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
=========================================

Congratulations to Stephanie for passing the boards!