Saturday, May 31, 2014

Residency Survival Guide 101: New Advice for the New Resident

Being in fellowship training has allowed me to see how residency training has evolved over the last few years. It has conformed to society's latest fads and the newer graduates of medical school. This is an ever evolving guide to surviving residency training, in this day and age.

1. Be responsible using social media.

It has become a selfie-dominated residency generation. And mind you, this has exploded over just the past 2 years or so. In the age of the selfie, these past few years' crop of residents have been so eager to pose and post their latest outfits (nevermind that their white medical coats cover them anyway), their latest duck-faces (nevermind that a good number of them actually make themselves look worse than their regular faces), and their quote/s for the day, that they do not notice the little things in their statuses. The time stamp and the pictures can place them out of post should they be anywhere else in the hospital where they are not supposed to be. The selfie with the patient in the background can be a breach in the patient's privacy (I'm not a lawyer, but that should qualify right?). The blatant photo op at the ER can arguably be used against them, being that they should be attending to admissions first, and poses the least of their priorities.

Yet, social media has permeated every aspect of our society and its use cannot be prevented. Heck, this post is going to be on it. But careful judgment on what to post, when to post it and who to post it for goes a long way in making sure that you don't get sued.

So if you are a resident or planning to go into training, please think before you post.

2. Do not quote information without basis.

More and more residents are quick to pick up tidbits of information during rounds, most especially so when they like the consultants (criteria includes any combination of physical looks, elite status in the community, treats to free food at the canteen, and the like) and are just as quick to use this in medical conferences with corresponding quotes and name-dropped sources. Please, if you are one who does this, stop. Do not ever answer another consultant's question with, "But doc, Doctor so and so said that the, yada, yada..." (you get the drift). That will surely earn you an eyebrow raise and you'll get laid the smacketh down.

It is just different when you say, "Based on the current practice guidelines..." or "According to Harrison's..." or more if "The latest online issue of the New England Journal of Medicine has an article that tells us..."

3. Do not act like you are infallible.

There is always going to be someone better than you at something. A nurse can outshine you on knowing the patient. Acknowledge them. A fellow tells you to follow up on a urinalysis that you have not gotten to yet. Listen. You are not the perfect specimen of medical practice you think you are walking down the hallways with a stethoscope draped around your neck, white coat billowing behind you. You are in training, and learning from everybody, anybody should be your foremost goal.

4. Know your place

There is this hierarchy in medical training that has blurred somewhat in the past few years because of braver students with gifts of gab and older consultants who are content on quietly getting by treating their patients. The students can appear deceptively good, and the older guard, deceptively incapable of handling their juniors.

This past few years has seen an admitted change of philosophy in terms of medical training. It is geared more towards lifting residents and guiding, nay, nurturing them towards their goal as compared to the old Spartan way of throwing you into to the sea just to see if you can swim and survive. Admittedly, I am a mix of these two philosophies and I see advantages to both nurture and nature (hierarchial, pyramidal, etc) but the key is getting a balance of the two. Nurturing has led to "intellectual arrogance," a blinding of the clinical eye and an often uncompromising allegiance to guidelines. Nature has often seen bullies exploit their place in the organizational system, and those that cannot hack it are scarred for life.

The key is finding the balance. Know your role. You are here to train and learn. Respect those that have come before you even if a few months separate you. They have seen more than you have and are still there standing. And all the more for those who you do rounds with and report to because they do not have those additional letters at the end of their names for nothing.

Do not cross the line between pushy and timid. Once you establish that, do not rock the boat and tip yourself over.

5. Read, study and learn.

Yes, this still does the trick.

Friday, April 4, 2014

Where It Counts

These past few days to weeks to months, I've felt a little bit more stressed than what I've been used to. And for someone well into the his second year of Adult Cardiology fellowship, that is going to be a little bit understated.

But yes, I have felt a little bit more strain on my resolve lately from worries about friends and family and work has not been doing me any favors. My country's tax arm is slowly taking aim at my profession and at the same time poking one of the world's biggest countries. Talk about a messed-up government.

But that's beside the point...

This blog was initially just meant to be an outlet of sorts -- a chronicle of life experiences and work situations where I felt I turned the corner, not just as a physician but as a person as well, and maybe have the chance to have these little life stories touch whoever reads them.

I have in my care, a female charity patient, 28 years old who came in for difficulty in breathing. She is reed thin and any lay person could see the cachexia was eating away a few minutes of her life each day. She developed pulmonary edema (fancy words for fluid in the lungs) so she couldn't breathe well and we had to intubate (that thing on TV where we put a tube in someone's mouth). She had severe mitral stenosis (the valve that guards the left atrium and ventricle of heart is half-closed, or half-open, depending on how you look at it) with severe pulmonary hypertension (the pressure in her lungs were really high). Her right side heart chambers were extremely dilated, there was severe leakage of her tricuspid valve, and because of the right sided pressure and volume overload, the left ventricle was reduced to less than half its normal dimensions.

She was in severe heart failure. To what, I couldn't really say for certain unless I did some more tests. I couldn't subject her to valve replacement surgery because sending her to the procedure would be sending her to death on the table due to the severely elevated lung pressures. We had to figure out why everything was what it was before doing anything else.

But how? They were in the charity service for a reason. They had no money. How do you tell a mother or an expectant sister that you could not do anything more? We could not do hemodynamic studies, they had no money for medications and we barely scraped by with our three free days in the ICU.

Now she is thankfully out of frank heart failure. I see her everyday with her mother, sisters, brother and aunts, and everyday I tell them of how her heart is failing her and that she could go anytime. Yet they smile, seemingly in denial and acceptance at the same time, and say that "Prayers are all we have, doc" and "It is in God's hands now." I nod every single time, knowing how true it was.

Today, I went up to them and told them that as of this time, this is the best we were going to get -- out of failure, able to walk a few meters, smile and entertain guests, her talking about getting a whole serving of her favorite halo-halo and the possibility of home oxygen therapy -- until such time we were able to come up with funds to do the next steps in her treatment. They nodded and I ended the morning signing my name on their discharge orders and take home medications

Sometimes, I feel helpless amidst all the poverty, all the economic ruin my country is supposedly in, all the stress of training and the emotional strain with every family member getting sick or a friend in trouble. With all this, it would be so easy to dismiss the troubles of patients who can not pay their way to even a decent diagnosis, but I don't. I would never want that for anyone.

I have never thought of going abroad and plying my trade there nor has there ever been the desire to do so. I will work and serve patients here, and continue doing my best for patients with whatever I have just like how every physician gives a part of themselves to each patient that walks through their clinic doors. Despite this messed-up country, I feel that I am where my life counts and giving back to where it counts the most.

Thursday, November 28, 2013

Love Goes On

I received a phone call a few days back from a dear friend telling me her father was coming in for admission. He had been having exertional dyspnea (difficulty breathing on exertion) and a bothersome cough that got worse once he was lying down. I said I'd take care of him while she was still finishing up a few things as she was completing her residency training in my hometown.

I had gotten the chance to meet her father before at her wedding, but never got the chance to know him and on his admission, I shook his hand and introduced myself. He was a cheerful guy with an easy smile, talked about his symptoms and I reviewed his case. His medications, I couldn't understand since he had gotten them from somewhere in South America (for the life of me, I never knew we had blood thinners that we could dissolve in water). From just that conversation, I could see how his daughter got her demeanor -- calm, calculating, and a seemingly exceptional control over his emotions.

I walked out of the room, glanced at his labs and electrocardiogram and nothing stood out. His chest X-ray had some signs of congestion but it was on looking at his echocardiogram that I felt my heart sink a little. His heart showed a significant drop of his ejection fraction (the amount of blood pumped out of the heart with each beat) to 27% (normally >55%). His chamber walls were enlarged and barely moving. Everything about it was definitely not good.

I called my friend and broke the news. I owed it to her to tell the truth both as a friend and as a doctor. She asked me what was next, and being a doctor herself had questions and suggestions of her own. I said a viability study could be next to check the extent of surviving heart tissue, then maybe a coronary angiogram and if there is anything we can do next, cardiac bypass surgery or angioplasty. She took the news in with all the strength I knew her for. I could hear her voice cracking a bit as we spoke over the phone but I said we'll take it one step at a time, get the extra fluid out of his system, decongest his lungs and take it from there. She was coming in two days after some exams and we would talk then.

The next two days would have me visiting my friend's father often, chatting a bit and he was significantly improving. No more coughing on lying down, and he was up and about, walking around his bed, in the hallways and all the way to the hospital chapel. When she arrived, we all chatted in the room, and caught up. Everything was as smooth as can be.

Then came the call.

The resident's call came in at around 3 pm, "Doc, our patient went stiff and is unresponsive!"

"What?" "Who?!" "What happened?!" I could hear my friend in the background, screaming.

It was the fastest I've ever responded to a code in my life. In less than a minute, I ran from the male doctors quarters to the fourth floor and found my friend's father unresponsive. "Bri, he's not responding! He just complained of sudden dizziness and then this!"

Numbly I processed everything, tried to remain calm and tried to establish an airway. I brushed off the nurse offering a pair of gloves and a mask so I could save a few more precious seconds as I inserted his ET tube, while my friend took out her father's dentures. Arrhythmia most definitely, as I ran down the list of differentials in my head. We started CPR and waited for the cardiac monitor to come. Ventricular tachycardia, torsades (really bad abrnormal heart rhythms), you name it, we had it. He was responsive, restless and was still able to respond to us by blinking his eyes. We did everything -- antiarrhythmics, defibrillation, CPR for a good two hours. I did not want to stop until I had him back, talking, smiling.

But I knew it was bleak. His heart was too weak.

It broke my heart to see my friend, her tears freely flowing, never leaving her father's side, saying everything was going to be okay, that they will take care of each other if he chose to go, that it was alright to let go if it hurt too much already. She looked at me and I gave her a hug as she sobbed. I knew she saw the defeated look in my eyes and she managed a nod. She understood how most of these situations turned out.

We stopped everything after nearing two hours of resuscitation.

I keep asking myself, what could I have done differently to make sure we had a different ending? Everything was so sudden, and in just one sweeping moment, I lost a patient. A patient who not only was someone who just happened to walk in through the ER doors, but someone who was dear to a close friend. And that made him, part of me. And now, his memory is part of mine.

How God chooses when to bring people from this life into the next is beyond any man's comprehension. One thing I've learned from this profession is that each death is meant to teach us something, no matter how close it hits to home. I have to brush away notions of what-ifs and what-would-have-beens to able to look my friend in the eye and say "I'm sorry for your loss," and carry on with treating more people.

Life and love truly go on after a loss, and as I see my friend and her family carry on, I am reminded of how fragile our existence is on this earth and how unpredictable our life scripts are being played out, and how, despite everything, we should make this existence count.