Big City Doc

ICU

2009-06-24T21:30:00.001-07:00

So here I am. In a few days, I'm going to be a fellow. At the tail end of my residency, I can't believe how the years just rolled by. I've come a long way from being that lost intern three years ago.

I guess it's fitting that I end my residency in intensive care. Nothing like ending everything in a rotation where medicine is at it's finest and most brutal. Everything you've come to learn and understand about the profession are distilled and purified in this one place in the hospital. The patient load hasn't been bad at all but, oh boy, the quality and intensity are all there just the same. From the clinical to emotional, the challenges are there everyday.

There are no words to describe how I feel. Fulfilled, fatigued, triumphant, exhausted, elated, nostalgic, wistful. All emotions tunneling into one being at this one moment. I can hardly breath. I need a break from myself.

Next week, next month, next year, I will look back at this point in time and I will feel different at each remembrance. Right now, I just want to empty myself out and close my eyes. Feel everything and nothing as I end and start another chapter in my life.

Night Float

2009-03-10T07:01:00.000-07:00

I've been working nights for the past two weeks and, for the most part, it has been slow. I am the senior resident on call at night and only get busy when the junior resident is capped with patients or if other services, such as surgery or rehab medicine, need a medical consult. But those are rare in the middle of the night.

Last night was busy and I was running around seeing patients starting at around midnight. I didn't mind being busy this time because, frankly, I wanted the time to pass and seeing patients was one good way to make time pass quickly.

There were the usual cases - a good mix of chest pain, seizures, syncope. I was a little bit happy to be able to do admitting orders for patients. It was a good night in a way. After all, I was graduating in a few months and I would not get a chance to be this involved in patient care for my two years of fellowship. During that time I would only be doing consults and I'm a little afraid sometimes of not having the chance to exercise my internal medicine skills.

This is really a great job to have for the most part. It's never easy to explain to someone not in the medical profession how rewarding and how frustrating working in this field can be. It's sad to think that some people actually think doctors are only out to make money and that hospitals are part of some conspiracy to take advantage of patients. I believe in my heart every person who joins this fields as a doctor, nurse, or a lab tech only wants to help make people feel better - as cheesy as that sounds. Besides, there are easier ways to make money - spending a decade training is not one of them.

I guess part of the problem is that the balance of knowledge is always skewed towards the medical professional. One of the most challenging tasks is trying to explain medical problems and all possible options to a patient. We have been trained for too long in the jargon of medical terminology and the numbers of evidence-based medicine, we have lost the ability to communicate with the people under our care. It takes a little bit more effort and time to do this and time is the most precious commodity when you are in training. But when your patient finally nods in understanding and you are on the receiving end of gratitude, I must say it is time well spent.

Tired

2009-02-11T20:06:00.000-08:00

So here I am - in my third year of residency. Never have I been so tired in my life. I'm in a rather busy time of my third year. For some reason, my schedule this time of year includes a line-up of weeks of floors and weeks of nights. I virtually will have no life for the next month. Between in-patient care and board review at night, I am a cranky lady by the time I get home on most nights.

I'd really rather be cranky than what I am now. Frustrated and fatigued. I was just thinking how many sad stories I encounter in the hospital everyday. I became a doctor with the rather naive hope that I would be able to help people, make a difference. I have spent my twenties training for this career and now, in my early thirties, I have two more years of fellowship to look forward to.

Now, after spending all that time training, I wonder if what I'm doing is worth it. My patients who come in decompensated from a life of substance abuse will probably go out and use more drugs - despite trying your very best to get them better. I see so many elderly patients stuck in the hospital "awaiting placement" because they have no families who can come and take care of them. I have patients who come in so sick, on the brink of death, and you manage to bring them back and all they want to do, when they get their strength back, is to sign out against medical advice.

It's not them. Maybe, I should spend more time with the drug addict (it takes a lifetime, a herculean effort to get over an addiction after all). Maybe, we in the medical profession learn to let go and let patients do what they want. Maybe I don't spend enough time explaining everything that's going on to my patients.

But it's a system we work in. Everyone is tired. Everyone is pressed for time. Nurses are overworked. There are not enough people to transport people. There is just so much a social worker can do. I believe we are all trying our best. Sometimes our best efforts have good results. Sometimes, they don't.

I love my job. I am fascinated by the diseases I encounter. My favorite time of day is when I finally get all the scut out of the way and I get to visit my patients and simply talk. Unfortunately, lately, there has not been enough time for that. And maybe that's why I'm so tired. I don't get to do enough "doctoring" and I'm mostly doing "resident scut."

I hope it gets better. I hope when I'm an attending I remember this time. I hope I can still become that person that helps people and makes a difference.

Grief

2008-07-20T20:51:00.000-07:00

For the first time in my life, I have suffered a loss. Someone close to me has just passed away. I thought it would be more devastating but, thankfully, I am not in the depths of despair at the moment. Maybe it's because her death was expected. After living for five years with cancer, she just faded away quietly one morning. It was a peaceful death. No great agony like I imagined it would be.

The expectation of death does not take away the blow of the loss. An unspeakable sorrow still hit me when I heard the news. The tears came anyway despite the sense of relief I felt for her finally ending her pain and suffering. That first day, I felt like an empty shell - just going through the motions of the day. Again, another blessing - no real work for me. Just paperwork I could put off for another day.

Now I find myself, grasping at memories. Digging up old pictures of her. Exchanging them with my sister across the world. Getting her version of memories in return. As if staring at the photographs would bring her back to life again. It's amazing what surprises still come up. How digging through her things my sister finds our name bracelets from when we were babies taken home from the hospital. A box among her possessions containing pictures of us when we were children with her in the picture.

I managed somehow these past two days to go on with my life. To go out and take a friend around town. To cook dinner and invite friends over for a meal. I even managed to talk about her without choking up. In this experience of mine, grief is not the great dramatic scene I imagine it to be. More like an underlying theme in my day to day existence. Something gnawing at you - a dullness to the day that wasn't there before. How long will this last? The tears well up still and they probably will continue to come from wherever they come from. A part of me does not want it to end - lest I forget her totally.

But that cannot be possible. Where did I hear that - relationships don't end with death? I look forward to the day when the grief finally fades away and turns to joy.

ER

2007-11-29T19:56:00.000-08:00

Today, I just wanted to disappear. To be invisible. To not be in anyone's consciousness. To cease to exist. Not forever but for just 30 minutes. I wanted a break – even from myself and my own feelings. I just had an exhausting day in the ER. It was not more busy than usual but everything just had to be a little bit more difficult than usual.

For one thing, I had the most annoying patient today. This elderly woman who fell and turned out to have a broken pelvis. Her husband was with her. It was busy and so I had at least 5 patients under my care at any one time. All of them with active issues. One was constantly in pain. Another one needed IV access that a nurse could not get. I needed to call several attending physicians and an oncologist regarding some of them. My elderly lady with the fractured pelvis, believe it or not, had the least active issue at the moment. She was not in pain but was annoyed that her stretcher had been moved into the hallway. She was hungry. Where was her food? When was the orthopedic surgeon (a guy who was just as overwhelmed as me at the moment) going to come and explain to her exactly what the plan was? Earlier, I had to drop everything and run up to MRI because she wanted to go back home and she didn't understand why she needed an MRI of her hip. The husband kept following me around all afternoon. I had one other non-emergent patient who had been in the ER for at least an hour already. I kept on trying to get to her but little things kept getting in the way.

At one point, I wanted to just stop and it was then that thoughts of disappearing came into my head. I was so tired. Running on just 2 cups of coffee and no food. The whole day was like torture.

Finally it was time to leave. I signed out to the new doctor who was coming on. I had had enough. But being the person that I am, I couldn't leave without wrapping things up. One more ekg to check. One more chest xray to view. A consent for a blood transfusion to get signed. One more resident to sign out to before heading home. The orthopedic resident finally got to me. That lady with the pelvic fracture – no surgical intervention. She could go home with crutches.
I decided to just drop by and say good-bye to my lady. She had been a high maintenance patient but she had otherwise been nice to me in the beginning. I found them dealing with her new crutches. Her husband was trying to teach her how to maneuver around with them. She was having a little difficulty. I told her she was making a good effort but she was getting tired. I helped her back into bed. Her husband shook my hand warmly. He said thank you and he said he appreciated all that I had done for them that day. He knew he had been annoying but he was just concerned about his wife. I said it was no problem. I apologized for being unable to give them more attention than I had. He wished me luck in my career. I wished them a safe trip back home (they were from out of town).

I finally got home. I can still barely think even as I write this. I'm basically just ranting, venting, getting all my feelings out. I was supposed to work on my fellowship application. I'm supposed to be working on a big presentation next week. But I have no emotional, intellectual reserve left for the day. After this blog entry is done, I will maybe cry and take a shower. I'm not sure if they will be tears of joy or frustration or exhaustion. Maybe a little bit of everything. Just like that little old lady and her husband – both the most annoying and the most gratifying encounter of the day.

Excited Again

2007-07-18T17:53:00.000-07:00

For the longest time, I've been going through the motions. Waking up, going to work, seeing my patients, doing all the myriad things a doctor in training is expected to do, going home, sleeping. Somewhere in there I manage to eat and relax. And then the next day I wake up and do it all over again. I was content. After all, this is the career I wanted and this is the place I chose to be at the moment.

Until last week. A friend told me that there was a recruitment orientation for MSF (Medecin sans frontiers - aka Doctors without Borders). At first I was mildly interested but I had other plans that night. I asked him to go and just let me know how it went. But at the last minute I decided to forego my moviedate and go to the orientation. As was typical of me, I decided to put career ahead of recreation for the moment.

Was that the best decision ever! I had always been interested in a career in international health. Call me a romantic. Call me an idealist. One part of me thinks I can save the world.

Alright, maybe not. But this is as close as anything. I had mentioned before that I was tired of having paradigm shifts. This is isn't one exactly. It's more like rediscovering a valuable piece of jewelry you'd forgotten you had and dusting it off.

That night, my dream of being able to travel to places where the need for medical attention is greatest seemed reachable. I was in a roomful of people who had the same goals. And they weren't just doctors either - there were nurses, mental health specialists, logisticians, administrators. I was so excited I could hardly sleep that night.

Of course, this is, at the very least, a couple of years away. But suddenly I had a goal again. Something to work for. Something I'm genuinely excited about. And, of course, there are many obstacles along the way - not the least of which is the weird questions I get from people. (Example: are they going to sponsor your working visa to stay in the US? Hmm...) It's going to be hard because few people will truly understand why someone would want to do this. The pay is low, the job is fraught with danger. Oh, but do they know the satisfaction of being able to help someone who truly, truly needs you?

Life in these United States is undoubtedly comfortable. But not everyone has the same American dream. I think I finally rediscovered mine.

Angel

2007-03-14T17:19:00.000-07:00

I haven't posted in a while and there's good reason. Internship has finally caught up with me. The sleep deprivation and overall exhaustion has finally worn me down. It's not even the physical aspect of it all.

For the past couple of months, for the first time in my very short medical career, I have been having doubts about my choice in life. A few times, I have come very close to rethinking everything. It was the fatigue getting to me. But I was so tired, that having a paradigm shift at this point in time was just not going to happen. Believe me - this is very disturbing. I always held this conviction that I had made the right choice. Everything in my life to this point has pointed towards this direction. Becoming a doctor fit like a glove. Having even any inkling of a doubt was not something I was ready to deal with.

It wasn't anything in particular. Just a little of everything - the long hours, the emotional involvement with work, the pressure, the intellectual demands. I know residency is just a few years and no one said it was going to be easy. But for the first time, I was starting to forget why I wanted so much to do this in the first place.

Today was one of those days. Just one of those days that can really weigh you down. A patient of mine going into the unit. Being caught in the middle of a difficult ethical situation. And just a little of everything going wrong today. By the time I signed out my list, I felt like a spent dishrag. I was starting to have one of those "is this what I really want to do for the rest of my life" moments.

So this was the general feeling I was having sitting at the bus stop, waiting for my ride home. I was resigned to ending the day on this rather sour note and just writing it off as part of the whole deal with internship.

Absorbed in my own thoughts, I nearly didn't get my bag out of the way when a woman tried to sit beside me. I was with it enough to let her sit. When the bus finally came, we both got on and ended up sitting beside each other again. She leans over and says "I guess we were meant to sit beside each other." I smiled. She saw the journal article my attending gave out on morning rounds in my hand and asked if I was a student. I explained that I was an intern doing my rotation at the hospital on the next block (I am currently working in one of the leading cancer centers in the country/world - at least that's what they claim to be).

She laughs and says that she's there all the time. So I asked what type of work she did there. No, she says, she's a patient. This woman, with this cheerful personality, has been battling cancer for the past 4 years. She then goes on to tell me about her ordeal with her bone marrow transplant and the infections she's had. She tells me about how she has such bad bone disease they've had to put rods and screws in her back. She asks how long I'll be at the hospital. I tell her just a month since I come from a program on the other side of town. She tells me she's had nothing but good experiences with interns and residents from my program. She amazed me with her warmth, optimism and just overall cheerfulness.

We continue to have a long conversation. I tell her how I've had a long day, how busy it had been. I tell her that the part I hated most was getting lost in all the scut work I didn't have time to have conversations with my patients like I was having with her. I don't really remember what else we talked about, but in that moment, on that bus, in the middle of rush hour traffic, I was reminded why I want to become a doctor in the first place. As she got off the bus, I thanked her and really meant it when I said I was glad to have met her.

I'm a bit superstitious and despite all of my so-called scientific training, I believe in miracles. I believe today God saw that maybe I was getting a little bit desperate. So I was sent an angel to cheer me up. How strange and wonderful that it should be someone who has every reason to be sad and depressed. Josephine, I don't know if I'll see you again but thank you! We were definitely meant to sit beside each other.

Bagong Bayani

2006-11-06T20:35:00.000-08:00

I am now back home in Manila for a much deserved vacation. I've been looking forward to this for weeks and weeks. It couldn't have come at a better time too - right after the toughest rotation thus far (working as night float) and just when it's starting to get really chilly in New York too.

You can imagine my dismay then when I realized that one of the things I need to do while I'm here is to pass by POEA (Philippine Overseas Employment Agency). Given that I am only spending a grand total of ten days in the Philippines, spending any amount of time processing papers in a government agency is really going to be a pain. (Insert expletive here).

I guess I really shouldn't complain. After all I chose to do my residency under an H1 visa and this whole thing comes with the territory. But still.

Just a little over four months ago, I had to go through this whole ordeal prior to leaving for the US to do my residency. Back then, I had to pay approximately 7,000 pesos. The amount was supposed to cover OWWA fees, PhilHealth premium and a few other things. I also had to go through a physical exam for medical clearance AND I had to sit through a seminar about how to conduct myself in a foreign land. The presentation included dire warnings about contracting STDs while abroad. Oh, did I mention about the IQ test that I had to take before I could get cleared? It was pretty disturbing. I had to complete sentences that began with "I think all women are ______." Or what about "The men above me are________." The rest of that exam was pretty difficult... in a weird way. I don't know what they were trying to weed out of the bunch of us who took it. Anyway, I went through the whole process, whining all the way I might add. Back then, I had thought about doing something - like writing to a newspaper about it or something. But I never got around to doing anything about it. I got caught up in moving to another country and then consequently getting busy with my training.

And then I have to do it again. Not as involved a process as before but a process nonetheless. I mean, really. What do I get out of this? Exemption from travel tax and terminal fees? I would pay much less if I had to pay for both rather than pay 7,000 pesos initially and now 2,000 pesos. Protection and help from the OWWA just in case I need it? Help in repatriating my body just in case? I would really like to know if the POEA or OWWA played a pivotal role when a bunch of Filipino workers were kidnapped in Africa or Iraq or, just recently in the news, drowned in the Baltic Sea.

And the whole deal just lends itself to graft and corruption. Take my experience today. I walk in there determined to be nice and not to snap at anybody. After all, they're all just doing their jobs. I ask for directions from the security guard. He's friendly enough - even asks if I have a ballpen with me. First mistake. I have no pen. I have all my papers but no writing tools. He sells me one for 10 pesos! It better have gold for ink or something. I fill up the required form and I see the long line at the windows. To me, time is more precious than money, so I walk over to the express lane where you just basically submit all your documentation including fees and then they send over papers you need straight to your door. How convenient. The whole deal will cost me 2, 495 pesos. I hand over 2,500 pesos expecting my change back. Second mistake. What change? The five pesos was going to cover photocopying of my documents - a grand total of 3 pages! How petty of me but in the grand scheme of things, that 5 pesos will add up. The lady at the desk realizes I have just recently left for the US and tells me that I will probably get a refund of the fees back since it's just been barely five months since I left. Well, at least something good I didn't expect. I walk away and glance at my receipt. The delivery and processing fee is 220 pesos. In essence, I visited POEA today so that I could pay an independent contractor to deliver me my papers and my refund. Glad that wasn't such a total waste of time (hear the sarcasm in that sentence).

But what really irks me about the whole thing is that I get the sinking feeling that the government is somehow taking me for a ride. I am backed into a corner with no choice but to do this because if I don't, some official in NAIA is not going to allow me to travel out of the country. And, forgive me for sounding petty, but 2,000 pesos is 2,000 pesos - not an easy sum to part ways with, OFW or not. I don't care if you're earning in dollars, rupees, pesos, francs or euros. Money is money that is hard-earned. I'm very lucky. The money I earn is mostly mine to keep or spend. I don't have to worry about my starving family or my kids in school or my sick grandparents somewhere. What it comes right down to is that this is 2,000 pesos I won't be able to spend on food, clothes, shoes or any of those other fun things I would rather be doing with it. But that's just me. What about the other OFWs? The ones who are truly the bagong bayani? The ones who have to worry about a starving family, kids in school or sick grandparents? That would have been 2,000 pesos that could have been spent on food, tuition fees or medicines. Don't even get me started on the hassle of going there - the bus, the jeep, the tricycle that one has to take to get to that corner of EDSA and Ortigas avenue.

You would think that after dealing with the loneliness and homesickness of working in a foreign land, our OFWs would get a better welcome than this. We should be holding street parades everyday for these hardworking countrymen of ours. Instead, we slap them with more fees to pay and more bureacratic mumbo-jumbo to get through everytime they come home for a break. I'm sure that there must be something we all get out of this whole process at the POEA but couldn't it be more streamlined and couldn't the fees be a little bit cheaper? At the very least, make it clean (no 10-peso ballpens at the entrance please!). Those medical/physical exams are too tedious. All you need are a few simple tests. And speaking of tests - those so-called IQ tests are really the most ominous parts of this thing. Someone should take a look at those and tell me exactly what they're trying to look for in our OFWs.

I could go on and on, but I don't really know if there's any point to me writing all this except maybe to let out a little steam. And here I am whining again - just like I did the last time. Even worse, I'm whining in public. But at least I accomplished one thing today - I didn't snap at anyone when I was there.

End of Life

2006-10-12T16:09:00.000-07:00

My ICU rotation is coming to an end. And today I caught myself saying the strangest thing to my fellow intern. I said, "What a sad day - two people are dying today." As soon as the words flew out of my mouth, I realized how strange that must sound if taken out of context.

And yet it was true. In the few weeks that I have been working in the intensive care unit, most of the patients under our care have managed to improve enough to move out to a regular floor. There have been a few who were ill enough to make the future a bit uncertain but most of them, because of the close monitoring and care they receive (or maybe even despite of) manage to pull through. And so today, to have two patients actually hovering near death was a bit overwhelmming.

Yes, I am still overwhelmed. Back home, I had been part of more than enough medical codes. Medical care in a government hospital in a third world country doesn't quite match the kind of care available here. Mortality rates are higher than what they ought to be. I have seen my share of people dying. But death is not something you get used to.

Most of us would rather not think about matters concerning the end of life. But being in the position that I am in, I realized how true this is for most people. Technology in the medical field has become so advanced that now we have the ability to keep a person alive for prolonged periods of time - even if that person has no hope of ever regaining his full faculties again. Suddenly, there are difficult choices that have to be made: to intubate or not to intubate, to keep the ventilator on or to turn it off, to keep giving tube feedings or to withold nutrition, to continue giving medications to maintain blood pressure, cardiac output.... the number of decisions to be made seemingly endless. Permutations and combinations of outcomes and events that are almost impossible to predict and that doctors, with all their knowledge, can hardly ever foretell.

You would think that if someone had put down in writing his/her wishes about end of life matters things would be easier. Advance directives are what we call them. But this is not fool proof as well. Some patients will qualify that they would like all measures to be taken if the illness is reversible but would rather not have extraordinary methods used for irreversible conditions. But who judges when an illness is irreversible or reversible? There are many instances when no one can tell. Not even the doctor backed by years of education and experience. And then there are the family and friends who find it difficult to let go, even while knowing that their loved one would rather not have wanted to be subjected to so many procedures, medications, or machines.

And so, despite of technology or maybe even because of technology, the lines continue to blur. In the end, each one of us will have to deal with his/her own mortality. But in the middle of all this uncertainty, there are a few things that are certain and true. Life is what we have now and what we have now is great. Humanity has come far - and I'm not just talking about technology. Our achievements in science and technology have forced us to contemplate on what it means to be human, what it means to be alive. Ethics, morality, mortality are areas in which we will advance as well. Scientific achievement cannot run blindly into the future.

This is an interesting time in which we live. This is an interesting profession in which I work. There are days when the going gets rough and I feel like just another worker bee. But there are days like this when I realize just what a wonderful, complicated, difficult profession it is I have chosen.

Great Expectations in the Big Apple

2006-10-12T15:56:00.000-07:00

A few months back, I started doing my residency in Medicine in New York. Since then, I've barely had time to breath. This blog is my attempt to pause, take a breath and reflect on this crazy life.