In Stagnation

I just can’t help but feel so useless.

With the situation in our house these days, with both of my grandparents seem like time bombs ticking, I’m the only one staying at our house most of the time. I guess being the only one unemployed, the position was handed to me by default. Someone needs to stay at the house in case either one of them needed to be rushed to the hospital, and with their condition these days, I guess that could mean any minute now. Sure I can still go to the gym--- I’m only gone for two hours anyway… and during rush hour I have to pick up both of my sisters from work since our family driver resigned about a month ago, and no one else could pick them up… but nights out seem to be out of the question. Or any leisurely activity for that matter... because that would make me irresponsible and selfish. My social life has been greatly affected, but it’s not really a big deal--- at least not for now. My main reason for going out is to quench my thirst for alcohol anyway. And my grandpa has a lot of stock inside the house. He wouldn’t be drinking them anymore. No one else would but me.

What makes me feel so shitty is the fact that I do not have work. Just sitting inside the house the whole day waiting for the inevitable to happen is driving me crazy. Work gives me a sense of purpose, no matter how tiring it is. Yeah, it has been a long time since I was undergoing residency training, but even after that--- except for the two months or so when I was feeling like a lost puppy, I always had work. Even when I had to give up some of my work so that I could focus on my studies, I still went to work at least twice a week. Sure I haven’t really been doing any work for more than three months now, but when I was halfway around the world I never really noticed it. And now that I’m back here, reality has set in. I have graduated from med school 5 years ago, and still I’m going nowhere as far as my medical career is concerned. Sure, I have already focused on my goal, I already know what I want… but that’s still more than a year from now. I wish life had a fast forward button so i can skip through this lull in my life. I have to be preoccupied with something to get my mind off things. I need to do some work, I just need to do anything, and I doubt if my dad would allow me. He's gonna say I don't need the money. He's going to say I am more needed at home. He's going to say that i need to set my priorities straight. As always, he would use family as a tool for bargaining, just as he has always used family to keep me from doing what I want. As always, he would resort to emotional blackmail, making me feel guilty, making me feel like a person with no conscience at all. Don’t get me wrong, I wouldn’t want to be away from my grandparents when the inevitable happens, and I would want to stay with them and make them happy for the remaining days of their lives. And I want to be here for them especially in their time of need… if only there was a way to do that without drowning myself in self pity. Being here for them makes me feel good because it feels so right… but how can it be so right when at the same time, I am drenched in misery.

Toying With Lives

I have always said that I prefer working at government hospitals because that's where I can reach out to a greater percentage of people who need our help the most. But at the place where I'm working now, even when I know the right thing to do, the utter lack of facilities makes my profession futile, and downright pathetic.

First, there are stupid hospital policies, that the administration cooked up from God knows where. Blood glucose meters are not allowed in the emergency room because the department of health allegedly came out with a directive saying that CBG monitoring should be handled by the lab department, along with other blood works. Since when did the Department of Health come out with such a stupid directive? I know for a fact that this is not the case in other hospitals. It just boils down to common sense. There are many instances wherein a patient's blood sugar level should be taken immediately--- when an unconscious patient comes in for example, hypoglycemia should be one of the conditions that should be ruled out at once. But since there are only a few lab personnel on duty at a given time, they can't respond to such cases immediately. Things would be much simpler if we had a blood glucose meter in the emergency room. We had one last year, until the department of health allegedly banned such devices from the emergency room. Honestly, I can't think of a logical motive behind this policy. They even went as far as saying that they are only implementing orders from the Department of Health, when in truth, they are not.

Want to hear another stupid policy? Intubated patients cannot be admitted to the wards, or even in a private room unless they are connected to a mechanical ventilator. This means that if a patient cannot rent a mechanical ventilator, they are stuck in the emergency room until they are extubated, or worse, until they have expired. Staying at the emergency room is more expensive since patients are charged by the hour. We even have the tendency to neglect stable patients when a critical patient comes in. It would be understandable to impose such rules when the patient is to be admitted in the intensive care unit... relatives are not allowed to stay inside, so continuous ambu bagging by the relative is not an option, but to require mechanical ventilators in the wards even when the relatives can provide positive pressure ventilation via ambu bagging? They even have the tenacity--- or should i say enormity to defend themselves, saying such a directive is a standard protocol in all hospital. Christ, give me a fucking break! I wasn't born yesterday. I have worked at other hospitals, and I know for a fact that's not the case in other hospitals! I can't help but feel that it's just another ploy to milk these patients for more cash, just like that directive about the glucose meters. One such case was a patient with a "do not resuscitate order"--- basically we were just waiting for the patient to die. His life could no longer be saved. The family managed to get a private room, and yet the administration wouldn't allow them to be admitted at that room unless they would rent a mechanical ventilator. What the hell for?! The patient only had a few hours left to live, and the relatives only wanted to share their last moments with him in a private room, away from the chaotic atmosphere at the emergency room--- and they were to be deprived of that right because they had to rent a ventilator, of which the payment was non refundable?! Such practices may be acceptable (but arguably unethical and stupid) in private hospitals, but most of the patients we encounter cannot even afford to buy their own medicines, and most of them definitely can't afford to rent a mechanical ventilator. The fact that the administration proclaims that the hospital is a government hospital (even going as far as promoting the hospital as such in local papers), yet imposes such directives that would compel each patient to cough out more cash even when they are obviously unable to--- that's not just hypocrisy to the highest level, it's downright unethical.

And then during my last tour of duty, the only laboratory exams that were available were electrolytes, urinalysis, and fecalysis. That's right, even a complete blood count was unavailable. All other blood works had to be sent out. Good thing we still had paper for ECG tracings, and we still had x-ray films... there were many times that we ran out of both. Yes it's understandable that government hospitals do run out of these things due to budgetary constraints, but such degree of ineptitude is laughable. I would be laughing out loud if it weren't for the fact that the hospital charges exorbitant fees for such procedures, even comparable to the rates charged by some private hospitals. With the rates that they are charging, one would expect a little more quality in terms of services. If they could not deliver, then they should just slash their rates to prices that would be proportional to the pathetic services that they can offer.

And what about the laryngoscope with the busted lamp? We've been complaining for all eternity, practically begging for a replacement, and yet we still see no action. How many times do we have to insert an endotracheal tube blindly, hoping that we have inserted the tube on the airway, and not on the esophagus? And the worst part of my last tour of duty? A patient with a stab would on the abdomen came in dyspneic and very hypotensive. 2 Liters of IV fluid couldn't even raise his blood pressure to normal levels. The abdomen was rigid and slowly expanding. Breath sounds were clear upon auscultation, his dyspnea was probably due to an internal bleeding in his abdomen pushing his diaphragm upward. An emergency exploratory laparotomy was indicated. And as expected, no surgeon was available. Jesus Christ, in that fucking hospital, if it's not the surgeons who are not available, it would be the anesthesiologists. And if by some miracle both were available, the operating room doesn't have all the required materials for emergency operations. It's a NO WIN situation! As I've said before, with regards to these physicians--- if they can't make themselves available for emergency operations, why would they even allow themselves to be decked in the first place?! The surgeon on deck wouldn't answer his phone, and the others had something else to do. I can't really blame them since they were not the ones on call that night, but would it hurt to show even a little bit of concern during our conversations? They all sounded indifferent, some even sounded a bit peeved. We had a life or death situation, wherein every second counts, and I couldn't do anything. If I could operate on the patient in the emergency room, I would have. This has happened many times before, we should just put a huge sign at the emergency room entrance saying "Trauma patients cannot be accommodated in this hospital" to save all of us from trouble. Maybe something as explicit as "Trauma patients die in this hospital. If you want to live, just go straight to another hospital"--- yeah, that would effectively drive the message across.

So what did i do? I called up friends from where I used to work. I told them about my dilemma, and we all agreed that the patient was non transferable (obviously) because he could die any minute, but what else could I do? My hands were tied. i was working at a place that had the gall to call itself a hospital. In truth, it's only a hospital on paper, it's just a hospital by name. It's just a building that's pretending to be a hospital. So yeah, we agreed to transfer the patient as soon as possible... because I had no other choice. We were talking about a patient's life that could be saved. I had to transfer the patient personally because he could die any minute. When we arrived at the place where I used to work, they immediately recognized how critical the situation was, everyone worked quickly and efficiently... a far cry from where we came from, wherein only two of us seemed to recognize that the case before us required immediate action, wherein very few people genuinely seemed to care. Man, I couldn't help but reminisce on how things were more than two years ago, when I was the trauma resident on duty at the emergency room. We also lacked a lot of facilities back then, often we didn't do what is ideal and we often improvise, but we always managed to get things done, somehow. I miss working in a place where i can really help people. These days, on each tour of duty I'm still overwhelmed by feelings of altruism... but I can't seem to put such feelings into action. I genuinely want to help, but because I'm working in such a fucked up place... I just can't. It wouldn't matter if there were no doctors on duty at the hospital, because it wouldn't make a big difference at all. Tears are shed, lives are lost, and no one seems to care. No one seems to do anything about it, and it would seem that not one of those people who are in the position to take action would want to do any action. Patients are just sources of income. For them, lives are dispensable. For them, life just goes on.

Now I'm counting the days until my last tour of duty. I only have until next month, and this is one phase of my life that I couldn't wait to get over with. A person can only go so far before the sense of futility breaks him down. Even though I'm not doing it deliberately, I've had enough of toying with people's lives.

Of Least Concern

Another day in the emergency room. Usually exhausting, at times benign. Always unpredictable.

It was around 9 PM when those two stab wound patients came in. I've encountered a lot of trauma patients, and I have been trained regarding the proper management of such cases. Both Patients were hypotensive, but one of them already has parts of his intestines eviscerating from the stab wound on his abdomen. And he had a lot of other stab wounds on his back, which could account for the probable massive blood loss. On ausculation, his lungs didn't appear to be injured, but I ordered an immediate chest x-ray just to be sure. An emergency exploratory laparotomy was indicated. The other patient only had a single stab wound. Auscultation revealed a possible pneumothorax, but since he was more stable, i first administered fluid resuscitation and ordered an immediate chest x-ray.

While waiting for the results, i referred both patients to the surgery consultant on call. I was surprised by his response. First he asked me if there was a vacant room available. I told him there was none. He said how can the patient be admitted at the hospital when there's no available room. He reminded me of the "no room, no admission" policy. i told him in such emergency cases, a patient can be admitted even if there's no vacant room. Then he told me we lacked supplies at the operating room, and I said I already checked the supplies at the operating room. The hospital did not lack the necessary supplies. Then he said that he would need blood for the operation, and without waiting for my response he told me that's it's better to just stabilize the patient and transfer him to another hospital as soon as possible because we cannot operate on the patient. WTF?! Good thing one of the nurses had the foresight to check if we had available blood at the blood bank, so I told him that blood was available in case a blood transfusion was needed. Then this surgeon sounded irritated. Even more when I told him that I could do the operation for him if he would allowed me. He ran out of excuses, so he just told me he'll be at the hospital in thirty minutes.

Searching for an anesthesiologist was another problem. I already called all the anesthesiologists on deck at the hospital. Some said they had an ongoing case, others said they were out of town and that they wouldn't make it in time for such an emergency procedure... but i doubted if these anesthesiologists were telling the truth. It has always been such a chore finding an anesthesiologist in a government hospital. The others simply didn't answer their phones. I had no choice, so I just called their department chairman and told him the situation. I told him bluntly, if he can't find an available anesthesiologist, he had to administer anesthesia to the patient. I didn't care if he found me disrespectful. A patient's life was at stake, I've had about enough of these consultants and their stupid excuses.

The x-rays were done after that. The patient's chest x-ray was unremarkable, but the other patient had a massive pneumohemothorax on the left side. And whereas previously he didn't find it difficult to breath, after the xray he was almost gasping for breath. So I did an immediate closed tube thoracostomy without referring him to a consultant. It was an emergency and I've done the procedure dozens of times, so I didn't bother informing any consultant. Several supplies were not available, but miraculously, I managed to improvise. Afterwards, the patient became comfortable, although he complained of pain in the left lower quadrant of his abdomen. Palpation of the area elicited tenderness. Since the stab would was on the lower ribs, an abdominal injury was possible. I could have done an abdominal ultrasound to rule out an intraabdominal injury, but it wasn't available at the hospital. The chest xray didn't show any signs of pneumoperitoneum, so I decided to just observe the patient. An exploratory laparotomy could also be indicated if symptoms progressed.

And then Mr. Surgeon on duty came. He ordered the nurses to bring the first patient to the operating room ASAP. I mentioned the other patient to him, and that I already inserted a chest tube. He didn't seem to care, but when I told him about the abdominal findings, he told me to transfer the patient to another hospital while it was still early, because there's no way he could do another laparotomy. Christ. Is he aware of how difficult it is to transfer such a patient? Especially when the mentioned patient lacked sufficient funds? I can't just transfer a patient when I have already managed his immediate concerns. Most government hospitals already have their hands full, and they would not be inclined to accept a stable patient. What the heck. Screw him. I chose to continue with my present management. I knew what to do anyway.

The patient was stable when I endorsed him to my reliever. Ultrasound was still pending, but all abdominal symptoms have disappeared. Before I left, I referred the patient to another surgeon, who was more amenable. When he saw the post thoracostomy xray, his words were "perfect placement". He looked at the patient's chart and commended my management. He then asked me if I was already done with general surgery residency, and if I was just moonlighting while waiting for the results of the exam administered by the board of surgery. i told him no, and he seemed surprised. He told me that I more capable than a lot of doctors who have already finished surgery residency. I couldn't help but smile. I was extremely pissed a few hours earlier, and all those miserable hours seemed to have vanished suddenly. It's great to end one's tour of duty on a high note. It makes the whole day seem fulfilling, even when it's not.

I understand why a lot of consultants don't really want to accept patients at the hospital where I'm working. For one thing, they are not adequately compensated. Most of these patients don't have money, and I guess they often get promisory notes as payment for all their efforts. i understand where they are coming from. Of course I want to receive just compensation as well. But these consultants are aware of this fact when they signed up. They are aware that it's a local government hospital, therefore majority of the patients that they would receive won't really have sufficient funds. If such patients would always be the least of their priorities, or worse--- if such patients won't even be a priority at all, they shouldn't have signed up in the first place.

I. Saw. Red.

Went home intoxicated, with a glimpse of sunlight already on the horizon. Only slept for two hours. Had to force myself out of my bed. My day wasn't starting out right. And from the moment that motorcycle hit my car from behind as I was on my way to work that morning, i knew it would be a horrible day. It just wouldn't be my day.

I know how irrational patients and their relatives can get in times of emergencies... or more often, in times that they mistake for emergencies. Back in 2004, the year of my clinical clerkship, I experienced first hand how a patient's relatives showered utmost hatred towards the medical staff when we failed to revive their relative. Expletives were shouted, and they had the look in their eyes that screamed murder. In times of grief and despair, people tend to become incapable of rational thought. That's human nature, I guess.

There are a number of times that I behaved unprofessionally while at work. I can't help it, so sue me. I work at a government hospital, and although I like the fact that the patients we encounter are those who really need our help, one drawback is that most of these patients and their relatives are uneducated, some may say even uncivilized. They can't understand simple instructions, and they fail to grasp simple reasoning. I'm aware of this fact, and often I can show patience. But the workload can sometimes limit the extent of how this patience can be stretched... especially when these patients don't treat you with the respect that you deserve, I can't help but to retaliate at times. Respect begets respect, one does not need fancy education to grasp such a simple concept.

Often, patients demand to be admitted at the hospital even when they have no basis for admission. They just think they need to be confined at the hospital because of the subjective symptoms that they feel. To be admitted just because you want to be admitted is acceptable at a private hospital, but not in a government hospital wherein we save beds for those who really need to be confined. Most the time all beds are full because the bulk of patients in the general population seek consult at government hospitals. It would be both foolish and impractical to admit patients because they want to. Or how about those patients who go to the emergency room to seek consult for such simple and benign illnesses that could obviously wait until the next day? Do they not understand the meaning of the word "emergency"? It's fine when there are only a few patients. But when we are dealing with a lot of patients, most of whom are really in emergency situations, these patients can really be a waste of time and manpower. And it even gets more irritating when they demand immediate attention, saying they were there first, even when the patient who came after them is already gasping for breath. At times I can't help but shout at these patients. If they refuse to wait, then they better transfer to a private hospital. Their non- emergency complaints along with their money, would be fully appreciated there. It even gets more annoying when they start to namedrop, saying that they know the hospital director, or someone from the government. D-oh, as if those people can really do anything. So what if they are from the government? We can't just discharge patients randomly just so we can admit their patients. Often, all beds are full, all rooms are full. There are even makeshift beds and stretchers along hallways just to accommodate the huge patient load. If those people that they know can add rooms or beds just to accommodate them, then fine. But if they can't, then they better just shut the f*ck up.

There was a time last year when I actually challenged a patient's relatives to a fist fight. Highly unprofessional behavior, i know. There were a lot of patients coming in, and seeing that the patient only had a simple laceration, I asked him to wait. After about an hour, I fully explored the wound, and I saw that a tendon was transected. I couldn't find the proximal part, I had to extend the would longitudinally to find it. A local anesthetic wouldn't be enough. Such a procedure can't be done at the emergency room, and since the operating rooms were full, the patient had to be transferred to another hospital. I called another institution and they were willing to accept the patient. Our ambulance was available, so the patient was ready to be transferred. But then the patient's brother started rapping about making them wait. If I couldn't do something about his brother's condition, I shouldn't have let them wait that long. i explained the situation again, but he refused to listen. I was getting exasperated. I haven't eaten yet, and there were more patients coming in. i couldn't waste any more time explaining. Then I heard an expletive. My patience ran out. I shouted at him. I exclaimed an expletive as well. He answered back. he pointed a finger at my face, and I pushed his hand away. Then I challenged him to a fight outside to settle things. He then said something like what aprofessional I am, challenging him to a fight. I told him that was the way I am and he couldn't so anything about it. I was about to kick his sorry ass when the hospital's security guards grabbed him and brought him outside. Such unreasonable people can really bring out the worst in me, especially when I am stressed.

The last time I went on duty, things were going smoothly at first. I've managed to keep that stupid motorcycle driver who scratched my car out of my mind. From morning until the afternoon, the patient load was tolerable. Then that patient with two gunshot wounds to the head came it. He was brought in by the local rescue team. They said they found him by the road, so the exact time of injury was unknown. Both pupils were already dilated. On my assessment, his Glasgow Coma Scale was only 4... definitely not a good sign. But the patient was still alive, so we had to resuscitate him. I inserted an endotracheal tube, started fluid resuscitation, and after a few minutes, his vital signs began to stabilize. The patient was stripped as i searched for other injuries. His pockets were emptied, which had a small bag of marijuana among other things. I knew the outcome wouldn't be favorable, and an operation would be useless, but as per the hospital's protocol, I referred him to a neurosurgeon. Just as I suspected, the prognosis wasn't good. But an immediate CT scan had to be done just to see if an immediate operation would be of benefit. If there was a subdural or epidural hematoma causing a compression or herniation of structures, then immediate craniotomy would be of benefit. If there was none, then a craniotomy would be useless. The location of the bullets had to be known too. If the bullets were only superficially located, they could be excised. If the bullets were located deep in the brain though, excising them would mean dissecting the whole brain, which would only do more harm than good. That was when some relatives came. Since the hospital had no CT scan, the patient had to be transferred temporarily to another hospital. Good thing the relatives had sufficient funds. The CT scan was done immediately. One bullet did not penetrate the skull, but the other was at the center of the brain. There were no subdural nor epidural hematomas, only intraparenchymal hematomas around the bullet's trajectory. Based on my initial assessment, I figured that an operation was useless. The CT scan affirmed my presumption. When I relayed this to the relatives, that was when all hell broke loose. The patient's mother grew hysterical. She demanded that the patient be transferred to a private hospital because we weren't doing anything.(WTF?!) To appease her, I tried to call the hospital where they want to transfer the patient. The physician at that hospital told me that they could not accomodate the patient. The patient's mother grew even more hysterical. She screamed at me and told me that I was a liar. She said the hospital would accept them because money was no object... never mind the fact that that hospital had no available rooms. Obviously, she knew nothing about patient transfer protocols. I let that pass. I knew that she was grieving and she was still in denial. Then they wanted to transport the patient by themselves, which we cannot allow because the patient was intubated. Now the other relatives were also shouting. Why wouldn't we let them go, they ask. Jesus Christ. To appease them, I called another hospital--- one that I was sure had available rooms because of their exorbitant rates. And true enough, they can accomodate the patient. One of the patient's relatives, who was a doctor herself, asked me questions. She understood the fact that transferring the patient to another hospital was useless, that it would only incur additional expenses, and yet she wouldn't help me make her relatives understand. No amount of explaining could make things clear to people in denial. But she could somehow provide the voice of reasoning. When I asked her to explain everything to her relatives--- because maybe they would listen to her... she just remained silent.

Another half hour of crying and screaming. The mother shouting that her son was a good person, he had no enemies, he did not deserve what happened... i just wondered how good he really was, when illicit drugs were found in his pockets. He had two shots in the head, one on each side... a person must really be consumed with anger in order to do that to another human being... More crying. More shouting. It was a madhouse. I was glad when they finally settled their hospital bill. A few more minutes, and we were off. When we arrived at the other hospital, a few more relatives arrived. The patient's brother, who was crying and begging me earlier to let them transfer their patient to another hospital said something that really made my blood boil. He told his relatives that the doctors at our hospital weren't doing anything. He told them that we were stupid and we did not know what we were doing. And the he turned to me and said that all the years i spent in med school was a waste, because look at the way I turned out.

I wanted to punch him in the face.

I was trying so hard to control myself. I knew that they were in grief, and that's why I remained incredibly patient all that time. But to say something like that, to personally attack my and my profession?! That comment was way below the belt. It's bad enough when patients accuse you of not knowing what you are doing--- but when you are 100% sure that everything you've done is correct and they still question your management, it's even more offensive. I know I'm not perfect, and I know I'm not a great doctor. I've made a lot of mistakes in the past, but on that patient's case, I did everything right. I tried so hard to control my temper, simply because I wasn't at my home turf. I was at another hospital. If we were outside and I wasn't on duty, I would challenge him to a fight, punch him in the face, I don't care even if he's bigger than me. We weren't doing anything?! whether they brought the patient to a private or public hospital, it wouldn't have made a difference. We followed resuscitation protocols by the book. The treatment would be the same even if the patient was brought to a private hospital. And he calls us stupid?! They're the ones who can't grasp the reality that their patient was brain dead to begin with, that he wouldn't survive anyway--- and in the unlikely event that he does survive, it would only be in a comatose state. They kept on demanding that the patient undergo operation no matter how hard I explain to them that an operation is useless. If there's anyone stupid in the emergency room, it's their whole family, not us. I wanted to tell him that only a blind person would say that we were not doing anything. Only an imbecile would tell me that i don't know what I was doing. Only a moron would tell me that the things that I did were wrong. But what could i expect from a family that can't grasp the simple fact that their relative has no chance of survival? What could I expect from a family that keeps on insisting on an operation that isn't even needed? Mark my words, if the neurosurgeon at that hospital recommends an operation, he or she would only be milking money from them, knowing very well that an operation is not indicated. But what could I expect from a family that's drowning in denial? What could I expect from a bunch of know-it-alls? Stupidity must really be genetic. Their family is the living proof of that.

But i stayed silent. I tried to symphatize, i tried to understand their situation. But I was really offended, and that feeling rises above all others. It doesn't dissipate... it lingers. I kept all that anger inside, instead of finding a way to release it. And now... two days later, I'm still pissed. Really f*ckin' pissed.

I should've punched that asshole in the face. Who gives a f*ck about consequences. I could deal with all that later. At least punching him would have immediately made me feel better.

The Hierarchy

One thing that sucks about being in the medical field is the hierarchy. Take a look at some of my entries two years ago, and you'll see how I felt about it. I don't know what is it about physicians that makes their seniority such a big deal. Just because most laymen see them as God, that doesn't mean they should expect their fellow physicians to see them the same way... no matter how ahead of the game they are.

I was talking to a friend who just resigned from residency training a month ago. He said he couldn't take all that red tape and seniority crap. About how someone who's just a year ahead of him can order him around and ask him to do petty things, like buying a can of soft drink during a busy day, and he should buy it as this specific store--- or else. Or how they could ask him to wash their cars, to clean their apartments... things that are definitely not part of his job description as a surgery resident. And when he tries to reason out, the usual response would be "this is the way it has always been. If you can't stand it, then you are welcome to leave." Man, I could really relate. I don't know why some people believe that just because you are training somebody, you have the right to treat them as dirt. I don't know why some people think that just because you are sharing your knowledge with another, that person owes you such a huge favor that you can demand anything from him. I hated the hierarchy so much. I hated it when someone who's only just a few years ahead of you can act so high and mighty. And I most especially hated it when that person who's acting so high and mighty isn't really any good at all. Heck, in some aspects, I'm even better. Back then I told myself I would never be like them when I become a senior. It's just not in my personality to treat others as such. For me, it is better to have juniors who do as they're told because respect they respect you, rather than subordinates who do as they're told out of fear. I'd rather have subordinates who treat you as a friend, rather than those who put a smiling face when you're facing them, but then stab you in the back the first opportunity that they get. But we all know how it all turned out. It would take more time before I finally become the senior resident that I've always imagined myself to be.

Most doctors have huge egos. That statement may be anecdotal, but it's a fact that's widely perceived. I guess it's because they know more about human life than the average person. It doesn't end with med school or residency training. Learning is a life long process. If a doctor gives up his quest for knowledge, he's going to be left behind by his peers. Intellect has become such a premium, so much that when someone comes along who seems to be better, most egos are easily trampled upon--- mountains are made out of mole hills, feelings are hurt, when they shouldn't even be hurt in the first place.

Last month, I had a sort of falling out with a certain consultant whom I used to see as a friend. For those who aren't in the medical field, a consultant is a doctor who is already done with residency and fellowship training. Thus, he or she already has a private practice, and they serve as mentors for med students and residents. Usually, residents put a wall between consultants and themselves. It's not just about the age difference and the disparity of interests that would result from such an age gap... I mean, you couldn't really show everything about yourself to a person who's continually teaching and evaluating you. You have to keep your best foot forward at all times, never show your vulnerabilities. You can't get too close or attached.

But she was different. She treated me as one of her peers... and her behavior is usually not to be expected from someone her age. Heck, most times she acts like me. So eventually, the wall broke down and i talked to her the way I talked to my friends... because to me she was no longer a consultant. She was a friend. And then all of a sudden just because I tried to reason out and I refused to do what she wanted because I didn't think it was the right thing, she had to bring up the fact that she was already a BOARD CERTIFIED CONSULTANT and I was just a mere resident, so I should do as I was told.

First of all, she was not the consultant on duty that time so i didn't think she had a right to put her fingers where they didn't belong. I had a point. If she wanted to do something, shew should do it the next day when she'll go on duty, out of respect for the consultant who was currently on duty. I really didn't understand why that was such a big deal. I didn't understand why she had to bring up her seniority just to push a point across. And even if she was the one on duty, I don't give a fuck if she's a board certified consultant or not. For one thing, I'm not in a training program. She's not training me, and neither is she the one who's giving me my salary. She can bring out all her papers,certificates and citations and shit, and they all won't mean a thing to me. We're all employees of the same hospital. I'm not in a training program. She's not my senior, and neither is she my boss. Now, when she tells me jokes, or shares her problems, or asks for advice, i don't respond like a friend would... i respond as a resident responds to a consultant. Whereas before i was willing to do favors, things that one would willingly do for a friend, now I make up excuses. She chose to build up this wall. If she wants to be treated as a consultant, then that's what she'll get. She can't have it both ways, depending on her mood. I can give her respect, but she can't expect me to treat her the same way i treat my friends. She can't behave like we're equals most of the time, then suddenly bring up how superior she is when things don't go her way.

And come on! I don't get it how many consultants see themselves as gods when they're with residents, as if they're all powerful and all knowing. Fine, the best ones may be all knowing when it comes to their respective specializations, but when it comes to other sub specialties, cracks are evidently showing! Heck, cracks are even showing in their own respective specializations! That consultant doesn't even know how to insert a chest tube properly. She can't handle pediatric patients properly. Aren't those things expected out of an emergency medicine consultant? So much for being board certified. And what does the hospital do? They give so much premium to these board certified individuals even when the residents are the ones doing the procedures... and some of those procedures, like umbilical catheterizations, closed tube thoracostomies, and tenorrhaphies are procedures these consultant don't even know how to do! And the hospital doesn't give due compensation to the residents who do such procedures. Instead, professional fees are given to the consultants! I'm just saying that credit should be given where credit is due. Last week, one patient who got into a vehicular accident and was subsequently discharged by the ER consultant on duty. He came back and he couldn't move his arms. I don't know if it's only because I had sufficient previous training, but when I reviewed the x-rays of the patient I could clearly see a cervical spine fracture. Two days ago, my mom was misdiagnosed. Now she's at the hospital, and what I thought initially turned out to be true after all, I wondered how her doctor could have missed it. Maybe it was his age. Then again, maybe he wasn't such a good doctor in the first place. He couldn't even prescribe the right dose of a widely used drug like Paracetamol. Again, so much for being BOARD CERTIFIED. All those papers don't mean a thing if one couldn't see it in their performance. Instead of displaying those things on their walls just to prove their worth, better to just use those certificates to wipe their asses.

We're all doctors. At the most basic level, we're all humans. We're great at some things, and we suck at others. No one's perfect. Why can't we just accept that fact, so that instead of trying to trump one another and refusing to admit that in some ways others are better, we could just learn from one another and be better ourselves. Is that so hard to do?

Ramblings.

Whoa. It's been almost a month since I've last updated this blog! I've been a bit busy during the first two weeks of December, and just when I was about to post something...

BROADBAND BLUES

Our broadband modem conked out on me. I haven't been able to go online for about a week. It wouldn't have taken that long if only our Internet service provider immediately sent a technician to our house to check on the modem. For some reason, they found it hard to believe that the modem that they've provided would be broken after only two years. They must think I'm someone who doesn't know anything about computers. They kept suggesting that I try this and that, a lot of troubleshooting for the usual problems. I did as they said because they wouldn't send anyone unless they're absolutely sure that the modem was broken--- and as expected, nothing worked. It wasn't the software, it wasn't the LAN card, it wasn't the cable. It was the god damned modem!!! So when they finally agreed to send someone, it took three whole days before someone actually came. After sales support form our ISP definitely SUCKS.

THE TWILIGHT ZONE

That's where i thought I was when I was watching that piece of crap movie entitled TWILIGHT. The sound of all those girls gushing and screeching in the background made the entire experience even more nauseating. For the life of me, I could never understand why some people have been praising this film to high heavens. And I could never begin to understand what's with all that hype. Maybe I just can't appreciate this film because I never liked romantic films to begin with. Maybe I couldn't appreciate this film because i wasn't in the mood for something brainless when I went inside the movie theater. From what I could gather, I guess you could only appreciate this film if:

a) you are a girl within the age bracket of 6-16, and therefore do not look for much depth in movies.

b) you are a girl who is a hopeless romantic.

c) you are a girl with some serious vampire fetish.

d) you are a girl who's a sucker for any movie with a hint of romance

or

e) you are a guy who thinks like a hopelessly romantic teenage girl with a vampire fetish who's also a sucker for any movie with a hint of romance.

As for the rest of the human race, we're better off watching something else. Okay, so it's not really that bad. The basic premise, although littered with several cliches and a number of misses, is actually quite interesting. Kinda like Buffy 90210, if you're into that sort of thing. Heck, I've seen movies released on the big screen that are far worse--- but I expected something more because of all the hype surrounding this film. The whole movie feels like a B movie--- from the cheesy acting, to the corny dialogue, to the lame special effects. I would put it on the same level as The Covenant, which was released a few years ago. If people saw that film for what it really was, I wonder why they can't see through Twilight.

Yeesh. I'm still wondering if I could ever get those two hours of my life back.

TO STAY OR TO GO

Incidentally, me and my friend from where I used to work have reached an agreement. We've decided to take up residency in the USA, having realized that the future is really bleak for young physicians in this country. He has already resigned from where we used to work and we're on the process of studying all those things we've learned in med school again, and hopefully we could take the first exam (out of four) by March or April. And yeah, my dad agreed with this plan, but he says i have to go back here after my training--- haha. not if I can help it. Things holding me back? Yup, there's still my principles, that i'd rather serve my own countrymen, but I guess I would be able to adapt after some time. That's something I could get over with. Loneliness? I could live without my family and friends, part of me relishes being a loner anyway. On the back of my mind, there's only one thing really holding me back...

THE MATRIARCH

Yeah, my grandmother's been awfully sick AGAIN lately. Her doctor already told us last year that she's already counting the days, give or take a few years. She definitely won't make it for another decade, with the myriad of diseases in her system. She was rushed to the hospital two weeks ago, she was already in heart failure. Prior to that, another encounter with the father, about me not being able to recognize that she was in heart failure, about me being seemingly aloof and not caring at all. I've already posted about my issues in this blog, on why I seem not to care, that I'm starting to sound like a broken record. I don't like being a doctor. I hate internal medicine the most, the realm in which her diseases fall into. I hate the fact that even at home I can't escape from the thing I hate the most. To make matters worse, I find the immense pressure of treating my own grandmother hard to take, and the lofty expectations of my family making it even more difficult. She'd make an pretty good case presentation--- one that I would find very hard to present. Diabetes, myocardial infarction, heart failure, recurrent urinary tract infection, nephropathy, hypertension, recurrent pneumonia, and just recently, squamous cell carcinoma, which was already excised a week ago, but we're still awaiting the final pathology report.... hey, at least that last one's surgical... and yet I failed to recognize the lesion for what it really was. D-OH! Yeah, on one hand, I'd be glad to leave. It would be great to be away from all that pressure. It would be a relief to finally escape. But on the other hand, I'd be away for more or less five years. I'd hate to be away when she finally croaks... I owe a lot to her, almost my entire state of being. In spite of everything, in my heart I know I really love her and I'd hate to see her go.

WEDDING BELLS

Back to my friend from where I used to work. We've been having several discussions, one of which was the process of residency applications... which programs were feasible for us, which ones were hard to get to, how to make it easier to get accepted... The fact that the US is in recession won't be a problem since healthcare is one of those sectors not affected by the recession. i.e. there are no massive layoffs, and hiring is still on the upswing. Then he says something about having a better shot at getting into the program we like if we were citizens of that country. He's planning to marry his girlfriend this year, and that girl is a US citizen. As for me? He suggested that I marry his sister, who's also a US citizen (his family migrated years ago). Instantly, my eyes popped. What the fuck?! I'm not going to marry someone I don't even know! He says it would be okay with his sister, we don't really need to be together, and we could easily get a divorce after. I couldn't help but laugh. Was he serious? Apparently, he was. But I just couldn't agree with him. Even if I knew her, I can't marry someone I don't love. Heck, I don't even believe in the sacrament of marriage in the first place, so I don't give a fuck about religious ramifications. And even if it was okay with her, marrying her for the reason of residency applications would be blatantly using her. I just can't do that. Using someone for selfish gains is against my principles.

But there's that wild, foolish side of me that got a bit excited with the prospect of a shotgun marriage. There's that sort of thrill when I think about the idea of getting married just for the heck of it. So who knows? It's going to be a long 2009 for me, full of promise, different paths to take, a chance for a fresh start. Let's just see how things turn out. LOL. :)

Oh yeah...

MERRY CHRISTMAS

May it be a yuletide season for all of us. :)

Square One

I couldn't help but smile. But there’s that underlying feeling of uncertainty that prevents it from being a full blown smile.

It’s no secret that I didn’t really want to go back to the place where I used to work. I was practically forced to re-apply. So being my mischievous self, I devised a plan of sorts. I applied for a different program, because I knew my dad didn’t know any of the consultants in that department which would prevent any under the table deals. The fact that they would only be accepting two applicants means there would be lesser chances of me getting accepted. But--- it was a program that I did like… so in case I got the job, I would’ve gone through with it. I would even treasure the position since it’s a very competitive slot. I said during the interview that it’s okay if I don’t get accepted for the straight TCVS program--- that’s true. I also said it was okay if they give me a slot in the general surgery program instead, the same program I was in last year--- that’s a big lie. No way would I be repeating that experience, even more now that I’ve experienced first hand how easier life would be if I choose to be in a subspecialty program.

So yeah, the plan worked perfectly. Everything went according to plan. The brightest of the bunch got one position, and what I would suspect someone with strong connections got the other--- with her lousy performance during pre-residency, I doubt if she got in fairly. Don’t get me wrong, no way am I being bitter. I would’ve been fine either way. One consultant called me up offering me the general surgery slot, which I said I would take in the event that I wouldn’t get accepted in the TCVS program. It’s also the position promised to my dad by his friends in the department--- and guess what? I said NO. LOL. I just said I was uncertain before that’s why I said I would accept the position during the interview, and it’s only now that I have realized that I really wouldn’t want to take it. If I really wanted that, I wouldn’t have resigned last year. If I really wanted that, I would have chosen that position as my first choice. My dad is still in abroad on his business trip, and by the time he gets home it will be too late for him to do anything. Oh yeah, there will be fireworks. All hell is going to break loose. It’s going to be war all over again, but I think it’s about time he let go of his dream of having his son finish residency in that stupid institution--- we’ve been in a standstill for far too long. I’m not a complete asshole--- I sometimes pity him, I see the great efforts that he’s making to bring me back, and I bet he had to swallow a lot of pride, which is very difficult for him, being the person he is… but it’s not something that I want. It’s really difficult to live the live others want for you and not the life you want for yourself. It’s been this way for far too long, and it’s making my life more difficult. It’s bad enough as it is.

For the first time in weeks, I couldn’t help but smile. But there’s that lingering feeling of doubt, whether or not I made the right choice… it could be that I’m just letting my tendency to be hard headed take control again. Then there’s that feeling of uncertainty--- where do I go from here? The whole experience may be a blessing since other opportunities have opened up for me, but I have no idea which path to take. I’m back to square one again. Crap, it’s been two years after graduating from med school, and I still don’t know what I really want. Part of me wants to stay here, part of me wants to go away. The financial rewards are far greater abroad, but I may not have the same satisfaction that I get when treating patients in my own country… and yeah, I could only imagine myself in the surgical field, I can’t imagine myself as a primary care physician in the fields of internal medicine, family medicine, pediatrics etc. for the rest of my life…. and those are the feasible residency programs a foreigner could get in the US! I could still choose to apply in the surgical fields, but they say it would be very difficult. So it’s a choice between the easy way that I don’t really want, or the hard way that I really want. Man, how I hated internal medicine in med school… I’m not sure if I could do that and just think about the financial rewards, even though I get no fulfillment in what I’m doing because I’d be treating my work as a chore.

Crap, crap, crap. Decisions, decisions, decisions. I have to arrive at a definite decision as soon as possible and stick with it. After all, I’m not getting any younger.

The Subspecialty Schedule

I mentioned before that i applied for the straight fellowship program in thoracic and cardiovascular surgery (TCVS)--- that means I only have to take up general surgery for 3 years instead of the usual 5 years, then I could proceed to fellowship training which would last for another three years. To give us a glimpse of our possible life for the next six years, pre-residency this time around had me rotating in general surgery for two weeks, while the latter half would have me rotating in TCVS.

I've been rotating in TCVS for about a week now, and I just have to say that the difference between general surgery and any sub specialty (TCVS, urology, plastic surgery) is like night and day. Everything is organized--- it's possible in general surgery, and I kept on wondering why they can't seem to fix things. In terms of schedule? I couldn't be more happier. I can squeeze a few hours of sleep even when I'm on duty. I can go home every three days. During week days, i can go home as early as 7 PM. I had time to go to the gym. On weekends, we're done by 11 AM! And today, I'm on call, yet I've managed to go to the mall and buy a few clothes, watch a movie, and eat a decent meal... I even went to a bar a few hours ago! LOL. Good thing there were no emergency cases. I was back in the hospital just in time to log in. :)

Come to think of it, going back at the same hospital isn't so bad--- as long as I'll be going back under the TCVS program. I'm familiar with everything already, I already know a lot of people here, asking for favors would be much easier... during the first two weeks while I was still in general surgery, I immediately remembered why I left this place... seeing all the things I hated--- things haven't improved... in some aspect, they have worsened. But in TCVS--- I believe I could live like this. Yeah, I would still have to go through three years of no life in general surgery, for three whole years this hospital would swallow my entire life again... but after that, it would be three years of getting my life back, with the added bonus of surgical training. I guess that's a fair exchange. :)

Yeah there are drawbacks... they say it would be better to finish general surgery first so i would be board certified to handle cases in both general surgery and TCVS... they say I would be more capable to handle intra-abdominal lesions if i finish general surgery first... add the fact that several hospitals prefer those who finished general surgery compared to those who underwent the straight program... but i'm tired of the whole general surgery lifestyle--- at least in this hospital. I guess all this though is a bit presumptive, i haven't been accepted yet. LOL. If I don't get accepted, I'll be given the option to undergo general surgery instead--- an option I won't take, even if I said during the interview that I would be willing to. If I'm not accepted, that would be fine with me. It's not something that would bring me down. That just opens the door for other opportunities to explore, opportunities that would arguably be better. I love helping others, it's just that I'm sick of giving up my entire being just so I could be of service. This time, I'd like to leave a little piece of my life for my own. That's not too much to ask for, right?

Time in, Time Out

It's day 12 of this replay of pre residency training, and things are getting crazier and crazier. Tension has been escalating exponentially, and the so called seniors are making things harder and harder. One of the things that i don't understand is that we have to sign in for attendance at exactly 4 AM each day, even though we're at the hospital all the time. Thrice my name was already crossed out. I wouldn't mind it if I came from home and was really late. Heck, I wouldn't really mind it even if I was at the hospital and failed to sign because I fell asleep. But during all three instances, I was at the hospital working! and it's not like I was really late in signing. It was only 4:15 AM when I went up to the surgery lounge to sign in a few minutes ago, and they already crossed out a lot of our names!

That's it. I don't care about that stupid "attendance" sheet anymore. It has turned into nothing but bull--- another tool to whet the appetites of the power hungry. If they want us to drop everything we're doing no matter how important it is, even if doing so would be detrimental to our patients... just to be able to sign on some stupid piece of paper, then so be it. If they're seriously considering using that stupid attendance sheet as a criteria to determine the people who would get accepted in the department of surge-fuckin'-ry, then they have more than a few screws loose. It's just another proof that the way they run this so called pre residency training is so fucked up. They can cross out my name for the next two weeks for all I care. In my heart I am doing my work.I am not slacking off in any way. If they will base my performance on the number of signatures on that attendance sheet, then that's their call. I don't care at all.

Impedance... Redux

Pre residency training redux.

Prison Break fans could relate... Remember how it was in the end of the second season two of prison break, when Michael Scofield found himself in prison again after a tumultuous turn of events? That's exactly how I felt the very moment I reported for duty a week ago, at 4 AM, in the place where I used to work. A slightly different program, but in the exact same department, in the exact same hospital where I submitted my resignation papers more than a year ago. Back to the no eating for a maximum of 2 days, no sleeping for a maximum of three days, no taking a bath for a maximum of a week lifestyle. In a way it's easier the second time around. I already know the ins and outs, I already know the rotten system and the ways to get around it. Plus, the first year residents seem to find it awkward giving me orders, because they know for a fact that if I had not resigned, I would've been their senior. So yeah, work wise, there's less stress involved. But a lot of my seniors have been giving me a very hard time. Clearly, a number of them do not want me back, and some aren't even blunt about it. I'm somewhat ostracized. I feel like an outsider more than ever. Some people who I've used to think as friends now seem like strangers--- as if the months I've spent with them, sharing their work, their problems, their pain... as if those months never even happened. And add the fact that when I did this the first time, I was having fun even though the work load was unphysiologic, because I liked what I'm doing. Now everything's a chore. I even find the whole exercise useless. Pre residency training is meant to orient incoming residents regarding the ins and outs of the system. Geez, technically I've already had more than 8 months of orientation last year. I'm not learning anything new. I even know a lot more than the current first year residents. Not to mention the fact that I can operate on a patient a lot faster. Many times I was tempted to just grab the instruments just to get things done.

Crap. The next 5-6 years of my life trapped in that place. There'd be little time for anything else, because in order to work in the place,you'd have to allow the system to swallow your entire being. But i guess after 5-6 years, i'd finally be able to do what I like, right? Rewards are directly proportionate to the sacrifices we make... at least I hope so.

One person seems to be really happy about all this though--- that's one positive thing I could see. My credit card bills have miraculously been paid, and when I got home this evening, a gourmet meal was waiting for me, prepared by you know who.

Crossroads

I'm at a crossroad again. Before, going away and seeking greener pastures elsewhere was out of the question--- because of my principles, I said I wanted to stay where I am and help my own countrymen. But these days, that choice is becoming more and more enticing. Most of my friends from med school have already left. In fact, most of them have started residency training in the US. When I told some friends who are still in the country about my half baked decision to go back to where I used to work... to put it mildly, they thought the decision was STUPID. Why the hell would i go back? Don't I remember how I used to feel back then? It's like eating the food you've just vomited, taking back stuff that you've thrown away in the garbage---- yup, those exact words. It's like hearing my own thoughts coming out from the mouths of others. And to make things even more confusing, one of my closest friends, who was pestering me to go back a few weeks ago, is now telling me that he wants to resign too. He said he has finally realized that he'd rather go abroad also, that it would be the best decision. He says should I decide not to go back and just go abroad, he would instantly resign so that he could join me. He just doesn't want to do it alone. Truth is, I still want to serve my own countrymen. I still don't think I would be comfortable treating foreign patients. What makes that path so attractive is the chance to finally get away--- away from all the pressure, away from being controlled, to finally put an end to the feeling of being imprisoned. Sure I would miss some people, sure there are a lot of things that would make me want to stay, but with the weight things are now, the desire to leave is so overwhelming that I can't help but overlook the things that I would regret leaving behind. Am I really ready to make such a big step, or is this another case of making decisions haphazardly? It could be that I'm so clouded by emotions that I can't think clearly. I might make another decision that I might regret. I actually applied for a slightly different program. It's the straight program for cardiovascular surgery. Yup, it's still in the same department, but it's a sub-specialty that to my knowledge, my dad has no connections. If I get accepted, I would think that it would be done fairly. No under the table deals. If I get accepted, then maybe it was meant to be. I may be meant to stay here. I guess I have to wait for a month or so, wait for how things would turn out. Then i would make my final decision.

In The Spotlight Again

I hate being the center of attention. Yeah, I have the occasional fantasies of becoming a rock star, but I would never take the step to convert those fantasies into reality. That fantasy would forever remain in the confines of my bedroom and bathroom. LOL. If I liked all the attention, I would've agreed to several modeling and acting jobs offered to me a few years back. The easy money made those offers really tempting... but after some thought, I came to the conclusion that that just wouldn't be me. I wouldn't be comfortable with that line of part time work. I hate being noticed, it makes me really uncomfortable. I hate being talked about, I hate it when people keep looking at me, and especially when they blatantly stare at me. That's why I always try to keep a low profile... something that would never work no matter how hard I try, according to some of my close friends, because some of my features really stand out in a crowd. Like my eyebrows. Or my light complexion. Plus the fact that for some weird reason I still look clean even when I'm all sweaty and wearing really dirty clothes, and even when I haven't taken a bath for a week, which made me really stand out in that place where I used to work. Even when I'm minding my own business and my facial expression practically screams LEAVE ME ALONE, sometimes even a stranger would approach--- in the library, in a restaurant, in bar, in the gym, wherever. When I'm at work, I'm usually the one patients approach for consult. For some reason, I just stick out even when i'm not doing anything.

By now a lot of people have heard the news that I would most probably be going back to where I used to work-- practically a done deal since I already took the exam and I'm scheduled for another interview this week. Just like that, I'm the talk of the town again--- that is, if they ever did stop talking about me. As much as I'd hate it, all eyes would be on me the very moment I step on those hallowed grounds again. To make matters worse, it has come to my attention that the things my dad did late last year has become common knowledge... and people ahave been talking about it repeatedly. How he asked several politicians and a number of the biggest contributor's to the hospital fund to call the hospital director, insisting that they should hire me back--- never mind the fact that I did not really want to. It's what my dad wants. I found it hard to keep a low profile before, no matter how hard I tried to stay in the background. Now all the attention is enormously magnified,probably a hundredfold.

If only there was a way to turn off that damn spotlight.

Soul Searching

Being pissed, almost reaching the breaking point--- and then remission.

Being pissed, almost reaching the breaking point--- and then remission.

Being pissed, almost reaching the breaking point--- and then remission.

Like a broken record that plays the same tune again and again, that seems to be the recurring cycle in my life. When I woke up I thought this was going to be another day when nothing significant would happen. No utter joy, but no misery either--- you may say an extended phase of remission. Then one of my grandmother's medical problems rears its ugly head again, and then the father gives me that look of disgust, explicitly accusing me of not caring at all--- even more so when I left the house when everything seemed okay, just to have some time off, just to get away from it all. I didn't go drinking, I went to the gym to do something healthy and productive, and release all the tension I was feeling at the same time... a fact that he found so hard to believe probably because he saw that bottle of Johnnie Walker and that pack of Marlboro Reds on my bed. Hey, when placed under enormous pressure, I need to smoke, I need to drink. So sue me.

As I rode my car, I could see that look of disgust on his face. How could something so simple make me so pissed? At one point I wanted to crash my car on the nearest post, or make a sudden right or left as I was crossing the flyover... good thing running at 160 km/hr with rock music blasting from the stereo at full volume was enough to soothe my nerves. How could something so simple give me so much pressure? A little psycho analysis may be needed. A little soul searching. For one thing--- the possible root of it all... I don't want to be a doctor. I'm working as a doctor, yeah--- but I'm only doing this because I already am one. My educational background doesn't qualify me for alternative occupations, unless I do more studying... and it seems pretty stupid to waste all those years in med school by not working as a physician. Every day I feel forced to be doing something I don't really want to do, even though no one's forcing me to keep on doing my job. I hated everything they taught in med school, save for a few that I found remotely interesting. It was like turning me into something that I did not want to be. So i picked surgery for residency... because I really loathe internal medicine. Pediatrics is internal medicine for kids... I hate doing internal examinations in obstetrics-- the fact that women are at their worst during pregnancy further aggravates my ill feelings towards that field. Radiology is boring, so is pathology. At least all that blood in the surgical field keeps me on my toes, and i couldn't deny the emotional high I get when I do operations... I picked surgery by the process of elimination. But it's still a part of the field that I do not want to be in--- How far could that interest go? As I discovered, it couldn't go far enough.

Now every time I go HOME--- the place where i'm supposed to be able to get away from it all, to get away from anything medical... there's always that chance that I'm going to manage a medical case. Diabetes, Pneumonia, hypertension, a variety of cardiac and renal problems... all diseases that are within the bounds of internal medicine, the sub specialty that I HATE the most... and my grandmother has all those! It's not that I don't care, it's just that I feel like I'm being forced to be doing something I hate doing--- again and again and again! Add the fact that I'm not really good in that field! I didn't really pay attention in school because I hated the subject, and now everytime I go home I'm bombarded with questions in internal medicine, even pressured to do some action! And it's pretty stupid that my father is pressuring me to go back to the place where I used to work, and expect me to be available immediately every time my grandmother begins to experience more health problems--- WTF?! He knows that's impossible with the work schedule. In fact, family problems, even ones concerning health, are not valid excuses to miss work, unless that immediate family member is on the verge of dying, if not dead already! Whenever she has health problems, my father wants me to just stay with her because I'm the only doctor in the family. It doesn't matter if I have plans. It doesn't matter if I have work. Even when she's already stable, I still have to stay with her because of the possibility that those health problems could still recur! If I don't, then I'm ungrateful, I don't care at all. I'm all things rotten and evil in this world. It doesn't matter if I'm not skilled enough to handle her case. Since I'm a doctor, to them I should be skilled enough!

Are my reasons valid? Or do I already need to schedule an appointment with the friendly neighborhood psychiatrist because I've become highly irrational and unreasonable? I may not need a psychiatrist yet, but I sure could use a drink...

right about now.

D.N.I., D.N.R.

Do not intubate, Do not resuscitate. Usually, we give relatives of critically ill patients a choice, whether to resuscitate the critically ill patient or not. We explain the patient's case thoroughly, and when we believe that there is no more hope for the patient to get well, we inform the relatives of this option. People have different reasons for not wanting to resuscitate their relatives. Most people say that they do not want their loved ones to experience any more pain and suffering, especially if the illness has been chronic. Their loved one has already gone through enough. I believe others base their decision on their finances... though they do no admit it. I believe most of them really do care for their relatives and they want us to keep trying even when all hope is lost--- they just couldn't afford it. But I get the feeling that some are relieved when we bring up this option--- relieved that their bank accounts could finally take a breather. Whether or not they truly cared for their patient is beyond my perception. I understand how someone could choose not to resuscitate a person they loved deeply when resuscitation could offer nothing more than to prolong the inevitable, and simply result to broken ribs in the process. When all is lost, the best option at times is to let go.

But what if resuscitation can clearly save a patient's life? I understand patients who refuse to give consent--- after all, intubation seems to be a very uncomfortable, even painful procedure. If I was conscious, I doubt if I would give consent myself. But when the patient cannot decide on his own, whether conscious or unconscious, I can't understand how their guardians choose not to resuscitate even when we explain the benefits to them. Why bring these patients to the hospital when they refuse to allow us to perform the appropriate management? At times I'm tempted not to follow protocol and just pretend that the patient has no guardians or relatives so that I could do whatever I must do to try and save a person's life. I couldn't understand the relatives of this one patient who could still speak, who could still walk, who is still capable of emotions--- and yet his relatives ask us outright if they could already sign the form that says that we shouldn't resuscitate the patient in the event that he goes into arrest. I guess I'll never understand why some people behave the way they do.

Last week, another patient came in with difficulty of breathing. Breast Cancer Stage IV, with pleural effusion. Thoracentesis and closed tube thoracostomy done several times. The disease was no longer curable, patient was discharged from where I used to work a week prior, and was told to just let the patient spend the last few days of her life at home with her loved ones. Right off the bat, the patient said she did not want to be intubated. She did not want to have needles injected either, and inserting a chest tube was definitely out of the question. She was quite delirious, screaming and gasping for breath, yet asking for soup, which would definitely quickly ended her misery if her request was heeded. We turned to the relatives, and they said the same thing. They did not want to have any resuscitative measures done, because the patient did not want to. I wouldn't call it ignorance because we kept on explaining everything to them in simple, clear layman's terms. It would be harsh to chalk one up for stupidity, but I could think of any appropriate term. Maybe stubbornness. Maybe weariness. Maybe surrender. There she was, screaming and gasping for breath, and we couldn't do anything--- except watch her slowly die. A few hours later, she finally succumbed to pulmonary arrest---- just when her relatives decided to just bring her home. Maybe we should've just let her have her soup--- at least she would've died with some sense of satisfaction, her last request granted.

I've always thought that I was already numb to the idea of death, having witnessed a number of deaths each day that I am working at the hospital. One patient died, no big deal, just move on to the next. But on that moment, I couldn't help but feel sad. I knew that our hands were tied and it wasn't our fault, but I couldn't help but feel guilty. Maybe we should've tried convincing them more, maybe we should have tried harder. Maybe we should've thrown protocol aside and just pretended that we did not need their consent. Foregoing consent may be deemed unethical--- ignoring the patient's rights, physicians playing God, imposing on others what they believe is best... but for me, the sin of omission seems just as unethical... even more so.

But what do I know? I'm just a hospital employee carrying out orders, following protocol, in a line of work where having a conscience is a sign of weakness. With all the pain, death, and suffering we face each day in our working environment, letting emotions overwhelm you could only lead you to the brink of your own sanity.

Omission

It started out like any normal day in the emergency room. Nothing out of the ordinary. Managing patients left and right. Writing down orders. The occasional cardiopulmonary arrests break down the monotony. Then someone came up to me, his face vaguely familiar. Was he a patient on follow up? He spoke some words that at first i could not understand. He seemed really upset, even angry. It took me a few more seconds to realize that he was blaming me for something...

He said his brother, a patient that I managed in the emergency room, died two days after being discharged from our hospital. And he was blaming ME for his death. Saying that we did not attend to his brother, that we basically just ignored them, that's why they were forced to leave--- because apparently staying at our hospital would bring them nowhere. That's his version of the story. I took me a while longer to remember his brother's case. With the number of patients we see everyday, faces have this tendency to blur.

They sought consult because of a carbuncle on his right buttock. It gave him great discomfort because it was very painful every time he tried to sit down. At first we directed them to the outpatient department because clearly such cases aren't managed at the emergency room. But since he looked weak, we decided to give him some primary treatment. Upon closer inspection, the patient was febrile, and he had yellowish sclerae. He was probably septic. The carbuncle, his primary complaint, was probably the result of a system wide infection. But since there were very limited ancillary procedures available in the God forsaken hospital where i am employed, I couldn't really pinpoint where the source of infection was. Empirical treatment seemed to be the only option, as always. But since the antibiotics of choice were not available in the hospital, we had to ask the relative to purchase the antibiotics in one of the drugstores outside. That's the first stumbling block that we couldn't seem to hurdle. The money they brought with them weren't enough to purchase the medications. If only the medications were available, then they could just opt to pay for the meds prior to discharge from the hospital. Sadly, such a scenario remains to be a dream in most government hospitals.

The second stumbling block--- the patient can't be admitted because there's no room available. Because he was septic, it was not advisable fro him to stay and wait at the emergency room when there's no certainty as to when he would be admitted. In the emergency room, patients with various infectious diseases are placed side by side. Prolonging his stay in the emergency room would only worsen his condition. We had no choice but to advise them to transfer to another hospital where adequate treatment would be given. I was about to explain this to them, when the patient's brother told me that they decided to go home instead, because they would be leaving for the province the very next day. I told them that it was not advisable to go home. And he was definitely not in the condition to travel. I specifically told them that they should transfer to another hospital. I thoroughly explained his brother's case, but they were stubborn. They said they already purchased tickets for the trip, and they have to back to the province the next day. They would just seek consult at the provincial hospital. I told them that if they would insist on what they want, they should sign a waiver that they want to be discharged against medical advise. They agreed. It was against hospital policy to give a referral form when patients decide to go home against medical advise, but I gave them a referral form that they could show to another doctor when they decide to seek medical consult. The patients vital signs were stable, and though he was weak, he could still walk. I signed the discharge papers saying it was okay for them to go. That was two weeks ago.

And then the patients brother suddenly showed up, accusing me of negligence. Accusing us of being numb. Saying things like just because they are poor we didn't give them the necessary treatment, making the whole thing case of oppression, a clash between socio economic classes. What did they expect us to do? Shell out money to but the medications outside? If we did that to one patient, shouldn't we be doing the the same thing to each and everyone of them? If I had enough money, maybe I would have done that out of pity, but I certainly didn't have enough money to buy medications. Just because we are doctors doesn't make us martyrs. Sure, we could be martyrs if we wanted to, and I have been a martyr several times in the past. But in reality, doctors couldn't afford to always be martyrs. Majority of doctors can't afford to be martyrs at all. And it's not like I gave them faulty advise. I kept on reiterating that they must transfer to another hospital, they should not go home. I explained the possible consequences. I kept on explaining this to the patient's brother and he can't seem to understand. It even seemed as if he suddenly had selective amnesia, completely forgetting the preliminary treatment that we gave, forgetting the fact that i was persuading them to transfer to another institution, completely forgetting the fact that it was THEIR choice to leave. I kept on explaining and yet it couldn't get through his thick skull. He kept of blabbering the same things, keep on sputtering those accusing words, and my patience was slowly running out. I decided to look at the other patients before I said anything I would probably regret later on. I could still see him at the corner of my eye, just standing there, as if waiting for something. I had no idea how long he was waiting. I just realized that after some time, he finally left.

I know i did what was needed to be done. I managed his patient properly. I know I wasn't negligent. I am not guilty of the sin of omission... but why do I feel a tinge of guilt? A few hours after he left, when the work load became benign, my conscience started bothering me. Did I do something wrong? Was there something more I could have done? Maybe all I felt was empathy that I've mistaken for guilt. I could feel the deep sadness as I looked into his eyes. I could feel his pain. I could feel his loss. I could also feel his frustration... hopelessness... futility... anger. Anger brought about by loss. Misplaced anger brought about by a lack of understanding. And with the amount of anger that I also saw through his eyes--- even an innocent man would probably feel guilty with such a hateful gaze directed towards him.