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… ^_^

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! ^_^

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… 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.

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 ^_^ 

Today was my first day in Family Medicine.  A part in my medical career, that I vow to PERFECT.  Come on, if you can’t be a simple all-around family doctor, then how do you expect to manage the really tough cases?  I was really nervous (as usual) going into the ambulatory care clinic, but I was lucky enough to have a wonderful resident with me, Dr. Fadrilan (is the spelling correct?)  She gave us a good introduction and orientation, and then guided us through the entire shift.  Duty in Fam Med is different from the usual duty in other departments.   Either you are day or night shift, each lasting for 12 hours.  It went by more quickly than I thought it would.  I was lucky enough to get the day shift on the first day.  Night shift meant that I still have to attend the morning OPD from 7:30-5 pm and then go on night duty from 7 PM till 7 am, and then going on OPD again from 7:30 am till 12 NN.  Night shift is pretty tough, and I go on night shift on Thursday.  That’s 2 days from now.  But for tomorrow I go on normal non-duty status, meaning just attending the OPD from 7:30 AM till 5 PM, with a quota of 15 patients per day (not so bad).  This rotation will last for 2 weeks.  and then off we go to Community Medicine!  Get set for the cool province shots that we’re gonna be taking while being doctors at San Juan Batangas!  ^_^ I’m kind of scared about the oral reports though coming up next week.

I got lots of stories already about the patients I encountered today.  But I’m kinda tired, so let’s just leave that for another day.  Thanks for reading! ^_^

I just realized that I had so many stories to tell during the time I was in the pedia wards but I didn’t write a single thing on my blog for the simple reason that I was really busy.  Well, I am finally done with pedia wards and I have now moved on to the Nursery Catching Area to take care of newborns.  I’m excited and frightened at the same time… Why?  Because this is my favorite part of Pediatrics, dealing with neonates (newborn babies).  I always said that if only I could have be a neonatology resident only and not have to deal with the other parts of Pediatrics that would be great (Fat chance!).  Tomorrow is going to be my first duty, and now I have this heavy feeling on my chest that I always get when I am anticipating the arrival of a new baby.  This is the only real place when it is music to my ears to hear a baby’s cry and to see it flailing about and turning pink before my eyes as it catches it’s first breaths.  It is magical I tell ya.  But the tension could really kill me.  I don’t know if I am just exaggerating, but the tension that surrounds keeping that newborn alive has reached a whole new level since clerkship.  As a clerk, you feel scared but comfortable because you know that your experienced resident or intern will always be by your side as you resuscitate that baby.  But as a PGH intern, now that’s a whole different story.  They warned us that there will be times when a resident won’t be there, and that now, you have a clerk of your own to assist you.  Ahh!!! Responsibility!!!  And with all the babies that come in to PGH in a single day?  Scaaaary… Please wish me luck, tomorrow is my first duty.  Let it be a benign one please I beg you.  Save the weird cases for later.  (ok time to review!)

A few days ago one of my dormmates told me that there is an issue going around the show Desperate Housewives. I’m not a big fan of the show, but I heard it’s a really good show. Apparently, Susan (played by Teri Hatcher, who formerly played Lois Lane in the Superman show “Lois and Clark”), made a racist comment, saying “Can I just see those diplomas ’cause I just want to make sure that they’re not from some med school in the Philippines”.

Those are pretty big words to say, and I don’t know if she knew the weight of her words when she said them. What a grand welcome for someone like me, a graduate and affiliate of 2 great med schools of the Philippines (De La Salle Health Sciences Campus and University of the Philippines – Philippine General Hospital). It’s kind of intimidating to think that I myself am planning to go to America to learn more about medicine and surgery, and that I may face racist comments like that. I can’t help but take it personally. Then again, this issue also made me even more eager to do my residency in the US, so that I can show them what a Filipino med school graduate can do.

“Black Jokes” are not being said much anymore since the African Americans learned to take a stand and to show them how much they are able to do. Most of the great singers nowadays are black, like Alicia Keys, Beyonce, and Babyface and Usher. They knew they were good, and so they didn’t let the color of their skin get in the way of their career.

I went into the medical career because I believe that I could make a difference just as much as any doctor out there. In real practice, no one hardly looks at your diploma to know if you are a good doctor or not. It doesn’t really matter to patients if you are from Harvard or if you are from PGH. What matters to patients is that they must have a doctor who shows sincere concern.

I also demand a public apology from the writers of Desperate Housewives and from Teri Hatcher herself for making such a racist comment. There’s no doubt about it. But we Filipinos should not just go and get angry and carry pitchforks and tie them to a stake like what they used to do to people who are different. I believe that the best way to end racism is to prove that our race is at par if not superior to theirs.

This is a topic that I want to be really thorough about. I wanted to write “emergencies” ever since I started training in the emergency room of PGH. Me and my fellow doctors talk about it all the time. It is the primary duty of a doctor to know what is and is not an emergency, and what incident is more emergent than the other. First let’s start off by defining what EMERGENCY is.

According to Merriam-Webster Online Dictionary:

Main Entry: emer·gen·cy
Pronunciation: i-'m&r-j&nt-sE
Function: noun
Inflected Form(s): plural -cies
Usage: often attributive
1 : an unforeseen combination of circumstances or the resulting state that calls for immediate action
2 : an urgent need for assistance or relief <the governor declared a state of emergency after the flood>

I prefer to use the first definition because it is more complete. There are 2 important keywords: unforeseen and immediate. Unforeseen circumstances include gunshot wounds, vehicular accidents, seizures, and strokes. Emergency rooms usually do not let these cases transfer to other hospitals UNLESS the ER is very full. In cases that they have to transfer patients, we make sure that the patient is STABLE enough to make the travel, while explaining to the relatives that there is still a risk that the patient MAY die on the road. That is why in ideal situations, a doctor must either accompany the patient to the next hospital, or at least call the next hospital to check if they have vacancy. We hardly see doctors accompany patients to other hospitals anymore. PGH has too many patients and it would be too much of a loss to send a doctor out. Sometimes when a patient has to go out for a diagnostic procedure, the residents send an intern to facilitate it. A lot of other hospitals send patients straight to PGH because patients could not afford the prices in private hospitals. And a lot of patients are turned down because of improper conduction (or improper transfer).

Mistake #1: The resident of the hospital where the patient is coming from did not coordinate with the ER officer of PGH that they are sending over a patient. They send in people when in truth there is no more room for the patients. Sometimes they send the patient to PGH because they could not afford the CT scan there, when they do not know the the PGH CT scan is BROKEN. UP-PGH is the most popular and biggest charity hospital in the Philippines, and so we get a LOT of cases, that are sometimes too much for us to handle.

Solution: Coordinate well with the other doctor. It’s all about communicaton.

The next keyword in the definition of emergency is IMMEDIATE.

Mistake #2: Going to the emergency room but is not really an emergency.

Here comes a patient looking weak (acting weak?).

I ask politely: “Sir what is the reason for coming to the hospital at 2 in the morning?”

He answers: “My stomach hurts.”

Me: “Did somebody punch it?”

Patient: “No.”

Me: “Since when has it been like this?”

Patient: “Since 2 weeks ago.”

And my face melts. A stomachache of 2 weeks duration is NOT AN EMERGENCY. If it were a stomachache of 2 hours that is focused on the right lower quadrant, then maybe I would entertain appendicitis which requires emergency surgery.

Solution: A 2 week duration stomachache is best handled on an out patient basis! You should have come during office hours.

Mistake #3: A not-so-life-threatening case.

Triage: “Why are you coming into the emergency room?”

Patient: “My eyes are red and itchy.”

Sore eyes can be handled in an outpatient basis. It does not pose an immediate threat to the patient.  Cases like this which we cannot fully ignore are sent to “Ambulatory Care”.  The clinic in PGH which caters to not-so-emergency cases but are cases which cause the patient discomfort so we cannot send them home immediately.

Solution: Do not immediately send these patients away. Assess the patient well, and then make sure that the reason for coming is really emergent. Are you sure it is just Sore eyes? Maybe it is acid burn. A good history and PE is worth more than 1 diagnostic exam.

Mistake #4: Not being able to detect a TRUE emergency. Sometimes I want to bump my head into a wall when I hear about cases when a burn victim is brought to the ER 2 WEEKS AFTER the incident. The wound looks contaminated, and the patient cannot feel the affected limb. The time for saving that body part has come and gone. Time for amputation.

I really wish that people would learn to understand one thing:

FIRST COME, FIRST SERVED does NOT apply to the ER!

In the ER, the patients who get full attention first are the ones in the brink of dying, or in Tagalog, “Agaw buhay”.  I remember one time as a clerk in UMC, that I was ambu-bagging (pumping oxygen for the patient to breathe) a small infant whose heart suddenly stops beating.  All the nurses were busy fixing the patients IV line and administering emergency medicine.  My resident was barking orders all of the place in order to save this poor baby’s life.  Then with no sensitivity at all, this woman, a mother of a child with cough, comes up to me while I was ambu-bagging and says:

“Are the labs of my child done yet?  We’ve been waiting for hours.”

I really wanted to strangle her but of course I couldn’t do that while I was ambu-bagging hehehe.  Please, be patient.  One of the consultants in UMC who is very particular about doctor-patient relationships insisted that once in a while, we should tell the not-so-emergent patients that we apologize for the inconvinience that they are experiencing.  True, it would make them understand and be a little more patient.  But honestly, is it even necessary for me to tell you to WAIT while we try to keep this other patient from leaving the face of the earth?

Ahh… Emergency room DRAMA.  That’s why I admire those Americans who make TV shows out of hospital happenings.  Why don’t we do that here?  We get a lot of them in PGH alone.

Before I forget, I also want to emphasize this one detail about the ER:

ER is not = Ward

When a patient is stable but is in need of daily medical management, it is best that they are placed in the wards right after being stabilized by the ER staff.  Once they are not having airway or breathing problems, and all of their vital signs are stable, they should either be sent home, or admitted.  The ER is like a gateway.  It is not for long term care.  It is all about saving people enough to live another day.  Because of PGH’s large yet full wards, people end up staying in the ER for a long time which ideally, should not be the case.  That is why the ER has a room called the OU, which stands for Observation Unit.  In my opinion it stands for Overstaying unit.  It’s risky to keep a stable patient in the ER.  They could get infected by another patient or what.  They are lucky that there is a place like this in the ER.  Otherwise, they might have to be sent to another hospital with enough beds.  When I am in the ER, I like to get the job done quickly so that I could either send the patient home or admit the patient.  Because overstaying patients are the ones causing the crowds, not to mention that they also have watchers or relatives making the ER crowded.  How can we manage the real emergencies when so many people are getting in the way?  They make the ER more toxic than it really should.

The ER is a dynamic and action-packed place to be.  But not everyone should be there.  Now you know why in the hospital, we don’t just lump patients in one room.  There is the Out Patient Department (OPD), the Emergency Room (ER), the Operating Room (OR), the Pay ward, and the Charity ward.  Maybe one day I can discuss how things go in those are rooms.  But for now…

Know your place.