I was intoxicated with the idea of being of being a surgeon

 Surgeons acted boldly and decisively. They achieved cures, opening an intestinal blockage, repairing a torn artery, draining a deep abscess, and made the patient whole again. Their art re- quired extraordinary precision and selEcontrol, a discipline of body and mind that was most evident in the operating room, because even minor mistakes—too much pressure on a scalpel, too little tension on a suture, too deep probing of a tissue— could spell disaster. In the hospital, surgeons were viewed as the emperors of the clinical staff, their every command obeyed. We students were their foot soldiers. I was intoxicated with the idea of being part of their world.

Metabolic alkalosis

 Metabolic alkalosis 

is a relatively common clinical disorder that is most often due to diuretic therapy or the loss of gastric secretions due to vomiting (which may be surreptitious) or gastric suction. (See 'Introduction' above.)

The generation and subsequent maintenance of metabolic alkalosis require two separate factors (see 'Pathogenesis' above):

Elevation of the plasma bicarbonate concentration can be generated by excessive hydrogen ion loss into the urine or from the gastrointestinal tract, hydrogen ion movement into the cells, the administration of bicarbonate salts (or other alkalinizing salts such as sodium acetate or lactate), or volume contraction around a relatively constant amount of extracellular bicarbonate (called a contraction alkalosis).

•A decrease in renal bicarbonate excretion may be due to reduced kidney function, increased renal bicarbonate reabsorption, or reduced bicarbonate secretion.

Several factors are responsible for increased net renal bicarbonate reabsorption in metabolic alkalosis. In the absence of advanced kidney failure, one or more of these factors must be present to sustain the high plasma bicarbonate concentration:

•A reduction in extracellular fluid (ECF) volume or reduced effective arterial blood volume, including reduced tissue (and renal) perfusion in edematous states such as congestive heart failure and cirrhosis. 

•Chloride depletion and hypochloremia.

•Hypokalemia. 

•Increased distal nephron delivery and reabsorption of sodium ions in exchange for hydrogen and potassium ions. 

It is impractical to perform all possible screening procedures

 Within a population, it is certainly impractical to perform all possible screening procedures for the variety of diseases that exist in that population. This approach would be overwhelming to the medical community and would not be cost-effective. Indeed, the amount of monetary and psychological stress that would occur from pursuing false-positive test results would add an additional burden on the population. When determining which procedures should be considered as screening tests, a variety of end points can be used. One of these is to determine how many individuals would need to be screened in the population to prevent or alter the outcome in one individual with disease. While this can be statistically determined, there are no recommendations for what the threshold value should be, and may change based on the invasiveness or cost of the test and the potential outcome avoided. Additionally, one should consider both the absolute and relative impact of screening on disease outcome. Another measure used in considering the utility of screening tests is the cost per life-year saved. Most measures are considered costefective if they cost <$30,000–$50,000 per year of life saved. This measure is also sometimes adjusted for the quality of life as well and presented as quality-adjusted life-years saved. A final measure that is used in determining the effectiveness of a screening test is the effect of the screening test on life expectancy of the entire population. When applying the test across the entire population, this number is surprisingly small, and a goal of about 1 month is desirable for a population-based screening strategy

LUNG-EXPANSION TECHNIQUES

 LUNG-EXPANSION TECHNIQUES A lung-expansion technique is any technique that increases lung volume or assists the patient in increasing lung volume above that reached at his or her usual unassisted or uncoached inspi- ration. Rationales for the use of various strategies to promote lung inflation include

 (a) to increase pulmonary compliance. (

b) to increase partial arterial pressure of oxygen (Pao2). (

c) to decrease work of breathing. and 

(d) to increase removal ofsecreions . 

Lung-expansion techniques are meant to duplicate a normal sigh maneuver . Theoretically. sighs or periodic hyperinflations to near-total lung capacity reverse microatelectasis . Lung-expansion techniques are indicated to prevent atelectasis and pneumonia in patients who cannot or will not take periodic hyperinflations (94], such as postoperative upper- abdominal and thoracic surgical patients and patients with respi- ratory disorders due to neuromuscular and chest wall diseases. Adequately performed. maximum inspirations 10 times each hour while awake significantly decrease the incidence of pul- monary complications after laparotomy (95). Whatever techniques are used postoperatively (e.g., coached sustained maximal inspiration with cough, incentive spirometry, volume oriented intermittent positive-pressure breathing, intermittent CPAP, or positive expiratory pressure (PEP) mask therapy (961 ) , it should be taught and practiced preoperatively. when properly used, coached sustained maximal inspiration with cough and incentive spirometry—the least expensive and safest techniques—are as effective as any other method [97). Of the several commer- dally available incentive spirometers, the one chosen should combine accuracy, low price, and maximum patient accessibility (981. Because there are no definitive studies comparing the relative efficacy of volume- and flow-oriented incentive spirometers,he choice Of equipment must based on empiric assessment of patient acceptance, eaq• of use, and cost. mien chest Sion with postural drainage is added to the previously mentioned expansion techniques in patients without prior lung disea«•. it has failed to affect the incidence of postoperative pulmonary complications AIRWAY CLEARANCE Efficient mucociliary clearance and effective cough are the two basic processes necessary for normal clearance of the airways. In abnormal situations, this system may be dysfunctional and lead to mucus retention [ 100). A discussion of techniques aimed at enhancing airway clearance follows. 

AUGMENTATION OF MUCOCILIARY CLEARANCE Mucociliary clearance is one of the most important defense mechanisms of the respiratory system. Mucociliary dysfunction is any defect in the ciliary and secretory elements of mucocil- iary interaction that disturbs the normal defenses of the airway epithelium [1011. Ineffective mucociliary clearance leads to re- tention of tracheobronchial secretions. Mucociliary clearance may be ineffective 'be rnecti-- anisms or over Copyfish port, or both. Mu

Communication of bad news is an inherent component of the physician–patient relationship

 Communication of bad news is an inherent component of the physician–patient relationship, 

and these conversations often occur in a hospital setting where the

treating provider is not the primary care provider for the patient. Many physicians struggle with

providing clear and effective communication to patients who are seriously ill and their family

members. In the scenario presented in this case, it is necessary to have a discussion about the

patient’s poor prognosis and determine goals of care without the input of the patient as her

mental status remains altered. Failure to provide clear communication in the appropriate

environment can lead to tension in the relationship between the physician and patient and may

lead to overly aggressive treatment. The P-SPIKES approach (Table I-49) has been advocated as a

simple framework to assist physicians in effectively communicating bad news to patients. The

components of this communication tool are:

• Preparation—Review what information needs to be communicated and plan how emotional support will be provided. • Setting of interaction—This step is often the most neglected. Ensure a quiet and private environment and attempt to minimize any interruptions. • Patient (or family) perceptions and preparation—Assess what the patient and family know about the current condition. Use open-ended questions. • Invitation and information needs—Ask the patient or family what they would like to know and also what limits they want regarding bad information. • Knowledge of the condition—Provide the patient and family with the bad news and assess understanding. • Empathy and exploration—Empathize with the patient’s and family’s feelings and offer emotional support. Allow plenty of time for questions and exploration of feelings. • Summary and planning—Outline the next steps for the patient and family. Recommend a timeline to achieve the goals of care. Setting a follow-up meeting is not a primary component of the P-SPIKES framework but may be necessary when a family or patient is not emotionally ready to discuss the next steps in the care plan.

Safety is the first part of quality

  Safety is the first part of quality 

the healthcare system must guarantee that it will deliver safe care. Improving safety and quality in healthcare relies on understanding the frequency and type of adverse events that are occurring in the healthcare system. An adverse event is defined as an injury caused by medical management rather than the underlying disease of the patient. One of the largest studies that attempted to quantify adverse events in hospitalized patients was the Harvard Medical Practice Study. In this study, the most common adverse events were adverse drug events, which occurred in 19% of hospitalizations. Other common adverse events included wound infections (14%) and technical complications of a procedure (13%). Among nonoperative events, 37% were adverse drug events, 15% were diagnostic mishaps, 14% were therapeutic mishaps, and 5% were falls.

Why surgeons need to know some medicine and cardiology?

Why surgeons need to know some 

medicine and cardiology?

Right from the time I was a house surgeon  in 1979 doing my Surgical rotation up to the time, I was an assistant professor of pediatric surgery till July 1994 when I emigrated to the USA  this was my experience. Preoperative evaluation was entirely left to the anesthetist and post-operative and critical-care wasn't fully developed. and was haphazardly managed by surgeons and general MDs.

26 years after leaving India and working as an Internal Medicine Consultant in USA I came back to this country. My recent experience has led me to believe that there is some amount of improvement in certain aspects but much needs to be done regarding preoperative evaluation and management of Surgical patients and this country especially in Hyderabad.