Intern Blues

The other day, I let our medical intern in the ICU place a dialysis catheter on one of our very sick patients. It is a minor surgical procedure of placing a thick catheter in the patient’s jugular vein using ultrasound for guidance. Of course she had lots of supervision, as one of our senior resident was assisting her, and I was around as well for support.

The intern was not able to place the catheter that quick being inexperienced, so it took a little longer doing the procedure. Though that is nothing out of the ordinary. This is normal for a teaching hospital, as interns and doctors-in-training has to start somewhere.

While we were doing the procedure, the patient became unstable, and then went into cardiac arrest. We called a Code Blue (a call for help on a patient having cardiac arrest). Moments later the whole room was teeming with hospital personnel responding to the code.

The patient survived and was stabilized after several minutes of furious cardiopulmonary resuscitation.

The intern was visibly shaken to what just happened. I saw her later in the workroom crying. One of the senior resident told me that the intern felt that it was her fault that led to the cardiac arrest.

However after extensive work-up, we found that patient has a weak heart to start with, and in fact was in congestive heart failure and kidney failure, and that was why he was in the ICU. Then he suffered a heart attack, that caused the cardiac arrest. It was just coincidental that it happened while we were placing the catheter. It was not a direct complication of the procedure.

I reassured the intern that it was not her fault, and gave her some words of encouragement, that this is all part of our work. Besides, this intern is good, intelligent, comes prepared on rounds, and has initiative to learn. I see a great potential in this young doctor. Her only fault is that she is new and inexperienced. But we all have been there.

I have been an attending physician in a teaching institution for a long time now. In fact five of my partners in our practice, who are now full pledged Pulmonary and Critical Care doctors are once my medical interns in the hospital. So at some point in time, I showed them the ropes. And now they are probably better than me, and once in a while I asked for their opinion in difficult cases.

I remember when I started my medical internship in a Columbia University-affiliated-hospital, I was not a “good” intern. At that time, I was a new arrival to the US from the Philippines, was new to the American system of medicine, and definitely not the sharpest among our batch. Compared to our star intern, a graduate of Johns Hopkins University, I was like a kindergarten. I was really lost and I struggled in the beginning. But I am thankful for my seniors and attending physicians who saw the rough potential in me. Though I would be lying if I tell you I was not lectured on at times, or even chewed and spewed.

At the graduation ceremony of my Internal Medicine Training, they gave me the “Tabula Rasa” award. It took me a while to figure out what it meant. But I guess I was really like a “blank slate” when I started, which what the Latin “Tabula Rasa” means. I must also had that blank stare like a deer in the headlights, that goes with my blank mind.

But as I said, we all have to start somewhere.

teaching-rounds

hospital teaching rounds, circa 1940’s

In some academic centers they have a very defined hierarchy. Even one year of seniority feel like a world of difference. The attending physicians act like demigods as they would climb up their high horses when they do their rounds. The attendings treat the medical residents as dirt. In turn, the senior residents treat the junior residents as dirt. The junior residents treat the interns as dirt. The interns treat the medical students as dirt.

It may be hard to admit, but I witnessed this hierarchical state of thinking when I was in my medical school in the Philippines. And being the medical student, I was at the bottom of the totem pole.

But I don’t buy into this old-school hierarchical philosophy and system that treats our inferiors like dirt. I adopted a philosophy of providing a more collegial environment which I believe is more conducive to learning even for the least of us. A resident, or an intern or even a medical student can approach me freely without fearing of being chewed on.

Back to my intern, I hope she’ll learn something from that difficult day. I know someday she will become a good, experienced and a well-rounded doctor too. And if someday she becomes the chief of the medical staff in this hospital, as she has a great potential, or becomes the head of a big-shot medical corporation, or even becomes the US Surgeon General, I hope she remembers me and the words of encouragement I gave her during one difficult day.

(*photo taken from reddit.com)

 

Kwentong Kindergaten

Noong makalawang araw, habang ako’y nagbibiyahe patungong trabaho, ay aking napakinggan sa radyo ang isang report tungkol sa mga leksiyon ng buhay na natutunan natin sa Kindergarten. Isa na rito ang simpleng pagpasok at magpakita sa eskwela. Ano nga naman ang matututunan kung lagi kang absent?

Bigla tuloy akong napabalik-tanaw sa makulay kong mundo noong ako’y isa pang kindergarten.

Ako ay nag-aral sa isang munting Kindergarten school sa Sta. Mesa na patakbo ng NFWC. Dalawang kalye lang ito mula sa amin. Ang aming klase ay sa isang garahe ng bahay na ginawang classroom. Maaring hindi ito kasing tanyag ng Montessori, pero maganda rin naman ang turo dito.

Naalala ko minsan, matapos ang sunod-sunod na ulan, pinasok ng baha ang aming classroom. Kaya mga ilang araw kaming sa simbahan ng parokya nag-klase. Nabulabog kaya ang mga Santo sa aming ingay?

Natatandaan ko pa ang aming guro, si Ms. Genova. May nunal siya sa noo, na parang “red dot” sa noo ng mga bumbay. Siya ay mabait at bihirang magalit kahit kami ay makulit, at hindi siya kagaya ni Miss Tapia sa “Iskul Bukol.”

Tanda ko rin ang ilan sa naging kaklase ko. Si Yaren, na taga kabilang kalye. Siya ay naging matalik kong kaibigan. Si Big Boy na makuwento. Pero hindi ko alam kung bakit iyon ang palayaw niya, dahil patpatin naman siya. May kaeskwela rin kaming kambal na nakatira sa likod bahay namin. Alam ko kung anong inalmusal nila, hindi sa dahil amoy ulam sila, kundi kadikit ng bahay namin ang bahay nila kambal, kaya amoy namin pati niluluto nila.

Sabik din ako sa mga gamit ko sa paaralan noon. Tulad ng krayola, kahit walo lang ang laman ng aking kahon ay masaya na ako dito. Iba sa aking kaklase ay hale-halera ang laman ng kahon ng kanilang krayola. OK lang naman dahil hanggang red lang ang alam ko noon at hindi ko pa maintindihan ang fuchsia.

Gusto ko rin yung pambura dahil amoy kendi. Kulang na lang ay nguyain ko ito na parang Bazooka bubblegum. Nandiyan din ang lapis. Iyong ibang kaklase ko, magagara at may borloloy pa ang lapis. Iyong sa akin, ay simpleng Mongol lang: yung may nakasulat na eberhard faber, tapos number 2.

Maiba ako, alam mo ba ang ibig sabihin ng eberhard faber at number 2?

Si Eberhard Faber ay isang German na nagtayo ng kauna-unahang lead pencil factory noong 1861 sa New York. Kaya nakapaskil ang pangalan niya sa lahat ng lapis na gawa ng kumpaniya niya. Iyong number 2 naman ay grado kung gaano katigas ang graphite core ng lapis. O ayan, may natutunan ka sa akin na hindi mo alam noong Kindergarten ka pa.

Marami rin masasayang karanasan sa Kindergarten. Natutong magbasa: a-e-i-o-u, ba-be-bi-bo-bu, Bobby is bobo. Ano kamo?

Natuto ring sumulat, mag-drawing, mag-kulay, at kumanta. Isa sa natutunan kong kanta:

“Pusa ko’y may nahuling daga, mukha niya’y nakakaawa,

Meow, meow, meow, ang sabi ni Muning, di na kita patatawarin.”

Ang maging walang-awa ba sa daga ang itinuturo ng kantang ito?

Paborito ko rin ang recess noon, dahil nakakapaglaro kami. Dito ko natutunan ang larong Dr. Quack-Quack. Kahit muntik magkapilay-pilay kami sa pagkakabuhol-buhol sa larong ito ay maaring natututo rin namang mag-isip at mag-solve ng problema. Pero maniwala ka, hindi si Dr. Quack-Quack ang naging inspiration kaya ako nag-duktor.

Gumanap din ako bilang Joseph sa aming dula noong Pasko. May pintang balbas ang aking mukha, tapos may dala-dala akong tungkod na mahaba. Pero mas gusto ko iyong role ng aking kaibigan bilang wiseman, dahil mas magarbo ang kanilang costume tapos may bitbit pa silang regalo. Bakit ba hindi ako naging artista, eh itsurang artistahin naman ako? Walang kokontra!

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Christmas program, circa 1973

Sa Kindergarten rin ako natutong tumula. Sa katunayan ako’y tumala noong graduation program namin. Makaraan ang apatnapung taon, saulado ko pa ang aking tinula. Tungkol ito sa ibon na nakakulong. Ito ang dulo ng tula:

“Bagong pinta ang kulungan, may pagkain araw-araw,

Ngunit ibon di man lamang, umawit kahit minsan.

Ibon ay aking pinalaya, umawit ng tuwang-tuwa,

Tao’t ibon pala kapwa, maligaya kapag malaya.”

Tunay naman na kahit nasa Kinder pa lang kami ay ipinamulat na sa amin ang kahalagahan ng kalayaan.

Pero meron ding masasaklap akong karanasan noon. Tulad nang ako’y tumambog sa kanal galing sa paaralan at napuno ng burak ang aking buong braso. Pingot ang inabot ko sa nanay ko. Nasa Kindergarten din ako nang ako’y nabalian ng braso. Nakasimento ang aking kanang braso nang halos dalawang buwan. Kaya sa maikling pagkakataon ako’y naging ambidextrous, dahil natuto akong sumulat sa kanan at sa kaliwang kamay.

Tunay na pinahahalagahan ko ang edukasyon, lalo na ang mataas na antas na aking narating. Sang-ayon sa aking magulang, edukasyon lang ang maipapamana nila sa amin. Pero naniniwala ako na maraming mahahalagang bagay sa buhay, ay natutunan ko sa pinaka-mababang grado ng edukasyon – sa Kindergarten. Tulad ng:

Pumila ng maayos (siguro yung mahilig sumingit bagsak noong Kinder).

Makinig sa turo ng guro.

Huwag kunin ang hindi sa iyo, o magpaalam muna sa may-ari bago hiramin ang gamit.

Mag-share.

Huwag makipag-away.

Huwag mangopya.

Maging patas sa paglalaro.

Huwag kainin ang baon ng iba. Huh?

(Oo naranasan ko na may ibang kumain ng baon ko, pero nasa Grade 1 na ako noon.)

Isa pa sa aking naalala ay mabilis maubos ang aking pambura noong nasa Kinder pa ako. Dahil nginangata ko ang eraser. Dahil burara ako. Dahil marami akong mali sa pagsusulat, kaya’t pudpud agad ang aking eraser.

Isa sa mahalagang leksiyon na natutunan ko sa Kindergarten ay ito:

Ang pagkakamali ay bahagi ng buhay. Hindi lahat ng ating sagot o gagawin ay tama. Ang mahalaga ay natututo tayo sa ating karanasan, at ituwid natin ang ating mga pagkakamali.

At kung ika’y nagkamali at ika’y naihi sa salawal noong Kindergarten? Hindi ito katapusan ng mundo.

(*This article is lovingly dedicated to Kindergarten teachers, and all other teachers, who showed us the way. Thank you.)

Quitting my Day Job

I was again on-call the other weekend. After the extended hours of working a very long week (2 weeks that blended into each other), I felt exhausted and depleted. Am I getting tired of this profession? What if I call it quits today? Will I be able to survive on my current passion and skills other than being a physician?

I can give more time to writing. In fact, writing is my stress reliever, that’s why I still blog no matter how busy I get. I enjoy writing, maybe because I don’t have any deadlines or quota on how many articles I can spew out. I write only when I want, and is always on my terms. But that may change if I have to write to earn a living.

Talking about earning, I was offered an honorary* amount of $25 for every article that I contribute to a national newspaper in the Philippines. So that can provide enough money for a decent meal for a day. And on days I cannot produce an article, I guess I don’t eat. Forget about supporting a family or sending my children to college.

But maybe I can write a book that will be a bestseller. Then maybe my book will be adapted into a movie. Then I certainly have it made. I can dream, can’t I? Or maybe I can make big money from this blogging? Ha! Dream on.

How about if I pay more attention to my piano playing? I was asked to play for a funeral service once and I did it out of respect. I was not expecting anything in return, but was surprised when they gave me an honorary sum of $75 for about 30 minutes of playing. Not a bad gig at all! But then I need to find more dead people to play in their funeral to make this a living. (Hanap-patay instead of hanap-buhay.) That’s not a good wishful thinking.

Maybe I can hone on my violin playing once more and move back to New York City to play at the Lincoln Center. Did you think the concert hall at the Lincoln Center? No! I’ll play in the subway station at Lincoln Center. I read some news articles that panhandlers in New York City can make up to $200 – $300 a day! Really? Really.

I can also consider teaching or giving lectures. Last year, a national medical organization invited me to speak in one of their educational courses. I obliged to give the lecture since they prepared all the materials and slides, and all I have to do was present it. I did it for the love of teaching, but was delightedly surprised when they handed me an honorary fee of $200 for spending about 2 hours with them. They invited me again this year, and of course I said yes. Did I mention they gave me free lunch too?

Maybe I can be a traveling lecturer, like the ancient Greek philosophers. Maybe I can assume the title “Pedagog.” Or maybe I can be a motivational speaker. That will be great! But wait a minute. What if I am a lousy teacher? Or what if I am a boring speaker? And what if…….

*****

After giving so much thought on all these options, I have decided that I will keep my current day job……..for at least a little bit longer.

(*honorary job really means without pay, so an honorary fee is definitely less than its market value; in other words, they can pay you better but they wouldn’t)

Teach? Just Let Me Sleep!

I was on-call a few nights ago and I received a message from “Call-Transfer” at such an unholy hour of the night. I fumbled to reach for the phone in the dark and tried to shake myself off from sleep. It was a little past 1:00 AM.

“Call-Transfer” is our health-system call center (similar to the call centers that studded Manila) that handle all requests from other outlying hospitals and physicians to transfer their patients that they believe are so complicated to handle in their local institutions. These kind of patients they believed are better served in our tertiary, level-one trauma center, and academic hospital.

Most of the time, when I received these kind of calls they would like to transfer some kind of a “train-wreck,” a term we use for very sick patient with not just one but multiple problems. Usually they are intubated and on ventilator, or in critical cardiac failure, or in shock.

Frequently these patients will be fetched by our air-ambulance (helicopter), and would arrive after 30 to 45 minutes after I approved to accept them. Though almost 100 % of the time we consent for these transfers, except if there are no more available beds in our ICU. If the weather is too dangerous for the helicopter to fly, then they would be transferred by land ambulance and would arrive in our institution after about an hour to two hours depending on how far they are. Sometimes, we would receive a patient from more than 100 miles away.

I returned the call to the Call-Transfer and was soon connected to the Emergency Room (ER) of the outlying hospital. The ER doctor started to give me the history over the phone of the patient they are treating – a young volunteer firefighter who was fighting a brush fire for a few hours, and was brought to their hospital due to exhaustion, difficulty breathing and headache. My dreamy mind started to paint several different scenarios in my thoughts on why they would want to transfer this patient……..

Maybe the patient succumbed to smoke inhalation and was in respiratory failure and was intubated and required ventilator. Maybe he had airway thermal burns that requires me to do bronchoscopy (a procedure where a long flexible scope is inserted into the nose or mouth and down into the throat thru the vocal cords, and into the trachea and bronchial tubes, to directly visualize the upper and lower airways) to determine how extensive is the burn. Maybe he had significant smoke inhalation and suffered carbon monoxide poisoning and needed to be treated in our hyperbaric chamber (a pressurized chamber where patient is placed and subjected to 2-3 atmospheric pressure with 100% oxygen, like diving in a submarine, to eliminate the carbon monoxide in the body rapidly to prevent long-term neurologic sequelae). Maybe……

hyperbaric chamber

As the ER physician gave me more details of the history of the patient, it was nothing of the different scenarios I imagined. The patient was awake, alert and is not in severe respiratory compromise. In fact, he was even feeling better after several minutes in the emergency room with the application of supplemental oxygen by mask. His carboxyhemoglobin (carbon monoxide level in blood) is less than 10 %. A 20-25% or higher is dangerous and definitely need intervention, but less than 10% is usually insignificant.

I told them then, that I don’t think the patient needs to be transferred, and I don’t even think he needs to be admitted in the hospital. He just needed to be on supplemental oxygen for an hour or so and then can be released.

I was glad that I can go back to sleep and that I don’t need to leave home and drive back to the hospital. But before I can hang-up the phone, the ED physician told me that he was a senior resident, a doctor-in-training, who was moonlighting in that emergency room. He asked me what were the “teaching points” in this case.

“Are you kidding me? Do you have any idea what time of day it is?!!” Maybe that was my first thought, but that was not what I said. For I obliged, and was able to muster a few teaching points about carbon monoxide poisoning to this young physician even in my half-awake brain.

I know I was in that situation before. And I am thankful for all the teachers and instructors that gave their time and effort to teach and guide me. If it was not for them, I would not be where I am now. Now it is my turn to do the same. That is one reason I practice in a teaching hospital.

I laid awake for more than an hour afterwards and cannot get back to sleep after I hung-up the phone. Darn! So much for teaching points.

(*image from here)