Blast from the Past

Change. That is the only constant thing in this ever-changing world.

Not too long ago, we cannot get by our daily lives without the typewriter, mimeograph machine, telephone booth (not just Superman), cassette tape recorder, floppy disc, and film negatives. Do you even know what they are?

When was the last time you placed a 35 mm roll of film in the film cartridge of your camera? Or when was the last time you held a real printed photograph instead of viewing it on a computer monitor or from a smart phone?

In the world of medical radiographic images, the same is true. In our practice, rarely do we see a real printed x-ray film nowadays. Instead, everything is now digital or electronic.

Gone are the days when we have to wait for several minutes for an x-ray technician to develop the film in a dark room. Then wait for it to dry. Then hand you the film. And then you have to find an x-ray view box to hang it so you can read it.

Today, we view radiographic images digitally through PACS (Picture Archiving and Communication System), which is a network of computers used by radiology department, that we can access through our desktop, laptop, tablet, or even our smart phone. And if a referred patient comes with an x-ray taken by a radiology department not in our network, he brings in his x-ray images in a CD that we can load and view.

However the other day, a new patient referred to us came in with a real copy of her chest x-ray film. A real film!

I have not held one of these for a while. I missed the feel of its smooth texture on my fingers. The crisp sound of the film as you pull it out of the envelope and wave it softly in the air. Its peculiar slight acidic scent (from the x-ray developer and fixer chemical solution). The unmistakable exotic taste of its…..ah, er……. no, I have not done that.

Who knew that a plain x-ray film will bring me such nostalgia?

As I hold the x-ray film in my hand, I looked around for a viewbox (negatoscope is the technical term), but can’t find one. I guess they don’t install them anymore. I was in one of our newly constructed multi-specialty satellite clinic, and they don’t have a negatoscope in the whole building. None. Zilch. Nada.

So how did I view the x-ray?

I held the film against the bright window and squint my eyes a little, just like the “old” days.

IMG_5808

Right after graduating from medical school, almost twenty-five years ago, I worked in a small (and I mean really small) rural hospital in Plaridel Bulacan, in the Philippines. There whenever I ordered an x-ray, I even helped with shooting and developing it. That’s why I cannot forget the aroma of the freshly developed x-ray film. And while the film was still wet, I would hold it against the light, squint my eyes, and read it.

That was just like yesterday. Yet so much have changed.

As I looked at the film of my current patient, I also peered through the window and looked outside at the present world I’m in, while I relived and reminisced the past through the window of my mind.

(*photo taken with an i-Phone; and in case you’re asking, the chest x-ray was normal)

Lessons from Plaridel

The world of medicine where I work now, is so sophisticated and “high-tech” compared to where I started many years ago. CT-angiogram, Positron Emission Tomography (PET) scan, High Frequency Oscillatory Ventilators (HFOV), thoracoscopy, bronchoscopy, hyperbaric oxygen therapy, and electronic medical records. These are just some of the technologies that are part of our everyday practice in a tertiary, referral, and academic center here in Des Moines.

downtown Des Moines

If I will be stripped with all these technologies, will I still be able to practice medicine? I believe so, for even though technology and scientific advancement are changing the field of medicine, there are basic tenets that do not change. Let me take you back 17 years ago……..

I was a fresh graduate of University of Sto. Tomas in Manila, and just have finished a year of internship at St. Luke’s Medical Center in Quezon City. Since I still don’t know what direction to take with my career, I did not start right away on a specialty or residency training. Instead, I stalled. I decided to prepare and review for the United States Medical Licensure Exam, and hope that I pass it and then try to apply for training in the US.

I needed money for the US exam, as well as to support myself while I’m reviewing, so I looked for a part time medical work. They call it “moonlighting”. I found work in a small clinic/hospital in Plaridel, Bulacan. It was located in a dirt road, off a main street. It has 5 in-patient bed capacity (it is bigger now when I googled it), an office clinic, a small emergency room with 2 beds, a simple laboratory, small drug dispensary/pharmacy, and an x-ray machine. I spent almost a year working there.

street scene in Plaridel (photo by diamonds_in_the_soles_of_her_shoes)

The clinic/hospital was owned by a couple, both of them physicians: the husband was a pulmonologist and the wife was a pediatrician. I worked on weekends, and certain nights on weekdays; basically as a coverage for the owners. In between work, I study. The income was modest, but enough to support myself, and definitely more than the stipend a residency program offers, which was at that time 6,000 pesos/month ($130/month).

Long before I learned to insert and float a pulmonary artery catheter in my Critical Care Training in New York, I learned first how to insert an intravenous needle (called butterfly) in the scalp of babies in Plaridel. Before I learned to do bronchoscopies in my Pulmonary Fellowship, I learned first how to draw blood from squirming little kids, while their tense (making me tense too) parents watched. Perhaps it was due to my stint in Plaridel that I realized that I don’t really care much about Pediatrics, but find Pulmonary interesting.

butterfly IV cannula

Because of the limited ancillary tests available in Plaridel, and due to the fact that most patients can barely afford to pay the doctor, much more any additional lab tests, I learned to come up with a diagnosis with the least tests possible. I believe this is where I honed my skills in critical thinking. Armed with just a stethoscope, pen, script pad and an analytical mind (mind? I still use it sometimes) – that’s all I need to treat patients. Of course the pharmacist has to decipher first what I wrote.

There were also a few instances that patients will tell me out right, that they don’t have enough money to pay the doctor’s fee plus the medicines. So what can I do but to waive the professional fee (of course with the consent from my employers, who themselves practice the same compassionate spirit), and have them buy the medicines they need. If they offered chicken eggs as payment, I probably would have accepted them.

I have learned from my experiences from Plaridel, to treat each patient with compassion, and give them equal respect whether they have the ability to pay me or not. So today, whether I am caring for a millionaire who’s organ systems are failing, or attending to a drug addict who overdose on illicit drugs, I am always reminded to give them the same compassion, the same care, and the same and equal respect for life.

Plaridel, town proper (photo by barrera_marquez2003)

Once, a man was brought in by his family, early in the morning, to the clinic in Plaridel. He was coughing up blood. Lots and lots of it. Minutes later, he flopped in the examining table, lost consciousness and shortly after, lost his pulse. I was not ready for this kind of situations nor were we equipped for this kind of emergencies, but there was no time to transfer him to another hospital. I had the owner of the clinic, who lives a stone-throw away, come emergently to help me, even though it was his day off. The two of us tried our best to save the man.

After many minutes of vigorous resuscitative efforts, and after lots of  blood spewed out of his mouth with each cardiac compression, the man died. Could he have made it if I am more trained, or we have more life-saving equipments, or if we were able to transfer him to another hospital with a higher level of care? Or is he beyond saving? God only knows.

Feeling exhausted and dejected, I learned that day to give all my best, even though my best may not be good enough. I know there will be times that I will fall short no matter what I do, just like an unfinished bridge. Even now, with many years of training and experience, did not change that.  I still (and always will) have limitations. We all do. I learned to accept mine.

unfinished bridge (photo by Cretense)

Plaridel. Simple and yet complete. It is amazing how some of the most profound things in my career and in my life, I learned not in higher academic centers, but in the most plain and humble places.

Thank you Plaridel.