moments of peace (with sounds of drilling in the background)

It’s kind of a late announcement, but I guess most of you guys know that my internship is finally OVER! Can you believe that one whole year has passed, and here I am still, blogging away, with full body intact. I can’t even believe that I gained a few pounds, which was the total opposite effect that I was going for in this internship. Even my make-up hours for OB and Pedia are done. So now I am supposed to be doing my reviews but I still haven’t formally started yet. Can’t a person have her long awaited vacation? I already went to my province for some quiet time, but I decided not to fully give up my dorm because I still want to go to the gym near it, and the internet here is ultimately better than the one we have at home. I’ll go back to my house when my review session in PGH is over and that’s gonna happen a month from now.

Isn’t it ironic that the annoying sounds of the basketball game combined with the drilling/construction work which happened for about 2 weeks or more stopped on the last day of my internship?

On the last day of internship, we held the annual “sunog”, which means “burn”… A few days before all interns submitted their votes on their most hated, most burnable people in all of PGH… I guess this is the only way we will ever get back on those professors, doctors, nurses, and staff, and even clerks, who made our lives more difficult than it should be. I was going to post the pictures of the people who were burned in this blog but I changed my mind because they might get more humiliated and there are limits to the embarassment people could incur. Their pictures would be posted on a big poster in the hospital itself anyway. I think they got all the people right, except for a resident who should not have been burned (I believe that she was only pressured by her seniors… oh well… )

The only thing I miss about internship is the interaction with people. Right now, the best interaction I get is with the Internet. I kinda wish that the new tenants of the dorm would come already just so I could talk to some other people. This is kind of a good environment for really reviewing and I plan to use it to the fullest. The earlier the boards are done the earlier my new life will begin.

Just this morning, my cousin called me to consult about his daughter’s cough, and all I could think of is, it has finally begun. I feel honored to be acknowledged by my clan as the new clan doctor, even if I don’t have my license yet. Just the fact that he called me means so much for a new doctor like me.

As I review my anatomy, I realized how relatively easier it is for me to take in the data compared to when I was in 1st year medical school. The experience I got from clerkship and internship are the reason I guess. I realize now how important each fact is to my practice… This realization is what will keep me determined to acquire that coveted surgery residency in the United States. I may not be the star scholar, I may not be the brightest of the bunch… But I know I have the determination. I guess that’s why I can relate to those cartoon heroes who are average but compensates by there zealousness.

For those of you who continue to support me, thank you very much. I will try my best, and not only aim to pass but aim for the highest spot. If you happen to pass by Taft Avenue, let’s have some coffee… ^_^

daddy and me

I don’t know if a lot of daughters still have good relationships with their dads.  I know a lot of adults are telling the world how awful my generation has become, and how much we have grown apart from our parents.  I know for a fact that I grew up most of the time “yaya-guided” by my beloved “Ate Its” (yaya means nanny in Tagalog).  My dad worked day and night as a surgeon.  I would wake up in the morning and he’d still be asleep.  When I return from school he’d still be in the OR (operating room).  By the time he’s back I’d be asleep.  It never was an issue to me, because I knew he was just doing his job to earn money so that me and my 2 older siblings would stay in school.  Now that I have decided to follow his path, I couldn’t praise him more.  Most people would think that I have full advantage having a surgeon for a dad.  It’s partly true.  I started watching his operations when I entered 3rd year med school.  Just watched from the back, not assisting.  I started assisting during my clerkship, just last year.  He didn’t treat me like a family member but a real surgeon in training, and I thank him for that.  Now that I’m an intern, I assist him every time I go home.  The pic above this article is just one of our operations together (my dad is the one at the left).  He’d give out a snappy comments like:

“Your job is to make things easy for me, the head surgeon, not to make things worse.”

Then after the amazingly short OR, he’d treat all of us to dinner, like nothing happened.  He has taught me a lot, not just through his words but through his actions.  He lets me go with him as he makes rounds.  I smile at the fact that he sits beside the bed of his patient and holds his or her hand.   He explains  their diagnosis as simply as possible.

Whenever I feel that my mind is already so poisoned by the goings-on at my hospital, I just look at him and I’m reminded that there are still good doctors out there.

Like what one of my teachers said when I was still in med school,

“Never let reality dilute your values “.

I told my dad, “I wish I can be just as good a surgeon like you.”

His reply was simple, “I wish you would be a BETTER surgeon than me.”

Love you Papa! ^_^

when you don’t like what’s happening

In the medical field, your seniors are like idols… Supposedly they are put there on that spot to inspire you, so that one day you can be in that spot too to inspire the juniors that follow you.  Like in any typical medical series like Scrubs or Grey’s Anatomy though, there are those seniors that are just out there to get to you, to make your knees weak so that you’ll realize that you are not cut out to be a doctor.  These people I have learned to handle.  You just take what they say, let it go in your left ear and out the other ear.  These things should make you a better person, because like the saying goes, “What doesn’t kill me, makes me stronger.”

But this article isn’t about the power-hungry residents of teaching hospitals… It’s about the other kind of terrible doctor.  The ones that are in my opinion, unforgivable, and should never be copied.  They exist.  I know for I have seen this a lot.  But never to the extent like the one I saw yesterday.

Right now, I am rotating in the OB-GYN department.  It was a relatively benign time, and so I decided to take a breather and read on my case.  Then I heard yelling from outside of the Labor room.  It seems that a knew patient has come in.  The difficult kind.  Not the annoying arrogant type, but the silent type with mixed and confusing answers.  The patient was pregnant, but did not seem to be in a healthy state.  She kept her eyes low and refused to answer directly.  I could tell that they wanted to know the answers quickly because this patient looked like she could die that very night.  She had bruises on her body, with one particular bruise on her pelvic area.  And as this fragile patient sat on the wheelchair provided for her, some of my seniors (no names promise) swooped down on her.  They started yelling at her to make her blurt out what really happened to her.

In Tagalog, they said:

“WHY ARE YOU COVERED IN BRUISES?! WHERE IS YOUR HUSBAND?!”

“YOU KNEW YOU WERE PREGNANT AND YOU STILL DIDN’T GO FOR A SINGLE CHECK UP?!”

“HOW MANY TABLETS OF MEFENAMIC ACID DID YOU TAKE?  3?! DON’T YOU KNOW THAT’S BAD FOR YOU?!”

“YOU ARE THE MOST DIFFICULT PATIENT WE’VE HAD TO INTERVIEW THIS WHOLE NIGHT!”

This patient apparently never went for a single check up for prenatal care because she had no one to go with and she didn’t have any money.  A few days ago she was severely beaten up by her own husband for reasons she would not divulge.  This result in blows to her pregnant abdomen, cause her placenta to bleed (abruptio placenta).  For the pain, she took Mefenamic Acid 3 times a day for 3 days which caused her to start vomiting blood streaked material (NSAID induced gastritis).  They are also thinking of a coagulopathy or bleeding disorder (Disseminated Intravascular Coagulopathy) that could potential kill her.  And because of this, her 21 week old fetus was already dead for days inside her womb.

I could see why the residents were stressed about this patient, because she wasn’t a typical pregnant patient that they just had to deliver.  There was going to be a lot of explaining and managing to be done.

But I just couldn’t see why they had to resort to verbal abuse.  To think that this patient already suffered so many injuries from her own husband who probably verbally abused her as well.  Patients see us doctors as saviors right?  I could already see your faces shaking in disappointment.  I couldn’t help but feel ashamed that I was a witness to this embarrassing deed.  I don’t mind getting verbal abuse from my seniors because I know that they just don’t want me to make fatal errors in my own practice.  But verbally abusing patients to teach them to seek help urgently?  Do you think that patient is going to come back to such a mean doctor again?  I don’t think so…

There are just some things that I could never stomach.

I told my friend Hannah about this… She told me that there are just some people who are all brains but no EQ…  They know all the diseases and management, but when it comes to patient communication and rapport, they just don’t cut it.

I know I got a lot to learn regarding textbook knowledge and clinical practice guidelines.  I am just an intern after all.

But if there is one thing I will never forget, it’s that there are problems that you cannot solve by yelling.

If that’s what I need to be in order to be a smart doctor, well, no thanks.

Please don’t let me turn into them…

shifting dullness

Shifting dullness… It’s actually a physical finding that pertains to ascites, or to put it more plainly it’s like having abnormally large amounts of fluid in your tummy.  But when you are talking intern-lingo, when we actually say “I am experiencing shifting dullness right now.”, we mean we are in the state of adjusting to a new rotation or environment.  Right now that’s exactly what I am feeling… SHIFTING DULLNESS.  As I probably described in my earlier write-ups, medical clerks, interns and even residents have a schedule of departments to rotate in.  Like right now, I am in my second day in the OB-GYN rotation.  I am going to staying in this rotation for 2 whole months, and then later I am going to shift to Orthopedics.  That’s where we got the term shifting, I guess.  And when I personally come into a new rotation, I become this robot that kinda acts slow, still trying to get into the natural speed of things, trying to remember what I learned last year in clerkship, etcetera etcetera.  If you’re lucky, like me right now, you’ll enter a new department on a post duty status, meaning you don’t go on 24 hour duty on your first day, and you don’t have much work to be done, so you kind of get the chance to ease your way in.  But if you’re UNlucky, you enter the rotation as a duty intern, where you spend your first 24 hours running around still trying to recall, “What labs do I have to request for again?”.  It’s like riding a bike again after years of not getting on one.  You know what to do, and you’ve done it before, it’s just taking the time to seep it’s way into your system again.  Usually it takes a week for shifting dullness to subside, but letting it get to you makes you look lost.  And so now you know exactly how I feel at this particular moment.  Tomorrow is my 3rd day in OB-GYN, and it will be my first duty in the OB Admitting Section, where I get to see people frantically wanting to get in coz their water bags broke.  Please pray that my shifting dullness is cured by tomorrow.  And as extra precaution, I am going to be reviewing from this point forward.

Doctor Beans, signing out.

classic case

Patient for discussion today is:

General Data: RD, a 30 year old, male, single, Roman Catholic, Filipino, currently residing in Metro Manila.

Chief Complaint: rashes

Profile: Patient is a non-diabetic.  Known to have Prehypertension (According to JNC VII).  He is a heavy smoker, and is an occasional alcoholic beverage drinker.

History of Present Illness:

The patient was apparently well until 8 days prior to consult, when he experienced low grade undocumented intermittent fever (Temperature undetermined).  This was accompanied by low appetite and generalized body malaise, with no diarrhea, no vomiting, no headaches or abdominal pain.  Patient sought consult with a relative who is a doctor, and was advised to increase oral fluid intake and to take Paracetamol 500 mg/tab 1 tablet q 4 for Temp greater than or equal to 37.8.  Patient’s fever lysed 3 days prior to consult.  It was also during this time when erythematous pruritic rashes started to appear all over his body.  No medications were taken.  No bleeding episodes such as melena, hematemesis, hematochezia occurred.

On the day of consult, Tourniquet test was done, which revealed a positive result.

Review of Systems:

General: (-) unexplained weight loss/gain  (+) generalized weakness (+) anorexia

Skin: (+) rashes (-) jaundice (-) pallor (+) pruritus  (-)ecchymosis (-) hematoma

Head and Neck: (-) masses (-) lymphadenopathy (-) headache (-) nape pain

Eyes: (-) icteric sclerae (-) blurring of vision (-) eye pain

Ears: (-) decreased hearing (-) ear pain (-) discharge

Chest and Lungs: (-) dyspnea (-) cough (-) colds

CVS: (-) palpitations (-) orthopnea (-) orthostatic hypotension

Abdomen: (-) abdominal pain (-) vomiting (-) nausea (-) diarrhea (-) melena/hematochezia (-) hematemesis

Extremities: (-) weakness (-) edema

Past Medical History:

Patient has not had a similar illness before.  Patient has not had previous surgeries or hospitalizations.

(-) DM, HPN, Ca, Asthma

Personal and Social History:

(+) smoker

(+) alcoholic beverage drinker

Patient previously worked as a call center agent.

Diet is high in salt and fat.  Lives in a crowded community with note of stagnant water in the surroundings.

Physical Examination

Vital Signs: BP 130/90 HR 90 RR 23 T afebrile

GS: awake, conscious, coherent, oriented to time, place and person,  not in cardiorespiratory distress

SHEENT: warm, good turgor, anicteric sclerae, pink palpebral conjunctivae, (-) lymphadenopathy, no neck vein engorgement, no tonsillopharyngeal congestion, (+) HERMAN’S RASH
C/L: symmetric chest expansion, no retractions, clear breath sounds

CVS: adynamic precordium, normal rate, regular rhythm, no cardiomegaly

Abd: soft, flabby, normoactive bowel sounds, nontender

Ext: full and equal peripheral pulses,  no cyanosis, no edema

 ASSESSMENT:

Dengue Hemorrhagic Fever Grade I

CASE DISCUSSION:

This is a classic case of DHF I.  It presented us with 5 day history of fever, with anorexia, followed by the appearance of Herman’s rash, a pruritic (itchy) red rash that spreads all over the body.  A positive Tourniquet test strengthened my diagnosis.  I did not do a CBC with platelet count anymore, since the patient is already 3 days without fever, and I am expecting the disease to be over soon.  We would only classify the disease as Grade 2 if there are other signs of hemorrhage, such as melena or hematochezia (bloody stools) or hematemesis (bloody vomit) or gum bleeding or nose bleeding.

PLAN:

I educated the patient on the course of the disease.  I told him to watch out for any signs of bleeding and abdominal pain (which could indicate internal bleeding) and further increase in weakness.  I told him to keep eating, but to avoid dark colored foods so that we could easily determine if bleeding has occured.  I gave him anti-pruritic medication for his rashes.  If bleeding would occur, I advised him to get a CBC with platelet count done and to see me or my dad for us to determine if he needs to be confined in the hospital for fluids management.

The End.

P.S.  Get well soon, kuya Ryan ^_^