique, and on innovations or even media issues related to surgery: transplantation, obesity surgery etc ... I wanted to mention that I see daily in hospitals: problems to work well, the emotional burden the bad news and always live surrounded by sickness and pain.
But my intention was to focus all of this from the standpoint of the surgeon, but has much in common with other hospital specialties, I wanted to reflect the complexity of our work, the implications of our decisions on the health of our patients, the loneliness you feel when you are the one you have to decide, you get no support from the company the silence that you take towards your teammates, the waning feedback you receive from patients, the feeling that you are alone with the danger and also have not mastered the craft. Noon , good surgical indication .

Another issue that I have developed several entries is to explain how it is defined, as constructed, what are the qualities required of a surgeon, is sum: "what a surgeon is? , surgery for the classic view , surgery a more realistic and less idyllic . As it relates to guards, to stress the conditions of work is at the entrance: : medical guards slavery of our time , the sick doctor , stress and surgeons.

How often do you update your blog?

write a term I have no issues arise as me, some are current, others are part of the handbook for residents, or really the antimanual because treatment issues that are not in any standard manual.

I've also started two new chapters of entries: clinical cases in power-point attempt in which release knowledge of surgery, and photos with history that is a section to the memory of some patients who have had powerful stories and also a new experience trying to humanize the image of surgery, usually perceived as unpleasant.

Is it possible to know the number of active supporters having your blog?

The number of followers is hard to know because many people read but is not a follower, so if you know the number of visits and which pages are the sources through the which is traffic. Since I began to count the visits in April 2010 have been viewed 22,800 pages, approximately, and I received 130 comments and so many messages and queries. Keywords used were: surgery, patient, MIR, surgeon, medical. Most of the traffic comes from blogspot, directorioplus, wordpress, networkeblogs facebook and twitter (@ fjaviherrera).

most visited entries have been, you can see them in the right column, "

popular entries - Choosing the wrong specialty ambulatory surgery .

- health Hyperspace

- The medical guards: a "slavery" of our time

- My recipes to choose from the MIR space

- The worst call of my life

- For medical students and new hope

MIR that you have used to learn a little more this blog, as always I hope your comments and suggestions to porder BETTER.

Straight Shotocon Mangas

Interview Medical Journal

Alicia Serrano A few days ago I did an interview for the Medical Journal (25-4-2011), I have come to know because it was an interview type written questionnaire but the talks were very cordial. Worst of all was having to pose for the photographer and looking at the photo chosen prefer not to see the rest. What surprised me was that I chose to me considering that there are at least 300 health posts in Spain, the response was that there were few surgeons and created my own opinion. Regarding the first statement is true in general and digestive surgery blogs I can find are those of July Mayol and mine, before starting to write my blog had not looked, do not count those who make propaganda of hospitals or clinics. If someone let me apologize and hope to receive your address.

For the second statement is not my intention to influence opinion in the style of famous gurus or lecturers who have elaborate recipes for all problems, I just want to tell you what worries me about our profession and I have ever heard at any meeting of surgeons. I am also concerned the training of medical students who study "miricina" the new realities facing residents health and without any training other than theoretical and come to our profession in the public health system.

For those who ye curious can read the interview in the Medical Journal or PDF formats - page: 20 -

In the next post I will present the full text of the interview more than anything because it clarifies some of the assertions of the article.

Finally thank you very much to the 625 who visited the blog yesterday, it gives energy to keep

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Parrot Chocolate

In times of cuts and health care has become fashionable to save issue as soon not matter, it appears that healthcare managers and policy makers on duty had not been the subject of saving on your magic-management courses at I say it becomes a simple medical x hours in a manager who gives up his essence. Today I read an interesting summary of the week blog health things input Emilienko on savings on health and I have come forward to participate in the prize paper airplane to the toilet more austere .

Title comes to mind that all cost-saving measures have met in the hospital were based on personal discomfort for the rebound effect, ie it is a contest in which you choose a very cheap surgical mask that had been assessed with a low score. As you begin to use it proves to irritation in the face; result needs to be replaced by another, that being out of competition is much more expensive. This can extend to gloves, suture material, ect ...

But one of the sites where you can save more money, oddly enough, is in the query area . It is not unusual for a patient have to go to consultation with 4 or more specialists and each order your own explorations, some of them very expensive and a little more performance. Example: a patient who underwent colon cancer requiring adjuvant chemotherapy, developed liver metastases and should be operated again. At least it will be seen by: medical oncologists, colorectal surgeons, liver surgeons and gastroenterologists for follow-up colonoscopy. Result: Reviews and multiply quadruple scans. Please note that in digestive tumors systematic reviews address the symptoms only demonstrated survival benefit in the colon.

Another issue is to review patients in the consultation by their health status or your inability will not be candidates for active treatment despite showing a tumor relapse. It is sad that an octogenarian in a wheelchair go to the query, taken from his home by ambulance, to offer you the inconvenience of travel and any return to health, do not forget that being treated by his primary care physician.

My proposal to save is to agree with management a pathology review program and conduct a coordinated multidisciplinary consultation nursing. The savings would be consultations and examinations such as the parrot chocolate. As this is quite complicated for the prize ....

My proposal to qualify for the paper airplane in the hospital is to centralize information for analytical review results and exploration, by phone or e-mai, l which Whereas it may appear this way. The savings would not only be of consultations and only hours of work permits given to attend the consultation.

not forget that for long-term savings are usually to invest!

Is Heather Brooke Married

Snowflakes and Mexico destination

Yesterday was talking to a good friend about the consequences of our actions and the constant care that is not going to be that the "Karma" will be displayed for payment in accordance with the planted crop. Somehow
touch the subject of the ultimate goal, to that for which we are preparing, for the purpose of life, and I remembered the snowflakes. Why
snowflakes? Ever heard that there are no two snowflakes are identical, and from what I've seen, their structures are symmetrical and beautifully drawn. The most romantic
think that God takes to draw or design them as manifestation of the complex within the imperceptible. The beauty of the details minimum.
But besides being able to contemplate the ephemeral designs of snowflakes, what else is there?
I remembered how to develop our lives as a tangle of details aimed at perfection or a lofty goal.
I personally do not believe in predetermined destiny and I can not explain the similarities or coincidences.
Maybe our lives are like snowflakes, complex, structured, casual, beautiful, sometimes referred to and the most ignored.

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Photos with history, memories that blur the look. Primum non nocere

This new entry photos history is especially hard for me because it brings memories away in time but close the heart. It was a fellow patient who was working at a health center near our hospital. As a result of weight loss and continuous epigastric pain an ultrasound was requested. The finding of a pancreatic mass triggered a study that ended in the operating room and tragedy for the patient, had a pancreatic neuroendocrine tumor occupying the entire gland also invaded the stomach and duodenum in a transmural.

The only surgical solution was the total pancreaticoduodenectomy and total gastrectomy with splenectomy.

first photos intervention

The patient had not complied 40 years and had already passed a traffic accident and viral encephalitis. As a doctor he knew the irreversible consequences that this operation entailed: diabetes difficult to control, severe nutritional problems and a life completely controlled regime, accepted the intervention and was performed without complications. He had the courage and strength to recover and return to work, was a dedicated and devoted care to their patients.

When everything seemed to go well in life and after 42 months of the first intervention, in a routine liver metastases were found 3 that were close to 2 of the 3 hepatic veins. He suggested that the best treatment was the resection but the liver due to nutritional disturbances had undergone degeneration fat with normal liver function that concerned us. Two days before the date of the timing of the surgery came to the emergency department with acute abdominal pain requiring morphine for pain control. Required an emergency intervention was found in the intestinal infarction of venous origin as a result of an internal hernia affecting the entire small intestine. Reduction was chosen, aspiration of intestinal contents and open abdomen. At 6 hours relaparotomy. Fortunately there was a recovery and did not require resection, at 14 days was discharged to be operated on the liver. Once recovered and past 2 months design a conservation strategy parenchyma resection with resection of segment VII and segments II-III and IVA retaining the right and middle hepatic vein.

The initial post was normal but developed an infection of the bed of resection required two reoperations without our being able to control, develop multiple complications and dying after a month and a half died. At all times he was able to convey their desire to live and we encouraged us to continue trying to cure fig. I still remember after more than 5 years my last conversation with her, which sent me your tired in the struggle to live but never lost the will to fight or be resigned, even encouraged us because he saw that we suffered for not being able to master the complications. Only I have the consolation that we offered 3 ½ years of life she intensely enjoyed despite its limitations, yes I have left in the memory.

liver surgery photos

Spider Womens Viginia

This aphorism is one of the keys to proceed doctor, or rather should be. Do not know why today I have come to the head, but if this has been the cause of that type on this issue highly topical hackneyed and inconclusive.

When I wrote the entry: "less is more" , and introduced some of the issues as I am more "veteran" on my list: Where has been the sense of As in medicine today. I would like to pose some questions to be answered if we believe that our public health system is financially sustainable, and humane and emotionally by the toilets.

Should we treat all patients with all means at our disposal and as citizens have equal rights?

What is the margin an actual doctor has to adjust or limit the therapeutic effort "when he thinks is best for the patient, in a system like ours," all inclusive "?

Why everyday a doctor has to act against their professional approach pressed by the family, the patient, the system or the fear of claims or complaints?

why when a know that patient has no chance of leaving the hospital continues with active treatment, not to confront the family ?

Why, in short, we have lost our sense of proportion and we are unable to speak clearly with patients and families? I think I have an answer: because we are tired of facing failure, death, lack of understanding of families, citizens and patients, in that order. No doubt there are many other causes, but family pressure is increasing and resources of professionals to deal with it, the interests of the patient-are lower. The helplessness we feel explains why doctors caved-in occasions in the fight against dysthanasia- aggressive therapy -.

I must admit that the whole responsibility is not to relatives, patients or citizens, some colleagues by education, moral or ethical considerations have a vision of medicine in which we must all do never think that sometimes "less is more ."

urgently explain to young people that medicine is not infallible, that our loved ones too sick and die, and that professionals are the ones most experience to make decisions about your treatment. The idea is transmitted to the public-especially young people, is that health is a service to the letter in which they can choose at their discretion. What nobody tells you is that this does not work that way, the citizens can choose between treatments that medical teams proposed as the most suitable for your condition, this is definitely ruled out and choose other alternatives.

I await your responses ... ...

How To Make Projector

colorectal liver metastases

I present the talk I had with residents of my service on the surgical treatment of liver metastases of colorectal origin. I hope you serve as a refresher or update. I hope your comments.

surgical treatment of liver metastases from colorectal

Jaundice In Dogs Curable

The "enterao"

The other day I had to go to Barcelona and professional issues and leaving the airport I got in the taxi queue and was assigned as a package, at a taxi in the second row by a guy with a boring face vest -reflective of those who some believe are uniform. The driver in question was about 50 years, the very beginning the "career" began talking with a colleague on the radio. The guy started to criticize Zapatero-calling insult him ignorant, bullshit and other niceties, "went with the speed limit, arguing that the car that consumes less than 140 to 110 - and just keep saying to see if he was dying Rubalcaba , was entered by a urinary tract infection, after the typical way to say about politicians in general: sausages, thieves etc ..., and take it with icing on the Moors and the "blacks."

Your partner should be of the same ilk because he cheered thanks. A rant after ended tried to follow the conversation with me, I really just wanted to take over his speech-I believe that you have not felt so uncomfortable and so eager to tell him he was a jerk. He failed to say anything more than: "It makes me a receipt please?

This situation made me think that in our environment there is much "enterao" about everything and does not know anything. The issues on which there are more "enterao" are soccer, politics and health. As expected, this brought back memories of the "enterao" hospital and I recalled a phrase from Martin Luther King: "Nothing in the world is more dangerous than sincere ignorance and conscientious stupidity"

Who? has not had to deal with the typical family, that after studying the medical encyclopedia or internet consular decides bitterness am getting the smartass with supposedly scientific questions.

Who? have not heard a comment in a waiting room or at the bus stop where a patient says to the other: "You do not pay any attention to medical I had the same and I did ... and I passed. "

Who? has not been submitted in the office for questioning or minioposición, usually by the youngest of the family that has seen many movies doctors.

All these "enterao" I would ask when you're training for something that you may feel that non-experts will give lessons. If the answer is "poor are jerks", apply the story when you go to hospital.

How to handle these situations: in the case of "enterao" pseudo asked: Do you have something to do with healing? Whatever the answer you loose an explanation with technical words can you think of a Latin word made without forgetting, if not the guild does not know anything and if so stay in professional plan.

For "enterao" type interrogator must answer the questions .. and plan to finish in jest ask: What makes me shout? usually remain somewhat puzzled ... then when you say with a smile, a joke!

Read Straight Shotacon Mangas

A surgical nightmare

write yet having recovered from an operation type nightmare of 9 hours without rest or respite. These situations leave you exhausted not only physically but especially from the point of morale. Stand it because you have to finish the job: an operation can not end because you're tired or stressed, or not serve the handover times, or hunger or sleep. There are no excuses that are worth: only worth a job well done.

is a young woman and I say it is my age and that also influences-diagnosed several months ago of a colon tumor with multiple bilateral liver metastases. When diagnosed, the 8 segments of a single liver was not affected by the disease. Presented at the meeting and decided to recommend chemotherapy. After 10 months of chemotherapy was reintroduced in session with an answer-size reduction of metastasis. After careful consideration we decided that if there was a possibility of removing metastases. The surgery meant removing 5 of the 8 segments of the liver to what was necessary to make a left portal vein embolization to achieve the remaining liver to grow enough to allow intervention.

far so perfect. At 9 am we started the incision and from the very beginning we realized that the intervention would be an obstacle: the liver had a dimpling appearance of shape metastases and chemotherapy in addition to adhering to the stomach a previous intervention. After exploring the abdomen and an ultrasound, we were wondering if it was possible resection or not. We knew it was the only chance that the patient is cured or at least got longer survival. The patient had been informed of the risks of surgery and had stated that the assumed. After weighing all the options we decided to go ahead. The resection was extremely complex, but we do it after 6 hours of intervention. When we finished we realized that the arterial blood of the little that we could maintain healthy liver was not suitable. To solve it we had to arterialized the holder to an anastomosis between the hepatic artery and portal vein. Among the above described, to give us hemostasis and close at 6 pm-9 hours of surgery with a break of 15 minutes. After the family informed of the situation patient and high risk for liver-fatal complication in most cases, the mother and father were older and did not understand the extent of their disease and less-technical explanations in these situations is difficult to capture the information. Once the drink is bad news to write the surgical protocol, talking to anesthesiologists and intensive care physicians. Results from the hospital at 7.30, ten hours after the start of the intervention.

The feeling of physical fatigue, stress accumulated frustration at failing to perform surgery without technical problems, the conversation with the family, explain to the rest of the companions, and in short, the feeling that all that effort was in vain and that the patient's hopes had been frustrated, got to be a day really hard, do not forget that, of those who leave scars and torn pages of the calendar. By now the patient is well, but with data from liver dysfunction, as expected.

Inside A Womens Viginia

Photos with history: an alien of 25 kilos. The doctor patient

Patient over 70 years since the last fifteen to the doctor for increased progressive abdominal girth. He carried out several tests and concluded that he had a large retroperitoneal tumor and recommended surgery. The patient did not accept because he was well and had to take care of their 6 children. Throughout this period the abdominal mass was growing slowly, despite the progressive deterioration of their quality of life, the family was unable to persuade her to return to the doctor.

few weeks before coming to our hospital the patient could not get out of bed, I could barely eat and had a progressive respiratory distress that prevented him from lying. I had to sleep sitting up. Cuando llegó a la consulta estaba en una fase preterminal. Le planteamos que la única solución era intentar quitarle la masa que medía unos 80x90 cm y que se originaba en el retroperitoneo izquierdo. La paciente aceptó la intervención-no tenía alternativa-sabiendo que podía morir en el quirófano. Cuando le pregunté por qué no había querido operarse antes, me contestó: “De algo hay que morirse doctor y yo ya soy muy mayor”. Supongo que al ver la muerte más cercana cambió de opinión: ¡quién no lo hubiera hecho!

Las imágenes que se presentan a continuación no son agradables. Recomiendo a las personas impresionables no see them. In any case that is under your responsibility to see

Image 1 appearance of the abdomen of the patient with marked incision.

Image 2 image of the tumor once the incision by holding the abdominal wall.

Image 3 tumor occupying the entire abdomen before removing.

Picture 4 beginning of the removal performed by four surgeons.

Picture 5 pulling the mass to gain access to the pelvis for its removal.

Picture 6 the tumor once removed of its size and weight (25 kilos) did not fit into any container, we had to use a container.

Picture 7 the abdomen of the patient once the intervention.

The patient was discharged without complications at 12 days was necessary to remove a muscle and a nerve root that has to do with the mobility of the left leg. Currently leading a normal life with a sequel in motion.

My Throat Glands Swollen After Alcohol

Today I started on Monday in the worst way possible: talking with a partner, become a patient. One is used to talking to all kinds of patients, delivering bad news, talking about cancer, to talk about life, quality of life and death: what is used is to give bad news to a person which is every day is like you, who understands your problems, with which you identify yourself, you appreciate but never would have thought that one day would be your patient.

It all started 4 days ago with severe abdominal pain which resolved spontaneously. My partner went to hospital and underwent an ultrasound that showed a cystic lesion in the pancreatic head. This morning he has a scanner and have confirmed the worst suspicions. At 8.30 pm I received a call telling me the case and digestive've come to see the scan is clear about the diagnosis, no data because I do not want anyone to even suspect whom I am speaking. Accompanied by my colleague Gastrointestinal we went to talk to him and we have informed our suspicions and treatment options, as with any other patient, with the important difference that if I knew that we were talking about a disease with a cure unlikely.

The conversation was friendly and without tension, without awkward questions, in short, has made us very easy, this has been what has moved me most: his generosity, his empathy by putting over his anguish, his tragedy, concern for us pass this bitter pill with the best of their smiles. I wish I could fit so news like integrity, in a manner so natural and so calmly plated!

Thanks mate for your example. We will see in the operating room if all goes well.

For those partners or other persons who have been patient with cancer I recommend reading this interview of a patient's medical .

Bread Maker Directions

My recipes to choose from the MIR space

This entry is dedicated to the new MIR facing the choice of specialty. When you finish the race and endorse the MIR medicine felt indescribable relief, has spent 7 years of his life-6 and 1 college preparation to MIR- choose a major that will mark his lifetime, but although he has studied all, nobody has explained how to choose the most appropriate specialty to develop as professionals and as people. Although some universities offer courses targeting most of them are purely theoretical and informative, none of them talk the fundamental issue which is summarized in two questions : How much would you dedicate your life to the profession? "Vouchers for the specialty you've chosen? Perhaps we should add others but not of orientation but of opportunities such as: Do I get the number to do what I want and where I? If I can not choose what I want I will stay close to home? -Understand how to choose thinking about bonding and non-professional.

I have my own medical classification: "Those who punctured, which cut and those that do not puncture or cut," "To those who are dying and that patients are not dying" , "physicians who work standing or sitting," "which is uncombed and not unkempt", "games and the trenches." Everyone who applies will be defined more. If you like going out with the parting of the hair or the curls intact, blood stains, gypsum or other fluids, without a dry throat, without a heavy heart, without levarte work home: Choose a specialty room.

How are you feeling in your flesh, the choice is not an easy issue as you play you in your future career and your personal achievement much, remember that you choose a profession, which if taken seriously, requires a dedication than most and is an emotional drain of the other, are completely: do not forget that unless it is your main objective, not going to be rich, you can live well, but always marked by the guards, the study and problems of your patients.

As I am a veteran with 28 years of medical practice and at least 40 residents who have made me think I can say on the subject. If we choose the square as a study of prognostic factors related to an appropriate choice we can study the variables involved: specialty, place of work, guards, research, career, income, professional opportunities, hard work, charging adds emotionally as they deem appropriate and sort them by score. It is free in that you really appreciate the effort and dedication, be cautious in assessing emotional exhaustion related to your choice: you know yourself better than anyone in this regard. Any subject is interesting but you must choose one for which you are endowed not you want or you have opportunity to do for number. Once we have the variables with more weight acts accordingly.

If you clear the specialty is much easier to take your number compare it with other years awards and you get an idea of \u200b\u200bwhether it is viable. If it is, and want to do close to home: visit the nearest hospital to your home. Talk to residents older with no guardian with the head of service, these try to sell the bike. On all questions of compliance with program specialty rotations.

Tip: If you doubt among medical or surgical specialty medical Singles: it is more likely to guess right, you can also choose digestive, cardiology and radiology with some intervention. Another tip-I know that you disagree with someone but it is my opinion, family medicine or primary care is often the choice of doctors more "vocational" who value the closeness and treatment with patient sophistication and depersonalization of hospital medicine. So far so good but the reality is that in the health centers on imaginary patients, over and drowns the bureaucracy and lack time to do the job well, when you take a few years do not know if you're a doctor or health controller glued to a computer- and without the salary of air traffic controllers.

If your interest is to have a life close to your environment and without too much hassle, no-resident guards always will do but a deputy or may not be located, and you have a family and a more or unconventional: Choose a specialty comfortable, no guards and close to your home. Or put another way, if you want to lead a life similar to that of your friends who have a medical profession do not choose the specialties of "trenches"-those who eat more brown-general surgery, trauma, emergency medicine, intensive anesthesia , pediatrics, gynecology and oncology.

If the deal with patients, or decrepitude and disease is not for you choose a specialty of "living" laboratory, pathology, conventional radiology, epidemiology ....

If you deal well with cancer patients, terminals or complicated not going hospitals, operating rooms, emergency, crowds of people waiting to be treated at emergency rooms, family talks with disgruntled or exalted, the impositions of hospital management, the daily struggle to try to do the job despite of "organization": Dedicated to the management and end up being a "friend" of your classmates.

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This new section is titled photos history, is born to give life to photos of surgery often seem harsh, bloody and depersonalized. We who know to the person behind, its history, its process to diagnosis and suffering to beat the disease, we give the human and artistic value they have, not for their photographic quality and its impact on non-surgeons, but because this image reflects the history of a person who gives life.

The case summary does not give data to recognize patients for this reason some data are approximate. All patients signed an informed consent as well as accepting the surgical procedure includes taking photographs.

Photographs can be hard to non medical which is published as links and have a comment associated with introducing the context.

S i are impressionable or just someone you are interested in the sleaze go to another page!

1 .- A hopeless case

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Photos with history Teaching of residents in surgery: Surgical

I dedicate this post to the PR who are thinking about choosing a specialty, that as you will read is not very encouraging, but I think it's better to know the reality before making of the most important decisions of your life.

MIR Teaching of surgery is governed by a decree which provides in detail the training program, courses, rotations, surgery and assessments. The program is perfect, but nobody is fully compliant, especially in regard to laparoscopic surgery, research and publications.

This lowering of the law is very typical our society in that he requires and he must meet that no will know fully. fraud is a law book! , especially when the resident at the end of the residence automatically becomes a specialist in general surgery and digestive system without a filter examination and practically nonexistent.

In fact I've never seen a suspension to a resident unless he decides to leave. The obvious result is that the training of residents is not guaranteed, the title itself. This alarming situation clearly does not worry health authorities more focused on solving the waiting lists and demands of citizens.

Most newly graduated specialists are able to solve common problems in surgery, but unquantified, percentage approaching 20% \u200b\u200b- is unable to solve them without help. Depending on the hospital, the service and the rest of the companions may be that patients treated by that surgeon did not receive proper care. There is a problem of degree but of discharging its functions: no guarantee your competition.

Many residents do not meet number of times that makes the training program or have been able to operate many patients with a type of surgery and none of another. Anyway, the minimum number of interventions, described in the decree does not guarantee competition at the end of the residence. The truth is that there are too many surgical residents and young deputy in training, this prevents residents operate the required number of patients to obtain the necessary skills.

Ambitions for laparoscopic surgery and research seem a joke in some hospitals. The teaching license has not been reviewed properly and residents services and even lying to auditors for fear of not being hired at the end of the residence. A specialist degree is given by the ministry of education but the means to ensure compliance with the training program in the hands of public health systems of autonomy. The public health care systems by recruiting every year 190 surgical residents so that the cheap labor and replacement of retirements is guaranteed. Quality does not matter if they have their title officer to exercise, no matter if they have more capabilities than others, or better training, cover a hole in the system, they can not choose and that is not for the many who are better trained.

The inclusion of core subjects in 2012 can further complicate compliance with the minimum number of interventions.

The English Association of Surgeons (ACS) has created courses for residents who can acquire the knowledge and skills in different areas of training or in other words the Super Specialty: abdominal wall, breast, esophageal, gastric, colorectal, hepato-biliop-ancreática, endocrine, multiple trauma, infections and even health management. Neck probably been easier to keep up, the problem is when you arrive at your service: the practice is different, do not let you apply your new knowledge, and practice the skills learned in the operating room.

This negative view and apocalyptic tone is not feigned but real sad end specialty residents are increasingly green -often with excellent knowledge theoretical. You need to take urgent measures to ensure the competence of the new surgeons. As in other areas this depends on many actors: public health, Ministry of Education, National Commission of the specialty, regional ministries of health, surgical services and residents.

What can a resident, or rather a group of residents is required to fulfill its training plan, if not it should be to inform the department head and the teaching committee of the center. If results can not request an audit committee of experts. If takes a passive stance, very common on the other hand, will need at least two more years of practice to acquire a real competition, expecting that you can work continuously and not only do guards. It's much better to have less well-educated residents than the usual coffee for everyone in healthcare.

For those who want more information : Training in general surgery and the digestive system: new program, same challenges. Joseph M. Bobadilla Migueleña

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requiem for pancreatic cancer

A new presentation slides presented in a course of cancer in 2006 on the criteria of resectability of pancreatic cancer and the surgical strategy to confront the most lethal of digestive cancers. I hope you serve for a touchdown.

Some of the criteria for resectability have been small changes that can be found in Surgical Treatment of unresectable and Borderline resectable Pancreatic Cancer: Expert Consensus Statement by Evans et al.

field image after surgical removal of the pancreatic head
(Whipple operation)

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Clinical case of Crohn

cave is not a bowel Crohn's disease
and typical cobblestone mucosa

For a change and not always talk about surgery hepato-biliary-pancreatic I present a case of Crohn's disease rather complex has kindly given me a resident of my service Geraldine Murature, a Buenos Aires stuck to this in the surgical arts.

Clinical case of Crohn's disease

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vocation as a trap for medical

Vocation is defined as: " Inclination to any state, profession or career . " Undoubtedly the vocation to help or cure this at the beginning of every doctor and she throws herself to withstand a 6-year career, a additional year of preparation of the MIR, three or five years of expertise as a medical intern and resident and a long pilgrimage tricky contracts, competitions, courses and seminars: what today is called continuing education, which means that everything you learn has a expiration date getting shorter.

When you complain that you have a schedule that will not let you have free time the rest of the life or take 15 years with contracts of 6 months, always leaving a cocoon that says : "do not complain that you do by calling!" that's when I have an lycanthropy attack and bite ... auh .... You may wonder why I get so, do not I have a calling? Am I a limp? Do you only work for money? NOOOO gentlemen, but I do not like to use the word vocation as synonymous asshole.

is very common that everyone thinks that his job is more complicated, more responsibility or that requires more commitment, and therefore legitimately believes that his company mistreated and misunderstood by the general public. Well it may be something about that or anything, but the hackneyed vocation is not an excuse to endorse issues that any other citizen would not hold or even holding him, the complaint would not have to hear: "Do not complain that you do it vocation! At that sucks eh ...!

vocation for me is an intimate affair, personal, and that all doctors have had or have some time but no one should use, read company or the general public, to justify treatment that would not hold in their work.

the vocation given yourself, when you want and where you want, but it is not required for others, not even a requirement for medical and not for many other professions. If we continue to believe that being a doctor is a special job for which you will need a cure or alleviate the diseases of people regardless of race, religion, political choice, social status, even though you fall ill or you think your life is not worth it: we respect the vocation of each and not use it as weapon.

Well it has become clear that I do not like to hear about the vocation, for those who have a less crude can read the article Casanovas Carlos Martínez