A Very MICU Christmas

MICU stands for Medical Intensive Care Unit.

In our hospital, the second-year residents go on duty every three days at this section -- the last bastion for medical management in the critically ill.

Due to certain unexpected leaves, absences, resignations, and a lot of crazy, gaah, I don't even have a word for it, I found myself answering the phone at around 7 am to a directive to go on duty for 36 hours at the ICU.

A day after Christmas.

Not exactly my idea of the perfect Christmas gift, but here I was, standing in the doorway of a full ICU with a lot of critical patients.

MICU 1: Really bad case of Pneumonia and Pneumothorax in septic shock. Her X-rays showed really bad lungs that I could see the fissures (Normally it'd be dark and black).

MICU 2: A case of sepsis (really bad infection) due to an infection of the urinary tract and pneumonia coupled with hyponatremia (really low body sodium)

MICU 3: Admitted a case of non ST elevation MI. Glad to see her not in pain, and in pretty good spirits

MICU 4: A renal patient with weird breathing. Congested X-rays and treated with aspiration pneumonia as well.

MICU 5: Hypoxic ischemic encephalopathy + Seizure disorder and underwent tracheostomy earlier in the day.

MICU 6: Dilated cardiomyopathy probably due to doxorubicin cardiotoxicity after undergoing chemotherapy for Hodgkin's lymphoma and with weird drainage coming out of her nasogastric tube.

MICU 7: A massive right middle cerebral artery infarct and underwent decompression with a right frontal craniectomy. Glad to see him responsive and doing actually quite well post-op.

MICU 8: Cholelithiasis with cholecystitis who underwent open cholecystectomy coupled with bilateral pleural effusions secondary to hospital-acquired pneumonia.

MICU 9: Myasthenia gravis in crisis

MICU 10: Cardiac dysrrhythmia, non-sustained ventricular tachycardia. (I hate arrhythmias)

TELEMETRY 1: Severe infection due to UTI and pneumonia

TELEMETRY 2: Another case of a non ST elevation MI.

These are the cases I greeted at the outset of my skeletal duty at the ICU. My first ever.

I transferred out 6 patients, but sadly lost one to overwhelming infection and its complications.

All in all, I survived.

I'll enjoy these last few days where I don't have to go on duty at the Intensive Care Unit because in all probability, I'll be doing it regularly starting next month.

Surviving that will be another achievement worth blogging about.

Gulp, pray I don't mess up.

Life is short. Life is beautiful.

Three days ago, I was reminded of the reality of how short this life truly is by a 24year-old patient who had just been out with his father, plying their trade as jeepney operators. Due to mechanical problems, they had to bring it in early and forego the rest of the day's trips. It was late afternoon when they finally solved the problem and went out to a machine shop to buy the parts. The father went down to buy the pieces and on coming back to the parked jeep, he was told that his son was out cold sleeping on the floor of their jeepney.

He was unresponsive.

He was rushed to our ER.

He was dead on arrival.

We had no idea what to put on the death certificate. We barely had anything to go on for our final diagnosis. No symptoms. No previous medical illnesses. Nothing.

It seemed like he just fell over and died.

I didn't quite grasp how his father reacted - seemingly unattached, seemingly afraid he'd be blamed, seemingly unbelieveling of what seemed to be another workday afternoon -- most likely in a state of shock. His mother wailed and fell to her knees when she arrived, exclaiming, "Wake up. Wake up, " vigorously shaking her son's body, "You said you'd just be out to buy food. Wake up."

That all got to us. Everybody at the ER felt for this family -- no parent should ever get to bury their child (John Q, beautiful movie!), let alone the prospect of having a very sad Christmas.

I took off the gloves, got my clipboard, and turned to go back to work.

24 years young. Now gone. Life is short.

As I went through my ward chores and charts, I kept thinking of life in general (profound noh?)- what I've done, who I am, how I've been - until I came to sit in front of my open laptop at our office. On the front screen of articles I came to read how Seal described his life as "the perfect life." (Hey, the guy is married to Heidi Klum, how can that not be close to something perfect? Haha.) But he described it as something happy, and having worked hard to get where he is today.

I sat back and looked at my own, and in another of the countless introspective sessions I've had with my own inner psychiatrist, I realized, I'm happy, I'm relatively healthy, I have a nice family behind me, I love the work that I do, and in a relationship where I'm unconditionally loved in return.

Perfection is hard to achieve and likely nobody will ever achieve it, but in all respects, like Seal aptly put it, it is the perfect life.

I didn't know that boy who died that day. There I was hoping he was happy, and that he had his own perfect life -- not the kind we have dreams of, but the kind, that considering everything around us, would be the life of happiness, contentment, shared with those that matter to us.

Life is beautiful but short.

No, life is short but beautiful.

Bits and pieces

Christmas time is here...
Happiness and cheer.
Fun for all
What children call
Their fav'rite time of year...

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Forgive me for there is a lot of angst in this post

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It just hurts when people disappoint you. Just when you think, you have people around you who have the same direction, the same set of ideals and the same purpose, they go around and do otherwise.

Just when you're ready to prove all the speculation, skepticism and the negative pub about your group, they just go and prove all the critics' points.

Prove yourselves.

You're there for reasons, which right now escape my understanding (maybe I'm just a little disappointed and mad right now, but I'm sure you guys are all more than capable of thinking, and willing yourselves to make something out of your abilities).

And when that happens, I'll be as proud to be a friend as I am when I'm defending you.

I don't claim to be perfect, but let's just say that a fair share of the blows I take during evaluations are blows meant for other people, and it hurts a bit when you get blamed for the actions of others.

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Wants and needs are set apart this Christmas.

I wish I could get my hands on the money to buy a new piano/keyboard, but some stuff you just don't need. Maybe I'll get to buy my own grand piano someday, but for now, maybe I'll just save it up for something else.

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There are times when the Philippine culture/nation/government/people disappoints me. Enough to make me say I belong to a stupid race (yup, that's how depressing we get sometimes).

Maguindanao is under martial law for some stupid government official who thinks he is above the law. The press is all up in arms about protection of the press people (why? should being a press person exempt you from a madman's massacre? How about all the other people? Shouldn't they be spared?) It seems like the media is all up in arms about the killing of several media people, but let's keep it on the human side and say that it's not about what the profession of the people killed but condemn the killing itself.

Second, on the recent furor in Maguindanao. There is this something called martial law.

Well, people are protesting this seemingly well-intentioned declaration to facilitate justice for the murders. Sure, when you're apparently "safe" (that is assuming we are, right Madame President?) here in the cities, it's easy to protest right? But when you've just taken a bullet and lying face down in a ditch somewhere in Maguindanao, I'm sure you'd want the law to put its proverbial giant foot down on somebody, preferably the one who pulled the trigger.

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Candidates. Schmandidates.

Off with the lot of you.

People protesting our current president, when they should be looking at who is waiting in the wings. GMA is not that stupid. She won't risk an obvious grab at power since we've proven that the Filipino people are very very powerful when they come together. But it's just that, nobody among the gazillions of Filipinos will satisfy all the others in terms of leadership and good governance.

A really smooth talker politician playing on his rags to riches story (but you're rich now right?), a reluctant son who is riding a colorful family history of leadership, a cutthroat strategist and economist, a prayer rally leader, an unknown who just happens to have a brain and no viable party opponents, and a fat, washed up actor who was once powerful, got overthrown by the Filipino people from whom he obviously stole from (c'mon who are we kidding here right Velarde?) and he wants back in?

And there happens to be this national hero who wants to hurt his stature in Philippine history by meddling in politics just because he has the money, the women, and the fame. Tell me, what actual laws are you planning to pass? You kno?

I might as well run this country myself....

Now there's an idea.....

The doggone days...

My thought for the day:

"My life has no purpose, no direction, no aim, no meaning and yet I'm happy. I can't figure it out. What am I doing right?

-- Charles Schulz

To This Day

I gazed up sleepily into her eyes and she let out a small laugh as I cleared the cobwebs from my head.

Aaaaghh, I dozed off again, and she wasn't giving me a hard time about it. I was on duty last night and despite the malaise slowly overpowering my body, I urged myself to go out to a nearby coffee shop to get some reading done. Getting up, she said we'd better get a move on if we wanted to get home alive and not have me dozing off at the wheel.

I knew better than to argue.

While driving, flashes of the past few years go by.

I remember seeing her coming up to class with books clutched close to her chest, the early morning sunlight streaking down her shoulder-length hair, and that ever familiar twinkle of her eyes. She gives me a smile and moves into their room.

I remember hearing her humming softly and singing quietly in perfect tune.

I know of her quick wit as we shared a laugh over a joke no one else seemed to get.

I've always admired her for being smarter than I am as she often appeared to effortlessly answer questions on exams that she would never openly admit on knowing the answers.

I remember her quiet understanding about the upsides and the downsides of my life.

The flashes go by like the lamp lights outside the car window. She was quiet as we went home with sleep slowly setting in.

To this day, she is still the same smile that lifts my spirits.

To this day, she is still the laughter that picks me up when I am down.

To this day, she is the hand that reaches for me when I reach out for help.

In this instance, she is the angel that wakes me up at this nearby coffee shop and kept me from being sprawled across the floor, passed out in exhaustion.

To this day, she saves me every waking moment.

Happy birthday.

525,600 minutes

A year ago, I was a scared, excited newly sworn-in doctor who was curious about his decision to train in internal medicine and fresh from a year of a great PGI-ship in Silliman (hence the title of this entry, piano music in the background).

I can't believe it has been one year. When they said time would fly by once you got into residency, they weren't kidding.

I'm done with first year.

Not that I'd miss having a ward with my name on it (as well as my phone number plastered all over the walls), the incessant nurses who page me every time anything went wrong from simple spelling errors on orders and deciphering unintelligible handwriting to actual codes, as well as the daily grind, DTR's (direct-to-rooms) among a whole lot of first-year stuff.

I'm moving on to subspecialties this year -- my first one is a personal favorite, neurology/endocrinology. I'll be going through a host of medical fields, cardio, gastro, nephro, you name it. Not to mention the added responsibilities of a second year medical resident.

And don't forget extended time at the ER and ICU - the dreaded rotations.

Sure, I'll miss my surgery dreams but I'll still practice shadow stitching and knot tying when nobody is looking, and I'll miss out on earning more and living the life moonlighting.

I guess I'm on my own adventure.

When I started out, I didn't get how people get into internal medicine. Yes, some part of it appealed to me then -- diagnosis, patient interaction, being in charge -- but I didn't get the dynamics of the field, the medication interactions, the fluid management and a whole lot of other stuff I could fill in but I won't. Now I have an idea of how much understanding it takes.

Not that I fully understand it yet, but trying to.

I'm one year in. Two more.

Two more and then the rest of my life.

My vote

Elections are fast approaching, and each candidate who is hoping for a shot at the glory of the presidency are out there, reaching out to people through media -- written, radio, and largely TV.

I hate traditional politics but I cannot deny its entertainment value. When election time comes, you can't help but get the latest fix of who is stacking up the most dirt against who -- from affairs and corruption to digging up old unpassed bills.

Every election time, we renew the hope of reviving our country from traditional politics and the entrenched corruption, yet who do we have as candidates? The same breed of people who were running the country in the first place.

That is why I've always been drawn to candidates who offer a reasonably radical change from the usual suspects, the usual program of change and the usual traditional politics.

The last time I voted, it was for the late Raul Roco -- which was a good couple of years ago.

I don't know if I'll get to vote this year, with residency and all. But if I do get the chance, Noynoy will most likely be at the top of my list.

I think someone who is running that actually doesn't want to run qualifies as a good sign. Having someone who does not have a premeditated plan to grab the presidency is somewhat refreshing in this power-starved government.

Whether I change my current opinion and whether I actually get to vote remains to be seen. I challenge you to convince me.

I think Conrado de Quiros said it best that Noynoy would probably be the only candidate among the rest where people will not mind being cheated on.

I think that's funny.

It's probably true.

Deadlines

Definition: Days I dread because I have to have something on that day to show for an effort spread out over a given period of time.

In the span of the next two weeks, I've had deadlines shoved in my face from a thick wad of census papers and evaluation forms, case reports, my first medical grand rounds, journal appraisals, and presentations for each one. I've driven myself crazy, sleepless over the past few days just to keep up.

I've caught a few breaks along the way -- a cancellation, being assigned to the Outpatient Department (though ER assist isn't really an easy rotation) and of course Tonette.

But all through the muck, I realized that it has almost been one full year of internal medicine residency under my belt.

And hopefully, hopefully, I'll move up a year level come November 1.

That's one deadline I welcome.

Deaths That Matter

There were a couple of deaths that mattered this past two weeks -- well, it probably did not matter to the rest of the world who did not know them but, they were intertwined and I was right in the middle of it.

In my ward, I had this patient, Mrs N who was suffering from gallstone pancreatitis. She had a poor Ranson's Score on admission and on re-evaluation 48 hours after. Her abdomen was distended with fluid and she was starting to get a yellow tinge to her sclerae and skin. But she was a fighter and gave it all she had -- smiled through the air hunger because her diaphragm was being pushed upwards by the fluid in her abdomen, followed all the restrictions, and was an over-all good patient. A doctor could not have asked for more. Her husband was always there beside her, encouraging, making her laugh, and buying the expensive medications without question.

Over in the ward next to mine was another patient, Mrs R who just found out she had lung cancer and was suffering from malignant pleural effusion (fluid in the lungs) for which she had to undergo an insertion of a tube into her chest to drain out the fluid. Pneumonia was quickly setting in and the infection was overwhelming her defenses.

Last week, on one fateful day, their paths crossed.

Mrs. N's condition worsened. She underwent an ERCP to remove the stone which was done without a hitch but a few days after that, she began to bleed. She vomited and put out blood, her blood counts were still high indicating an infection and her blood gas measurements showed severe acidosis (yup, that's bad). In the hopes of monitoring her better, her attending physician wanted her transferred into the ICU but she was number 8 on the priority list, which was not too soon enough for the attending. She told me to ask a favor from the one on top of the priority list -- Mrs. R.

At the time, Mrs R was morbid but stable. Her blood pressure had not dropped in two days. I spoke to her attending and to her and she gave me a smile, "It's okay doc, you can give my spot to her, she needs it more than I do."

"Are you sure?" I asked again.

"Yes doc, it's ok. I feel fine at the moment. Maybe if, God forbid, I have problems, I'd like to ask the same favor from the other patients." she calmly said.

So I said my thank you's, and Mrs N was transferred into the ICU.

The next day, I learned that Mrs N gradually deteriorated and was intubated, and a combination of disseminated bleeding, severe infection, and shutting down of her kidneys were among the few problems she was facing and had to undergo dialysis.

What made matters worse, was that Mrs R's BP fell. Her vital signs were unstable and infection was also taking over her system.

I was tried in vain to find a spot for Mrs. R to take so she could be moved into intensive care and I managed to move her up from number 8 up to number 4 and all the way to number 2, but, alas, they had no more money. Their lands had all been sold to keep up with the growing hospital costs.

I didn't have the heart to face her again knowing I failed. I talked to my co-resident in charge of her ward and even found out, she had expressed the desire to be transferred into the ICU, but the family had decided on a DNR status knowing full well the prognosis of her condition and the financial situation they were in.

She passed away the next day.

Meanwhile, Mrs. N was also losing her battle with her pancreatitis. The infection, the bleeding, the acidosis all took its toll on her body and she gave in and passed away the next day was well.

Before she passed away, as what I heard from the ICU staff, she pulled her husband to her side and said, "Thank you for loving me. Even up to my death, you're still here by my side. Thank you and I love you."

Hearing that, I was awash with emotions -- sorrow, guilt, failure and then later admiration.

For Mrs R, thank you for showing me the meaning of what selflessness truly is.

For Mrs N, thank you for showing me the meaning of what loving and what never giving up and finally letting go should be.

I've long posted that there will be many deaths on the roads we've taken, some harder to accept than others, some easier to let go, but what matters most is how we let it affect us.

As I close, I want to say, you mattered to me. You have affected my life in more ways than you know and I will carry the memories of these past few days with you as I go on treating patients and helping them through disease and in living my own life as well.

Thank you. Rest in peace.

Lessons Learned

Another month, another last minute last-day month post. At this rate, I'd be out of the blogging world in no time.

Well, August has come and gone the miles of hallways I've walked while doing rounds have officially crashed my body's odometer. Yet despite a fever (of unknown origin) and a depressed immune system, I forge on (jeez, the dangers we go through to take care of others, and sometimes forget ourselves).

Lesson number 1: Fate is twisted.

I've noticed that in a residency, there is always that certain consultant you mess up against. My co-resident Mush manages to get by with his slick hairdo and eyebrow-raising with most consultants, but goofs up against a certain cardiologist, who has corrected him several times from brand names to updates. Another co-resident Ian, drew the ire of a particular neurologist since I introduced him as a newly accepted resident, and since then he accidentally lost the signal of an important telephone call while updating him and he had vehemently emphasized they were not done talking.

For my part, I seem to spaz out with a certain pulmonologist from seemingly being nervous on updates (I try to talk fast, so I finish fast, so forgive me for seeming out of breath), to not intubating a patient in distress (the patient's family had opted not to intubate the patient, and he was sleepy-slurred in giving instructions).

Fate is truly twisted as much as it is wonderful sometimes.

Lesson number 2: The beating you get in a conference or some Q and A, is inversely proportional to the amount of preparation you had for the said event.

Faced with an unexpected turn at presenting a case at our weekly ICU Conference (which IMO is a bit weird being we present and defend management that are entirely not of our own choosing), I chose yet another doozy of a cardio case of Digitalis Toxicity. I wasn't ready having just prepared the slides the day before with Tonette. So basically, cramming was the only option. And that I did, thankfully, I managed to study the right stuff, and came up with some original facts for everybody to digest. (Hah! Hyperkalemia is protective for DigTox! But up to what level, I really don't know).

Lesson number 3: Sleep when you can.

I miss going back to sleep when waking up in the morning.

I vow to write more. But with the upcoming deadlines, aaggghhh...

Case reports, census (censi or censuses?), ECG's to read, books to read, reports...

September 30 it is. Hahaha
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Congratulations to Stephanie for passing the boards!

Here's to July...

I can't believe I haven't posted for July yet. Not a single post -- until this one and on the last day of month at that (don't get fooled by the date)

It has been a busy, busy, BUSY month for me.

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Doctors have this end of the month thingy called a Mortality and Morbidity Conference where we discuss all of the bad cases and deaths and see where we could have been a bit better to save this patient or that, but mostly really just nitpicking at diagnoses and theoretical/diagnostic dilemmas.

I had the task of presenting that particular case. Oh and what a doozy of a case it was. They say it was a pretty hard case to present -- loaded with cardiology with a dash of infectious disease and nephrology -- and I got roasted at the podium. I was sweating in a fully airconditioned room trying to answer questions from mundane basics to intra-operative cardiac surgery!

Good news, I got through it without them telling me I failed.

Bad news, I have to do it again in a couple of months. Aaaagggghhh.

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A mentor once told me that a back-breaking residency is necessary to getting better in the chosen fields of medicine you want to specialize in (you still haven't told me why Doc Ness....hahaha).

I mean, I can understand the back-breaking part, the physical willingness to do all the legwork to get a few more tidbits of knowledge here and there, and I've always gone the extra mile to get that, but the veiled insults and sarcasm, the stereotyped first impressions, I don't see that helping me any.

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I Love You, Man is a funny, funny movie.

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Imagine seeing a teenager with a double outlet right ventricle and so much future in front of him, undergo a total correction of his congenital anomaly and walk out of the hospital on his own.

Small victories.

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We have to contend with Christie telling us she's not coming back after her scheduled vacation leave.

I meant when I said to her that, if she's better now than when she first came in to this residency, then no one can take it away from her. She's all the better for it. If she stops now, then no one can blame her, because that's a decision she'll have to make for herself. But Ate Christie, no consultant, no senior, no person, nor animal can talk down to you and make you feel any less than what you think you are.

We -- Mush, Len, Ian, Jeff, Gladys, moi -- think the world of you and would love to have you come back, not only because it would mean one more to share this load we have on our shoulders, but more importantly, you are our glue. You keep us together and for just that, we'd love to have you grace us with your crazy, zany humor on August 8.

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Love just gets you through the day -- sometimes you realize it, sometimes you don't. But when you have someone who lets you sleep when you've gone the past 36 hours without it, or helps you with work, well you just can't go too long before you realize how great it is, to have someone love you back.

Thanks hon. I wouldn't have survived July without 'cha.

We Will Remember

I join the world in mourning as we lay rest to Michael Jackson.

I still vaguely remember, I was 8 years old running through our living room and my dad's stereo was blasting "Off The Wall" and "Wanna Be Startin' Something." We all had our favorite Michael Jackson song -- "Man in the Mirror" and "Human Nature" comes to mind -- mine will always be "Rock With You."

His death makes me feel, among other things, old.

His death renews my fear and my strength in my mortality.

We can only hope to be remembered once we pass, and Michael Jackson will live on in his music.

Thank you Michael, you made all of us who heard your music moonwalk together.

Getting Through the Day

One of the best things about being in medicine is that I get to meet people -- some I get to like and even get to be friends with, while some I just can't stand to see the sight of.

As I arrive around 6:45 am and get off the elevator, I enter the ward rooms I give a smile to Lolo G who is finally going home after spending nearly a month in the hospital. Their family is pretty remarkable as they've pulled together to get Lolo G through obstruction, intussusception surgery, post-op stroke and hypokalemia, to finally going home. They aren't the richest patients, but as people they are just as wealthy as most people. They've never grumbled about the costs, or the treatments, but trusted us to do the best thing. Now I'm just happy to see Lolo G smiling, toothless as he is, as his wife and daughters share a laugh around him. We go through a hundred wars with disease, dilemmas, and treatment failures, but I'll take them all on to have even just one victory such as this.

I leave to go on with my rounds, I see Mr D's family. Their outlook is not as good. His disease is an intracerebral tumor bleed and with alcoholic liver cirrhosis, makes it impossible to operate on, not counting the money they don't have for the surgery. The hemorrhage, plus the encephalopathy has gradually taken over his consciousness and is slowly bringing him to the brink. I look at his mom, every so often tears flowing down her face at her beloved youngest son, and pleads to me to help her. My heart breaks knowing full well the prognosis. I give her a "hang-in-there" smile and move on. Mr D would pass away that night.

Each patient has his or her own story, his or her own life, and happenstance has made me a part of theirs.

I'm just amazed at this job sometimes -- I guess, it's just me realizing all over again, I love what I do.

There are times that I just feel really really tired, burdened by responsibilities and the demands that the residency program and the profession brings, but at the end of the day, when I get the chance to lie down and sleep, I realize, I wouldn't have it any other way.

Sabbatical Recall

Today is the last day of my 1 week vacation leave -- a week where I didn't have a life in my hands, nor did I have to call and update any consultants on the condition and lab results of their patients -- and it nearly isn't enough to recharge the past 7 months of toil, sweat, and tears, and to come back and do it again for the next couple of months.

But it's definitely better than nothing.

My co-resident Mushar has his leave planned out already (though he did take a one-day "leave" to contemplate his life plans last month) and it consisted doing utterly nothing on the first day but a DVD marathon, the next day would be touring his hometown, the third would be a visit to the beach, and you get the picture -- relaxation and nothing remotely related to medicine.

Well, I'm a different animal, I guess.

June 1

I took a plane home, which was probably the more cost-effective way to travel, but there is always something relaxing, something spiritual with a long and quiet drive home. But after the reverie of Erving's wedding the day before (my heartfelt happiness and joy to Erving and Kay), I did not have time to prepare, so the plane it was.

I settled into my room, and brought out my reading stuff (yup, part of my idea of a vacation is doing some work without the pressure), and did what I sought most of the week to do...sleep.

And I did mostly that, and watch a little bit of TV now and then.

June 2

Frequently checked with all the blogs I follow, and it seemed everybody was taking the week off as well, except for Doc Ness of course. I attempted several times to write but nothing really came to mind (I failed in the attempt to make up for all my unblogging times by blogging everyday during this week), so I just let it go, content to browse the web for news and sports rumors about my beloved Pistons.

I got to starting on reading about my case, a supposedly rare case of Thrombotic Thrombocytopenic Purpura (everybody I've mentioned this to seem to be of the opinion that this isn't as rare as I thought it was, but well, it's incidence is 3.7 per million, I'd say that definitely isn't run-of-the-mill). I got to see SUMC again, and see a couple of friends.

Saw Kea as well, and she's pretty big now. We went to Manong Roy's despidida party, as he's finally off to Canada to join Manang Rhea as immigrants. See you guys when you come home.

June 3

Smoke tested the right car.

Pored over the charts of my case.

Transferred some notes into my trusty notebook.

Rode the afternoon away on the motorcycle -- gassed it up to a full tank and took a quarter off just riding around the city. It is another way to get a tan in Dumaguete without going to the beach. Sadly, Taster's (Home of the world's BEST BURGERS) is closed temporarily for renovations, as is much of the city's asphalt roads.

June 4

There's nothing like wind in your hair zipping through the city streets on the motorcycle. Couldn't find Ver or check if Aning was really pregnant na. Congratulations.(Though I've been hearing she is, she vehemently denies it. Nothing wrong with that Ann.)

Ai-ai arrived today. I missed my little sister (hehe, she's big time now)

June 5

The Magic got dumped on in Game 1. I've always rooted for the underdog, except when the Pistons are playing, but 25 points? In the NBA Finals? Jeez, c'mon Howard you can bowl over Bynum and Gasol on your off-days.

Jassen and Carol arrived. She's a cool girl, and I'm happy for my brother. Anybody who makes my brother happy is all right by me.

Most of the family got together to pray, and celebrate all of our birthdays. I saw my nieces and nephews running around all night, and the food was as sumptuous as always.

I'll be leaving in the morning. I have Tonette's Date and Walnut cake, Sans Rival for the people at the hospital, and Pianono and Chicharon all around (I think they ate the Pianono at the time of this writing na, Mama Gaya, next time na lang).

June 6

Back in Cebu. I got to ride on the extension all the way to Cebu and my back ached all over. Got some work done on my census, and took Tonette out to dinner.

The week is almost over.

June 7

The last day of freedom. I did my rounds of my ward and saw what kind of patients I'd be up against once I sign my name into the attendance logbook tomorrow.

I laughed quite a bit on the rumor that went around the hospital that I'm quitting residency (don't tempt me, haha), and was touched that a couple of friends (yup, brothers and sisters in arms, if you will) would call you up (wake me up, for that matter) and asked me to stay. Sorry if I played around a bit, but I'm stuck with you guys for the next couple of years, (or you are stuck with me, deal with it), that is until the next time I go on leave.

Right now

My back still hurts.

I feel like I'm still on the bus.

I lost to the Hornets while playing NBA 2K9.

I think I'd better get a good night's sleep so I can get up early.

The week was definitely good while it lasted.

On The Lighter Side...

In my last conversation with my mom, she said she got scared while reading my last entry, (somebody has to do it, ma) but she also said she had a laugh at the juicy fruit comment. Whoever says that being an ER doctor or any doctor for that matter is a cool, profitable, and easy job, is dead wrong. It often comes to the point of arduous toil, and yeah sure you get some money out of it but not often commensurate to the effort unless you get a really really big practice and it is a big responsibility to have another 's life in your hands, yada yada.

Anyway, I've posted so much about medicine, residency on this blog, I guess I'd like to turn the attention of you who read this blog (however few you guys are, hahaha), to something, well, light...

Like:

Archie finally gets to choose!

Between Betty and Veronica that is. Yup, we all read the strips once or twice, and personally I'm a fan. I read in an article linked on msn.com that publishers are gonna make him choose between girl-next-door Betty Cooper and sophisticated-sassy Veronica Lodge.

I say he really can't go wrong.

And how about:

This guy.

Kris Allen pulls off the ultimate idol upset by upending apparent favorite Adam Lambert for the American Idol crown. Not to take anything away from the cool laid-back sound of Allen whose stylings I can definitely agree with, but I'm thinking there were a whole lot of people who didn't want Adam Lambert to win, than actually voting wholeheartedly for the eventual winner. Personally, I liked Danny Gokey's voice and got to appreciate the sound of Allison Iraheta's voice, but Allen's victory definitely sits well with me.

And finally:



Good night!

Hehe

ER Forays of A Newbie

Our training program here has one quirk not found in other hospitals in Cebu (or so I think) -- first year residents get to go on duty at the Emergency Room.

Yup, First Year.

The reason given to us was that it would double our exposure to ER duties, and we get to see more cases, and get experience on how to handle these patients first-hand.

I get the logic, but that doesn't make the anxiety of being alone at the desk fronting the Emergency Room doors any less stressful. It takes triple the testicular fortitude to survive and conquer the fear of what comes in through those two swinging doors. So scared am I on nights prior to ER duty that I fear and depression drives me to my knees in prayer that everything would go smoothly (but it rarely does) and that He will be with me every step, order, and IV insertion of the way.

One thing for sure though, ER duties certainly have given me so many moments:

WORST: There was one time when, the outpatient consults were endless into the wee hours of the morning and right up to endorsement time, and after I got received (the next shift comes in) I literally had to run from room to room, ward to ward, get all my X-rays and scans, ECG's to get ready for endorsement (grilling time), and needless to say, I got fried to a crisp.

BEST: Just recently, at my last ER duty, we had someone come in, in severe respiratory distress. He was brought to the hospital by two of his neighbors after they found him knocking on their door for help, all blue and air hungry. We didn't know what he had because of a really poor medical background given to us, all the neighbors knew was that he smoked and drank a lot, was admitted the year before and a handful of medications in his bag. It was a cross between respiratory and cardiac, which is which we didn't know. He flatlined for about 5 mins. We treated him as best we could and revived him to full consciousness. To see him writing his name on a piece of paper, considering he was probably walking towards whatever light at the end of the tunnel he was in, is joy immeasurable to me. Now he has a second chance to be able to make peace with a family he has left behind, and that is just gravy.

FUNNY: An order on a referred patient's chart: "May eat juicy fruit - not the gum."

SCARY: There was a time where I had no activity at the ER whatsoever for the whole afternoon of a weekend duty, the calm before the storm if you will. Then it got crazy as first an arrested patient came in, probably a massive heart attack, followed in seconds by an electrocuted patient in ventricular fibrillation (a really scary heart rhythm). Needless to say again, everybody got plenty of action and exercise that night.

DRAINING: You get to take on really demanding patients from expats who think they deserve top billing because they earn dollars for a living to aristocrats and the psychologically-off patients who think they are the only ones in the ER.

COOL: I once said that if I could not become a surgeon, I'd be the one at the foot of the bed manning a code, shouting lines like "We need an ABG stat," "Start Dopamine 400/250 at 10 cc/Hr," or "This ECG shows an ST Elevation in Leads II, III and AVF, Morphine 2 mg now, O2 at 2 Lpm, ISDN drip at 10 cc/Hr, and Aspirin now."

And now I'm getting to do that.

Maybe not as confident, not as fluid nor as collected as I make it to be, but I'm definitely working on getting there.

It's been so long since I last posted that I'll be going on another ER duty in the next couple of days, so, gulp, here we go again.

The Lull of Lent

Cebu is surprisingly quiet for Lent -- that is compared to the regular hustle and bustle of the regular work week. I still remember celebrating the Holy Week in Dumaguete and recall the near empty streets, the processions, and the one of the few days of the year, or if not the only day, where we don't open up shop at the market to sell meat.

I came from duty on Maundy Thursday and we were on skeletal duty (to the nonmedical people, meaning only those on duty would be roaming the hospital). After endorsement, I was on my way home, and I the lesser-than-usual number of taxis and jeepneys driving around, the malls were closed and the quiet was a nice change from the honking and the revving of engines.

I spent most of the day sleeping, enjoying the peace and the sedative effects of the mid-afternoon breeze and went to say a few words of thanks at the church.

Good Friday was even more serene and beautiful and I took time to breathe in the freshest air I've ever inhaled since I've been in Cebu. I took the time to do some long overdue cleaning.

This was always the best thing about the Holy Week -- the peace, the quiet, the time for reflections, and in the same way I've always ended it, a prayer of thanks for Him who came and saved me.

And of course gave me a schedule where I could enjoy two skeletal duties in a row.

In connection, a couple of my posts that I remember having fun making or just simply made my day:

1. Who Wants To Be A Superhero?

2. Some Good Things

3. A Pedestal For Mellie

4. It's A Little Bit...

5. Piano By Starlight

6. The Years Gone By

7. Death Becomes You

8. In Sickness and In Health

9. Behind the Half-Rimmed Specs

Behind the Half-Rimmed Specs

Ahh, introspection. Where does one begin?

Lying down in my quaint rented bedroom, staring at the dirty-white paint on my ceiling, I paused to think how to write this next entry. As sleep slowly drifted and took away my conscious perception of the night, I took off my glasses and just stared into the blur.

There are two sides to my life at the moment, the one that exists and the one that exists in my head. The basics are out there -- Dumaguete City, Physical Therapy and on through medicine, though I never knew exactly why and how I came to be the doctor I am today and residency is the imposing and prevailing presence in my life at the moment.

I blink and pause to think about what I could do had I not chosen this path. I still love to lose myself in music and song as I float my fingers over a piano, or find solace and freedom in the lyrics I can make with a simple melody. Or had I worked hard enough, could I have played a sport for a living? Or anything remotely related to sports? How about movies? Me and showbiz...

I blink again and realize, I'm drifting off into slumber. Well, I guess while I'll do medicine, I'd do all those other stuff on the side.

Reflecting on the day that has passed, I still remember the mortalities that mattered, the mistakes and the right decisions, the days where I was too tired to think and the good days where going into a patient's room and giving good or bad news came easy. There those really depressing days where I'm tempted to stop and rest and those days where I feel really good that I did something right.

I twist in bed and accidentally roll over onto my glasses and I quickly remove it from under my shoulder and place it on my side-table.

These glasses don't hide a Superman, but I'd love to be a mild-mannered doctor and leap tall buildings in a single bound as well. I'd be the Philippines' alternative hero to Manny Pacquiao. I'd stop bad guys left and right, arrest corrupt officials, get rich, save lives, be someone, and the whole world will remember me....

And then I wake up...

Stare into the streaming sunlight...

Off to work again.

Maybe tonight I'll dream another dream.

I take a bath, stuff all my books and clothes in a bag, take my glasses from the table and got ready to go though another day. Oh the joy...

Medicines Are Funny Funny Things...

I am a really funny doctor.

Most of the time, while I'm giving prescriptions to my patients, I find myself asking if the medications I'm actually giving really do work. I wouldn't go as far as saying I doubt every medication I dole out, but I find myself skeptical most of the time.

Take for instance, cough medications. I've given my share of cough medications over the years I've had in medicine from internship to residency, and none of them seems to really stop the cough. Mucolytics, expectorants, antitussives, antihistamines ugghh, they seem to just not do the job. So, if asked what medication I'd want to give to patients having cough, on instinct, I'd say water. After all it still is the best mucolytic, in my opinion.

Well, it's different if you know the problem, say TB or Pneumonia, for which we can treat the cause of the problem. Antibiotics are great drugs. But again, there are stuff to consider like resistance, the bacteria you're up against on whether they're wearing Amoxicillin shields or Cephalosporin-proof vests. So you end up with just a grand old time figuring out what to give until the sensitivity testing comes out, that is if there are discs to use or microbes that grow on the cultures. Which is why most doctors start out with really broad spectrum antibiotics nowadays and work it down once the testing comes out.

Neuroprotective agents for strokes? Hmmm, skeptical, though theoretically sound.
Appetite stimulants? Nothing more appetizing than a well-cooked and seasoned meal.
Vitamins? A good diet is still the way to go, in my opinion. Vitamins will not save your liver if you keep on drinking alcohol or your lung if you keep on smoking. Most people think all they need are vitamins, asking for them left and right, and I make a face, but when all that's said and done, what they need is a healthy lifestyle, a healthy diet, a good dose of exercise and proper hygiene.

Don't get me wrong, I'm not trashing medications nor am I trashing my own profession. I love my job (though it's been often described as having a degree in knowing nothing) as we often get to save lives provided we get the right medications to the patient.

And there are drugs I believe in, after all, I'm still in Internal Medicine, say adenosine. I marvel and I hold my breath at the same time while watching that long, long, really long pause on the scope and gradual return to sinus after a supraventricular tachycardia. There are others like beta-blockers, epinephrine, norepinephrine, and a host of emergency drugs.

There still is good old Paracetamol, which when combined with a properly done tepid sponge bath brings down any fever in a matter of minutes. The nebulizations are pretty dramatic as well. Cardiac-wise, warfarin and aspirin have been pillars of the medical arsenal for a very very long time.

Medicines are really funny things. Some work. Some don't. Some you just can't see.

I guess that's why doctors are around to figure stuff out.

If we ever do. Hehe.

Kaleidoscope World

When Francis M passed away last week, I didn't think I'd be that affected, given that I never knew the guy, I didn't avidly follow his music nor did I patronize his clothing line.

But when news of his death broke out on the news, I could not help but feel the loss being shared by the members of the entertainment industry. It was more than just another showbiz personality passing away -- definitely, more than just that.

Well to me, Francis M played a big role in MY generation. Sure, we all did the dance to "Man from Manila" and "Mga Kababayan" way back in grade school. Some of my classmates even went as far as to imitate his clothing choices. At that time, he made rap cool. He was Philippine rap, hence his showbiz-imposed coronation as the king of Philippine rap.

What I most remembered about him during the days when I'd be playing marbles beneath the calachuchi tree in my grade school or sweating in the midday sun playing basketball with my worn Grosby rubber shoes or whether I'd just be sipping my Hi-C Orange drink in one hand and a 5-peso bag of spicy hot peanuts in the other, was that he championed the Filipino. And for that, I'd always feel connected to him in some way.

As I grew older, in my opinion, so did his music. I grew to like his Rap is FrancisM album and particularly liked "Meron Akong Ano" and the Royal Tru Orange jingle "Ito ang Gusto Ko."

But his masterpiece, in my opinion, had to be "Kaleidoscope World." It became an anthem for peace, equality, pride and a host of other things and it helps that it has great melody to groove along to.

I grew with Francis M. That is why in his passing, I can't help but be sad, not just because we've lost a pioneer in our entertainment industry, nor is it because I feel my age with his death, but it's more because my generation has lost an icon that championed Filipino pride, music and equality.

Rest in peace FM.

Truly, Every color, every hue
Is represented by me and you
Take a slide in the slope
Take a look in the kaleidoscope
Spin it 'round, make it twirl
In this kaleidoscope world.

A FreeMan with A Free Mind

Catching Up

It's been a while since I faced the blogger screen and typed my thoughts away, but now that I have my own connection, (woohoo!) I'm looking to do it more often, not as often as Doc Ness does, but once in a while, as opposed to never. Haha.

Residency is all I've had on my plate since starting almost 4 months ago, and it is pretty evident that it's about all that's happening in my life because all my latest blogs are about it. I have to admit, that there are times when it's really hard to get up in the morning and letting go of 5 precious minutes of sleepytime and get dressed for work. But it has not come to the point where I hate going to work, so forge on we shall.

Random thoughts:

1. We began residency 4 months ago with initially 4 doctors. Of the first 4, one quit. The next 4 came in last January, 2 quit (after 1 24 hr duty! arrghh). It's hard to lose a co-worker, sort of a brother/sister-in-arms if you will, who came in with the same purpose as you did, and cover for the same person's workload after he/she is gone. But now, we are at full strength again, and hopefully we make it through together.

2. Residency has become survival of the fleetest (fastest walkers get labs first, and do the appropriate intervention and finish their rounds first). When I slow down, literally, from my regular walking pace, my fellow residents whizz past me. Everybody walks fast. Well, it helps that I take big steps.

3. I did not know Dr Madamba personally, but I knew him as one of the institutions of pediatric practice in Dumaguete City, and even had 1 check-up with him when I was a kid when my pediatrician was out of town. For him to go in the manner that he did (he was shot, for those who did not know) is a tragedy and I hope the perpetrators get brought to justice. Not only does the city lose its only allergologist albeit in pediatric practice, it loses one good doctor.

4. I sit here with the Eraserheads reunion concert CD on the player (thanks hon), and they still sound good. Some good things never do last.

5. Slumdog Millionaire wins Best Picture! Truly, one of the best films of the year. If you haven't seen it, you should.

6. Congratulations to old friends and classmates who passed the boards -- Jeanette, Laurje, Jouie, Rainier, Ver, Chiong, Pura, Dinkoy, Siao, Nevi and all those who took the February 2009 boards. Welcome to the club. With your license comes great....you know the rest.

7. I'd like to apologize to Nevi, Cindy, Baby Boi, Carrie the other day. They passed by the ER and I was busy as heck with a full house and I wasn't able to chat. Uhm, my mood was less than pleasing during that time, but I think I managed a smile in between writing orders. Congrats guys.

I'm off to catch up on some sleep, err, work with today being a skeletal holiday.

Oh the simple joys...

Good night...

Tales from the Residency Dark Side

I had my first complaint this week. Or at least I think it was for me. And I don't think it was deserved.

I saw a patient the other day, something like a 29 year old female complaining of chest discomfort, squeezing in character associated with shortness of breath. I saw her a bit later in the afternoon and came into the OPD with an ECG in hand.

Nada, sinus rhythm, non specific ST and T wave changes (for lay speak, perfectly ok).

During the interview, I found out she has had this complaint fairly recently, she recently took the bar and was awaiting the results, and the night prior, she got into an argument with his brother.

No history of heart disease, high blood pressure, diabetes, and the like.

I pretty much came up with an anxiety reaction or a hyperventilation syndrome.

Sure, sure, it still could have been something more severe like a heart attack and the like but practicing here in the Philippines have forced doctors to sharpen their clinical skills and all the years of internships (though not much yet) told me that this was nothing like that. I could never, in my right mind, order for stress testing, angiograms or even cardiac enzymes for a clinical setting like that.

So I proceeded into what was like a 15-minute discussion of her symptoms, explained that her ECG was ok, and advised her to come back should she have any further problems.

I asked her if she had any questions, and she told me she was fine.

The next morning, while at the ER, the nurse received a call from the insurance coordinator relaying a complaint that someone consulting for chest pain the day before was not properly diagnosed.

I was pretty certain it was her.

Everybody can't be pleased. Would she have rather welcomed the news that she had coronary blockage rather than an acute stress reaction? And after spending the time I did to explain to her and her boyfriend, the nature of her reaction, I get that?

But I'll take that, 1 undeserved complaint in 4 months from a well-attended patient, that's a pretty good rate, I'd say.

Or maybe some people just have a funny way of saying thanks.

Small Blessings

I think we've all received this text message:

Little birdie in the sky
Dropped a poopoo in my eye
then something like
I thank the Lord, that cows don't fly.

You get the message, right?

I couldn't help but remember this message as residency life goes on for me (gasp, going 4 months of Internal Medicine, who would have thunk it?).

I went on rounds with one of my consultants the other day and came to a really well-off patient in the suite room on my floor. While doing the usual check-up -- BP, physical examination, pulse rate, a random scan of the labs and ECG -- the usual chit chat came to discuss his many medical problems and previous hospitalizations. He had Coronary Artery Disease (fancy medical term for heart blood vessel blockage), hypertension, Diabetes Mellitus and had underwent bypass grafting, percutaneous transluminal angioplasty, and a pacemaker insertion all in the last 8 years.

He casually chuckled and said that he had too many problems and it was all because of how old he was.

My consultant shared a laugh and said, "Well, you have lived a full life."

My patient said, "Well, you know, life is like money, you can never have enough of it."

There it was, the lesson for the day.

Well, this statement was coming from a guy who owned companies (plural) and had loads of money, but he longed for more days to his life as well. It helps that you have money to spend during those additional days too, but what caught me was how simple a thought it all boiled down to: You can never have enough of life.

Then I was brought back to how I measured my own life -- the sleepless nights, the endless reports and assignments, the proddings from our superiors, the way we drag ourselves out of bed EVERY morning -- and stopped.

I realized, I didn't have to look at it that way. I'll try my darndest to look at the small blessings -- the extra hour of sleep I get for finishing work early, sharing a cup of coffee, studying with the beautiful woman reading William's Obstetrics across from me, helping people get well, the mystery and allure of diagnosis that got me into IM in the first place -- the small blessings.

It's true, you can never get enough of life. One would want to suck it's marrow for how many days we are given. But the funny thing about it is that we don't have that expiration date stamped across our foreheads, so even though how much likening the need for life to money, it isn't measured with the latter, it's measured in blessings -- the blessings of how we lived it.

So thank God for the small blessings.

Thank you for yet another day.

Off to do rounds again.

Tinseltown Gets Scrubbed Out

Ahh, don't you just love the movies?

I know I do.

From my earliest recollection of going to the movies with my family, and the Betamax tapes stacked up in the corner of our bedroom when I was a kid, to the new-fangled special-effects laden movies and pirated torrents of today, I've always seen the imagination and cinema of movies as my refuge from reality along with books.

That is why I love the movies.

To narrow down 10 of the top movies of all time would be, difficult, in every sense of the word. I've seen too many movies, and loved most of them, hated some, laughed with and cried from, and each of them cleaves a place for itself in my wildly imaginative psyche.

But, like most of those submitting entries for this TBR, one has to try. And so Scrubbed Out's Top 10 movies are:

10. The American President - I happen to have the biggest crush on Annette Bening, but, I love this movie because it gives us a glimpse of how love works, even for the most powerful man in the world and it's just funny seeing a president find time to date.

9. Indiana Jones / The Goonies - Hidden treasure, adventures, and good times with good friends. What's not to love? I used to imagine myself riding a horse with a Fedora on my head and using my whip to swing over a crevasse of snakes and alligators, and finding a hidden pirate ship with loads of gold bullions and jewels beneath our house. Now, I don't think of those things as often as before, but the thoughts do cross my mind. I wonder what's under my apartment? Hmmm.

8. The Count of Monte Cristo - Betrayal, revenge, intrigue. So much weaved into the storyline and I loved how Jim Caviezel played Edmund Dantes in this movie --cool and calculating. Don't you just love it when the good guy who goes through heck get his due in the end?

7. A Knight's Tale - For the witty dialogue and the rags to riches story of a squire-turned-knight. It's a perfect blend of comedy, action, drama, romance and good music. I like how seamless the movie transitioned into modern and medieval times with great and fun performances from the late Heath Ledger as William. See ending line of #8.

6. E.T. - A score for imagination. Who doesn't love what ET brought to our world? I mean, aside from Drew Barrymore.

5. Braveheart - I loved this movie so much the first time I saw it that I was trying to speak Irish for a week. But I eventually gave up, but watched the movie again, and again, and again.

4. Shakespeare In Love - Yes, this movie stars Gwyneth Paltrow, but I don't like her as much as Annette Bening, haha. I think the movie is beautifully made and rightfully won the Oscar for that year.

3. Love, Actually - Great great movie. And well, this movie holds more meaning than just the actual movie for me. But several love stories being told, intertwined beautifully into one story involving among other people, the Prime Minister of England, his secretary, two porn stars, divorcees, a widower and his housemaid, in a story you just have to see to love. Oh Keira Knightley is in this movie too! Hahaha.

2. Mr Holland's Opus - I love music -- and music with movies are a plus. Here Richard Dreyfuss plays a music teacher who has, as a goal in life, to compose the perfect symphony, and keeps putting it off to teach and make an impact on the lives of his students. He is a music teacher with a deaf son and goes to war against the educational system that cuts art programs in school. He ends up retiring without his symphony but realizes that his each student became the notes of his real legacy and in the end, a fitting tribute as his students render him his completed masterpiece.

1. Hook - You have to love Spielberg's imagination in this movie. That Peter Pan grows up and goes back to Neverland and to save his kids, he has to find that Peter Pan again. Now why couldn't I think of a storyline like that? More than just the story, the fun, and the general makeup of the movie, this is the last movie that I can recall that I watched with my mom, dad, brother and sister at the local movie house in Dumaguete. And THAT is why it tops my list.

Honorable mentions are the sports movies I love to watch: Tin Cup, The Mighty Ducks, Major League, The Replacements, Rad and all those wacky, funny, inspiring, heartbreaking sports movies, I can't get enough of them from.

I'm sure I've left out some movie I love somewhere, but as of now this is the top 10 list I'm going with.

Oooh, Underworld is coming up...