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September 6, 2018

5.) Back:
Human Anatomy and Physiology Upper Extremeties:
Arm
1.) Head: o Anterior
a) Face o Posterior
Zygomatic (cheek) o Lateral
Maxillary (“ngalangala”) o Medial
Mandible (jaw) Forearm
Orbit (place where eyeballs are attached) Hand
o Supraorbital region (eyebrow area) Wrists
o Infra orbital region Digits – fingers

b) Cranium (part which covers the brain) Lower extremeties:


Frontal Thigh (above the knee)
(O) Occipital Leg (below the knee)
(T) Temporal Digits
(P) Parietal
6.) Brain – Cerebrum
 Frontal lobe – all voluntary movements
- signal will come from there
 Parietal lobe – interpret, sensation
- Brain processes the signal
 Occipital lobe – tell/process light
- vision
Injurty to mandibular area can be traumatic because such area  Temporal lobe – processes smell, taste
is not easily broken if affected. Napakakapal/compact ng bone
diyan. Cerebellum
- Balance
2.) Neck Area: - Coordination
Anterior – Front
Pasterior – Back NOTE: Alcohol inhibits the function of crebellum
Lateral – Sides (left lateral and right lateral)
Brain stem – most important part
3.) Chest - composed of vital parts of the body
Intercostal spaces (spaces between the ribs) - any type of injury would be fatal even the
Areola – generally cannot be used as a reference point slightest injury
- what is being protected is inside the area
4.) Trunk:
Ribs: Fixed structures September 13, 2018
Integral spaces – spaces between the ribs
Hemothorax – blood inside the thoraxic cavity; Difficulty of
Abdomen- can be divided into 4 or 9 region. lungs to open up
Pneumothorax – air inside the thoraxic cavity
BOTH: Decrease in oxygen/Low oxygen delivery
Cardiac Tamponade – Space between heart and the covering
Heart and Lungs – They both work together; Both inside the
thoraxic cavity
Cardio Respiratory Arrest – heart and lungs failed to perform
their duty
CPR- To make heart pump artificially. Pump + breathe in
oxygen

How to Compromise the Airway

A ruptured wound in the lungs causing injury somewhere there


either a blood vessel becomes injured or a portion of the lungs
becomes injured and blood starts to accumulate inside the
thoraxic cavity and in there would be the difficulty of the lungs
to open up.

Another condition let’s say for example the victim was stabbed
causing an opening in the chest wall in the 3rd intercostal space
in the left chest between the third and fourth intercostal space

Intercostal space – space between the ribs

PASION 3AA
Nasaksak – say it did not hit the lungs, would there be a - If you have this instance wherein the heart is not able to
problem? pump anymore, you call that as cardiac tamponade
- There would also be a problem because remember if wherein the heart and the space becomes filled up with
you stab and create an opening in the chest, what will blood and if you do that there will be problem with the
happen is magkakaroon ka ng communication between opening and the movements in the heart. Compromising
the outside and the inside and we already know that now the oxygen. And not not only the oxygen, it also
inside is negatively pressurized, so what will we expect? compromises the distribution of nutrients.
The air will go inside and the effect is, as air goes inside, o Deprived of nutrients it’s okay since you can
there’s now the tendecy for the lungs to collapse. So the survive for a long time without eating but if a
effect is the same. There will be a difficulty of the lungs few minutes you deprive someone of having
to open up. Hihinga yung tao, walang oxygen, victim oxygen, you’ll end up having a comatosed
might die for failure to deliver oxygen. patient.

If you protect the lungs from opening up, the victim will suffer, So let’s proceed. We have the HEART and LUNGS which are
ending ay mamatay yung tao. both located in the thoraxic cavity. They work together and
And it does not work alone, it has to work with the other organ these two are the main vital organs for you to live. The brain is
which is the heart which we’ll discuss later. also a vital organ but it is very very protected. As you have
seen, you have bones covering up the brain, the facial bones
This time you have air inside the thoraxic cavity and we refer to also giving additional protection.
this as pneumothorax – air inside the thoraxic cavity which is How about the chest? It’s also protected, the front and the back
brought about by the communication of the air inside and but there are some areas wherein may points para ma-damage
outside. Tapos negative pressure pa dun sa loob so if you stab *ito* and yun nga, if you damage any of the structures here, the
the person, you free the communication – the tendency is for heart, lungs and even the one controlling the heart, you’ll end
the atmosphere of air outside to go inside until mag equalize up having a dead victim.
na yung pressure na yan and if that happens, the lungs will not
open up. So if it does not open up, no oxygen, no delivery to If you’re going to read the dead certificates, ang madalas dun
different parts of the body. ay cardiac respiratory arrest which simply means that the heart
and the lungs failed to perform their duty.
Q: Other instances where in you can have problems with
the opening/movement of the lungs? If a person stops breathing, one of the first aids is doing a
Even restriction in the movement of the chest. You can find this CPR.
in cases of multiple rib fractures. Yung mga accidents like Wherein you pump and you give air.
tumama sa steering wheel etc resulting to multiple rib structure.
What will happen? In that instance, hindi naman bubuka yung Q: What is the objective on why you need to pump?
dibdib mo because of the fracture of the rib. So that will also In order to make it move artificially.
compromise the activities of the respiratory system, ending
lang ng lahat ng to is decrease oxygen victim that will die Q: Why do you need to give air?
To provide oxygen. It’s no use if you keep on pumping and
In the last board exam of Medicine, it was asked there is no air. For CPR to work, you have to bring in oxygen
and you have to pump the heart.
Q: “What is the cause of death in cruxificion?”
Asphyxia – hindi makakahinga yun pag crinucify mo. Kasi you DIGESTIVE SYSTEM/GASTRO INTESTINAL TRACT
try to observe that ano nakapako pa kung nakaganyan ka, There are 2 tubes.
there is difficulty for your chest bones to move di gagalaw yung The esophagus and the other tube yung nandun sa taas
ribs mo. Failure of your chest to move will result to decrease in connected to the lungs which is the trachia.
your oxygen absorption/oxygen collection in the lungs. Hindi ka The other tube goes into the lungs and the other tube going
makakahinga so eventually, you die. down here sa digestive system or the gastro intestinal tract.
If you eat food and you chew it, it goes down to the stomach.
That’s why the activity of the lungs is very very important kaya From the stomach it goes through the small intestines, after the
nga sabi natin last time, you cannot afford to have any injury in small intestines, it goes now to the other parts of the digestive
the brain stem. The movement of *this one* will be affected. tract, the bigger ones, which are the large intestines.
You’ll end up having low oxygen. You’ll end up with a dead
patient. Q: What are the functions?
This one is for digestion of the food, in the oral cavity, you
HEART digest food by biting, chewing, tapos pagdating dito, it will
The heart is located at the center roatated to the left and we shape the food and mix it with acid. Chemical breakdown yan
said last time that you can find the apex in the 4 th interpostal eh. Dividing it into small pieces in the stomach.
space. The usual location of the heart. After dissolving the food, the stomach will empty itself,
You should also consider that the heart is covered by a paparating sa small intestines.
membrane. It’s not exposed. The heart has a covering. And in
between the heart and the covering you have a space. That Q: What is the purpose of the small intestine?
space is actually a potential problem when you talk of traumatic Absorption of food and water. So it presupposes that the food
injuries in the chest. Ex: Stab wounds in the chest has been dissolved already. Wala na ibang gagawin kung hindi
- If blood fills up the space, what will be the effect? absorption.
- Similar kanina sa lungs, the movement of the heart will Whatever is not absorved will be delivered to the large
be affected. If the movement of the heart is affected, instestine prior to excretion (lalabas na dun sa dumi.)
you’ll end up having low oxygen delivery which will result
to a dead victim.
PASION 3AA
Q: What are the parts of the small intestine? Q: Is that bad? Yes.
Divided into 3 segments. Pinanglulusaw yan ng pagkain eh. If it spills out there, it will
1.) Duodenum – for absorption of nutrients destroy the abdominal cavity also.
2.) Cecum – water + nutrients The stomach contains properties that prevents itself from being
3.) Illeum destroyed by itself.
Some people will have certain abnormalities preventing their
You connect that with the heart. Absorb here and whatever is stomach from being protected by the acid. Kaya nagkakaroon
absorbed, tapon mo dun sa puso, for distribution in the ng ulcer.
different parts of the body. There’s a connection somewhere
there. So if you spill out acid in the abdominal cavity, it will cause
damage.

Q: Victim suffered multiple stab wounds in the umbilical


region. What will be hit?
Small intestine. If you hit this, it will spill out undigested food
particles.
Q: Is that a problem?
Not so much compared to the acid. Because this is clean. The
acid will be neutralized when it reaches to this part.

Q: Stab wound in the right lower quadrant? (Appendix is in


here. Which can be removed.)
Mabubutas ang bituka mo niyan which is the large intestine. If
that happens, expect that you will also have spillage. What will
come out is fecal material, bacteria.
- If you create any opening in the large intestine, you’ll
have problems because what will be spilled out is the
fecal material and bacteria which will be spilled in the
abdominal cavity.
- If kumalat yan, victim will die of infections.
If you have spillage of fecal material, there is no way to get that
out with antibiotics. You’ll end up dying.
You call this severe infection in the abdominal cavity as
Peritonitis (itis = inflammation)
- If you spill microorganisms or fecal matter in there, it will
Large intestine also known as the Colon be inflammed and you call this condition as peritonitis.
The large intestine is further divided into the following
segments: (ADTS) There’s this one criminal case wherein the victim suffered
1.) Ascending - pahalang multiple stab wounds. After 3 days, the victim died. The
2.) Transverse colon - pababa accused said he did not kill him. He died because of the
3.) Descending colon infection. SC said that the stabbing was the proximate cause.
4.) Sigmoid The victim died not because of the stab wound but because of
the infection.
Rectum- For the storage of the fecal material
Anus- And the storage dun sa pinakadulo Injury to any part of the abdomen, comparatively, is 3
structures.
Q: What are the purpose of these 4 storages? What we want to avoid is injury in the large intestine because
And digestive particles are stored in there. the possibility of the victim dying because of massive infection
Digested food are stored in the small intestine while the to the abdominal cavity, peritonitis, is very high.
digested particles are stored in the large intestine. - Mabuhay ka man, mamamatay ka sa infection. That’s
the problem there.
Let’s try to compare these organs:
Stomach contains acid. There’s this organ here in the right upper quadrant in the
Small intestine- no acid. It is form absorption abdomen. A very big organ under the diaphragm called the
Large intestine – for storage of undigested particles, feces. liver.

How are you going to compare these two? Q: What is the purpose of the liver?
1.) One in terms of function. One of the functions of the liver is to produce a substance for
One is for absorption. For food and nutrients absorption. absorption of bile. A chemical for the absorption of fats.
The other is for storage - We know that fats will not dissolve in water. So there
2.) Contents must be a component to dissolve that.
Large intestine – o When we wash dishes, we use soap with water
to remove oil and water. So you can remove the
Q: What if the victim suffered injuries to any of these? fats easily. Pero hindi ka naman kakain ng
What would you expect? Ex. Multiple stab wounds in the sabon para ma absorb niya ng taba.
gastric area. - That’s why you have liver. It acts the same way. The bile
Acid will be spilled out. All of these are located in the will emulsify the fats. Meaning the bile will dissolve the
abdominal cavity.
PASION 3AA
fats in water. It is synthesized by the liver and it will be Right upper quadrant – If you injure this, especially if you hit
brought down diyan sa bituka. the liver, maaring mamatay at hindi umabot sa hospital.
- So everytime you eat fats, mag didischarge yang bile.
You try to notice, bile is color green. That’s why there are If you injure any of the organs in the thoraxic cavity, ganun din,
instances when your feces is color green. hindi na aabot sa hospital. The possibility of the victim dying is
o Try mo kumain ng chicharon tapos tignan mo very high.
bukas kung ano kulay ng tae mo, kulay berde
yan. But injury *here*, you can tolerate. Kahit nakalabas pa bituka
mo, makakatakbo ka pa eh. Although it is gross, mabubuhay
Gall bladder – small balloon under the liver. pa rin.
Q: What is the function of the gall blader?
Storage of bile. In other words, bile is created here. It is stored THE REPRODUCTIVE ORGANS
inside the gall bladder. Uterus, Fallopian tube, ovaries, vagina, the canal, cervix (baba
- So everytime you eat fatty foods, the gall bladder will ng uterus)
have to pump out bile to absorb the fats. Cervix- very important sa mga buntis. Tinatanong anong size
o Kasi kung walang bile, ilalabas mo lang yan. It ng cervix mo.
will not be absorbed by the small intestines.
Q: Purpose of uterus and matress
Ramos vs CA Where child is placed for 9 months.
Ang problema ng pasyente dun, gall stones in the gall bladder. For housing of the child for 9 months.
There are instances when stones are formed in the gall bladder
and that is very painful. Ex: Kung mahilig ka sa matabang Q: So during male-female intercourse, what happens?
pagkain. The male through ejeculation will release semen. Then the
- The patient went to the hospital for the removal of the sperm will travel pataas papunta dun where it will meet the egg
gall bladder. Hindi naoperahan because when they were cell. They will meet somewhere there in the fallopian tube.
about to start the operation, sinaksakan ng tube and the Forming now the fertilized ovum.
tube, instead of going to the lungs, went to the
esophagus. Q: When does life begin? (Imbong vs Ochoa)
o Instead of pumping air into the lungs, air was Upon meeting of the sperm or upon implantation of the ovum?
pumped into the stomach. Kaya lumaki yung
tiyan. So pag manganganak ang babae, it would have to pass
through the canal in here, the cervix, it will open up to
Liver is another organ inside the abdominal cavity. Maraming accommodate the child. Lalabas yan sa vaginal canal and out
functions yan e. This is an organ that is easy to destory such the baby goes.
that when it becomes injured, there is a possibility that the
victim will suffer from massive bleeding. There are instances where in the female will suffer bleeding
- It’s very hard to control bleeding when you talk of liver kasi pag labas niyan, there is a lining in there na dapat
injury. matanggal. This lining is the one being excreted out every
- Kaya when the victim suffers right upper quadrant month during menstration. Every month, it is being shed of in
injury, we always try to asses immediately if there is an the form of menstration. Yan ang cycle niyan.
injury to the liver. If the answer is yes, delikado yan. The o The problem is the lining, pagkatapos manganak, it
possibility of the victim dying because of the massive will cause continuous bleeding on the part of the
hemorrage is there. female.

Q: Why is liver a very important organ when we talk of Q: What is the remedy?
injury? You remove this part here in the uterus.
It is connected to the heart. Is this a vital organ? Can you love without the uterus?
o Remember? The main objective of all of these (small Of course yes. It’s not a vital organ.
intestine) is to absorb nutrients and water. For this to Ang pinakatrabaho ni nyan ay lalagyan ng bata.
become functional, it has to be delivered to the heart. Kaya nga ang lalaki walang matres pero buhay naman.
For that to happen, it has to pass through the liver
first. Q: How about the stomach, can you live without the
o What will happen is it will collect all the nutrients and stomach?
there it will be forwarded to the heart. Hence, it is very Actually yes. May iba na pinuputol yan. Tinatanggal or
very rich in blood vessels. kinakalahati. Para mabusog kaagad.
o Isang malaking storage yan ng dugo eh. Hence, if you It is one of the radical methods of losing weight.
injure the liver, expect that there will be massive ….
Q: Can you trim the small or large intestines?
When you talk of left upper quadrant injury (although may Yes.
maliit na organ pa dito na Spleen which is also a bloody
organ – but the difference is nakatago yan) Q: Can you trim the heart, lungs, brain?
No. These are vital organs.
Q: Can you palpate the liver? It’s a very big organ but can
you palpate it? NOTE: The objective of this topic is for you to identify the vital
No. It is hidden under the ribs. Tinago yan ng Diyos sa ilalim to organs. Which if damaged will cause the demise or death of
prevent injury to the liver because pag na injure yan, the the victim.
possibility of death is very high. So far we have identified yung mga nasa taas (heart, lungs,
brain, liver and spleen)
PASION 3AA
o We can also consider the spleen as a vital organ
when you talk of traumatic injuries.
o Injury to the liver or spleen can both cause massive
bleeding which can cause the demise of the victim.
But when you talk of injury to the small or large intestines, it will
not cause immediate death. Delayed yan. Kaya nga sabi ko
kahit nakabitin na yan, makakatakbo ka pa sa hospital. The
effect will be delayed. Unlike with liver and spleen, on the way
ka pa lang baka hindi ka pa umabot sa car, you’ll die because
of massive bleeding.
- Moreso sa injury sa lungs. Such as in the case of Ramos
vs CA. Imagine, a few minutes. The court explained that
2-5 mins, lack of oxygen to the brain, the brain dies. In
that case, how many minutes where unaccounted for in
the case? About 15 mins were not recorded in there.
You are missing 15 mins. Anong nangyari dun. And you
only need a few minutes para ma-comatose ang 4.) Ramos vs CA
pasyente.
- Reprouctive organs are not vital. Yung ari ng lalaki, is
that a vital organ? Buhay ka pa rin kahit maputol yan.

Next meeting: Cases. Recitation.

September 20, 2018

1.) People of the Philippines vs Dan Ave Y Tabobo

Protocol is to admit the patient at least one day before the


surgery. Why?
1.) For convenience of everybody
2.) More importantly, to conduct initial examinations. To
prepare the patient one day before the scheduled
operations.
o For the anesthesiologists to do the pre-operative
2.) People of the Philippines vs Henry Togahan examination, wherein they will ask the patient’s
history, allergy etc.

In this case, to look at the patient’s airway. Thus, the


anesthesiologist was held liable. He failed to conduct a pre-
operative exam. He did not see the patient a day before. He
saw the patient on the day of the operation already which is
very material because instead of putting it in the airway, he
placed it sa daanan ng pagkain.
o Especially, we are talking here about a robust
patient. Medyo malaki. Masikip yung nape niyan.
Yung jaw medyo restrictive din which could have
possibly contributed to the injury of the patient.

It does not follow with the standard of care with


anesthesiologist which is you should see the patient at least 1
day before to conduct your pre-operative exam.

Surgeon was also liable.


3.) Fernando Estabas Mahawan Alias Pado vs People Under the Captain of the Ship Doctrine, if you’re the head of
of the Philippines the surgical team, you are the responsible for the negligent
acts of the other members of the team.

PASION 3AA
DEFENSE: Surgeon said that this doctrine does not apply
anymore in Jurisprudence because in the US.
- But SC has negated his claim by saying that here in the
Philippines, we still adhere to the Captain of the Ship
Doctrine.

MEDICAL ASPECT:
Operation is either elective or emergency
Elective – not an emergency case. Can be scheduled.

In the case, this is an elective procedure, a general operation,


wherein the patient will be opened up and to do that, you must
keep the patient in general anesthesia (walang malay)

 General anesthesia – walang malay. The patient is


asleep. The entire body is anesthetized.
 Local anesthesia – gising ka. Only parts are
anesthetized.

Q: How would general anesthesia be done?


For general anesthesia, muscles should be relaxed. But the
problem in GA is that if your muscles are relaxed, you wont be
able to breathe. So to be able to breathe, a machine will make
you breathe. For that to happen, there must be a tube inserted
*here* going towards the ventilator.
- Dun nagkaproblema. Sa insertion of the tube.
Remember there are 2 openings. One going to the
lungs, the other going down into the stomach.
- It was argued that the anesthesiologist inserted it In the
wrong place. Instead of inserting in the trachia, she
inserted it in the esophagus.
o What is the proof? Lumaki yung tiyan.

Q: What is the problem if it was inserted in the wrong


opening?
- No air. Imagine, ang humihinga sa’yo yung tiyan mo. If there
is no air in the lungs, there would be no oxygen going to the
heart and no oxygen everywhere.
- So in a few minutes, the victim went into coma. No oxygen
went into the brain which led into the comatose of the patient.
In 2-5 mins the brain cells will die.

Cyanosis - Bluish discoloration. A sign that there is lack of


oxygen.

Nevermind the rest of the body, but if the brain dies, such as
this case, the patient will die.

Surgeon is liable. Anesthesologist is liable. Hospital?

Next meeting: Professional Services Incorporated vs Agana


Who are the members of the surgical team?

PASION 3AA