all in a day's work

Nights on duty:

A year-old baby arrives at the hospital - a referral from another hospital. She is febrile and weak-looking. She is severely dehydrated and is breathing with difficulty. Pneumonia. Within the minute she arrives she goes into a seizure. Right away you consider meningitis and then cerebral malaria. You admit the patient immediately slightly piqued that the referring hospital did not call or send an SMS about transferring the patient. After admitting the patient and sending the ambulance away an SMS arrives regarding the referral. You conveniently forget to reply as you go on with your other admissions.

Two patients arrive almost at the same time. Both hypertensive with systolic blood pressures over 220 (normal systolic BP is 120 and below). Motor intact, sensory intact, no change in sensorium, oriented to person, place and time. Not stroke. One is congested, you start diuresis to rid of the fluid overload and bring down the blood pressure. One is diabetic and on insulin, blood sugar is in the high 200's. You give another shot of insulin. You monitor each patient closely the whole night.

A pregnant woman arrives complaining of lumbosacral pains. She has just gone into labor. A check reveals her baby is okay, fetal heart tones are okay. The woman's blood pressure, however, isn't. At 230/160 she is in preeclampsia. You start her on Hydralazine, load Magnesium Sulfate and inform her OB-Gyne. Her blood pressure goes down a little. In two hours time you are holding her baby. She had undergone an emergency Cesarian Section. They were okay.

Another pregnant woman arrives. She has been having uterine contractions since that morning. It was her sixth pregnancy. You do an internal examination which reveals that her cervix is fully dilated. You admit her directly to the delivery room. She delivers her baby within 15 minutes. The NA stands beside you to catch the baby. Both of you cringe as you notice a pinkish round noodle-like thing come out of her anus after the baby is delivered. A worm - Ascaris by the looks of it. You put a side note on the chart beside your post delivery orders and remind yourself to inform the OB resident to give the patient a purgative on follow-up.

You finally get some rest before 3 in the morning. You lie down and try to fall asleep knowing full well that the adrenaline coursing through your veins is going to keep you awake. Twenty minutes later just as your were about to doze off a knock on the call room door jolts you back into wakefulness. There is another patient in the ER. A mother has just brought her eight year old son. He has been vomiting and having loose bowel movement since the night before. He looks on innocently and smiles at me as he stands straight in his blue and white striped pajamas. You advise the mother to have labs done in the morning (the med tech had gone home for the day). Even though febrile, the patient showed no signs of dehydration. His clinical picture was that of a urinary tract infection - not viral gastroenteritis, not intestinal amoebiaisis*. You prescribed an oral rehydration solution, an antipyretic and an antibiotic, said goodbye to the kid and went back to sleep.

Two hours later you are awoken by another patient for admission.



*Labs done the following day did reveal a urinary tract infection.

back to work

I went on the trip alone. A colleague I usually go with had passed on work this month and was going home for a vacation.

I took an earlier trip. It was windy but the sea was flat and the sky was a clear blue. Another boat run almost parallel to the Baleno Otso before it veered a little to the left to head for Calapan. As the boat grew smaller in the distance I shifted in my seat and started reading.

"There is nothing nicer than doing nothing all day, then having a rest afterwards."

I agree. Take me away from the city any time. Take me away from the noise, the pollution, the congestion and anxiety. Give me space. Give me green trees and blue sky every day.

The boat docked at Abra in under two hours. I was lucky enough to get a ride on a passenger van that had gotten on the boat from Batangas.

I never get tired of the ride to the hospital. It is still a vision to see the clean green of rice paddies in the light of the setting sun. The coconuts frame the paddies in the distance. Only white cows and birds (egrets?) break the green sea.

Small towns always give me a warm and fuzzy feeling as I enter them. I always hope that this feeling of "home" is not replaced by a feeling of stalker creepiness. Small town people can be intrusive. They always know when somebody is new in town. In such a small place everyone knows what you've been up to.

After settling in and giving my dorm room a little clean-up I headed out to the hospital to chat up with the previous group of doctors. I had arrived just in time for a bon voyage party for two of them. After an unhealthy dinner of liempo and crispy pata we spent the rest of the night drinking and howling at each others videoke miscues.

I've never been much of a drinker. Occasions to drink don't come too often either. Recent R&R trips had me drinking more in a month than what I usually drink in a year.

At 2:30 in the morning I turned in earlier than the others. They would all be off in the morning while I was just going to start my work week. I made sure to hydrate and went straight to bed after I washed up.


I woke up early in the morning and run a 6k.



Reading:
Underwater To Get Out of the Rain: A Love Affair With The Sea (Trevor Norton)

reality check

A few days after coming back from Cebu I am still experiencing what one can only call travel-withdrawal. I still feel the sun on my skin and the salty spray on my face as I rushed to welcome oncoming waves. I can still picture running at the beach. I can still hear the loud churning of the motor boat and the soft lull of the sea as we went island-hopping.

{I smile at strangers with beach-hangover as evidenced by the flip flops and board shorts they are still wearing in the city.}


I keep thinking I need a few more days of R&R after my week-long vacation to help ease me from vacation mode to work mode.

Tomorrow I will be traveling by sea again. The 2-hour ride to Mindoro will be my wake-up call.

Reality beckons. I shall welcome it.

motivation

Maundy Thursday.

At midday, I was at Loyola Memorial Cemetery laying to rest my aunt’s sister-in-law. She had passed away due to complications of diabetes. At the funeral service I couldn’t help but shed a tear for the passing of a strong woman at such a young age of 53. Her own mother is the picture of health at 80. I cried as her 17-year old daughter said goodbye to her, describing her as their “home” – a place (person) where they were safe, provided for, comfortable and loved. With her passing the remaining family members needed to come together to rebuild a new home.

With each death in the family (there has been three for this month alone) my mortality haunts me.

I have enough motivation to keep me striving for health and fitness with my family history of hypertension, diabetes, coronary artery disease and cancer. I am glad that I’ve quit smoking and that I only drink occasionally. I suppose I’m also glad that even as I grow a year older in a couple of weeks my age cannot be considered a risk factor yet.

I’m lucky that I also have the added motivation of being a physician. If I want to continue to advise my patients to increase physical activity, reduce weight and eat right it would be hypocritical if I don’t do the same. I need to practice what I preach. I need to be the picture of health. My patients need to know and see the benefits of the advice that I offer.

By the age of 30 I’d like to be at my fittest, with a normal BMI, able to run a half marathon, able to swim a mile (or more), with updated immunizations, normal blood pressure and normal blood chemistry.

At this point I am confident it is not too hard to achieve.

home

Home again, with so much to do and write. I don't know where to begin.

A. I have new-found respect for a colleague. I have always thought highly of her but this time she is my new role model for good patient care. I need to be reminded that doctors treat patients, not lab results, not side notes on charts.

B. I'm rethinking my choice for residency training. Having been assigned to the pedia department I'm starting to have difficulty managing IM patients. Pediatrics was always an option from the start, it's just that nobody thought I could handle children.

C. I went out one night with other co-residents, none of us on 24-hour duty. When we came back we were greeted by a truck unloading patients from an MVA. Just like that, the bottle of beer I drank disappeared from my system. A co-resident smiled as he waded through the bleeding patients. "This is ER medicine," he retorts. It really was ER medicine.

Head-on collision between a passenger van, an ambulance transferring a patient to our hospital and a ten-wheeler truck = a terrible, terrible accident.

D. These days I keep wondering what people do with money. My salary is pretty basic. I am able to live comfortably within budget. I do believe money offers a lot of opportunities for learning and travel. But just because money is not overflowing from your pockets does not mean you will lack for opportunities. Seriously, what do people do with money?

E. On that note, I have a colleague who was born with a silver spoon in his mouth. "More like titanium spoon", another colleague often interjects. He has a job, a 17M condo unit, a 2M SUV, beachfront property and still receives money from his parents. A former chief resident (when he decided to quit his residency training) with a 3.98 GPA in med school. And guess what. He's not happy.

F. Sometimes I think I'm stupid.

drug for malaria loses potency

Ok. I admit I'm pretty slow on reading up on developments in molecular biology and medicine. There is just too much literature at times that I can't help but feel overwhelmed. I'm so glad I have friends who can point me in the right direction. (Thanks Cat!)

I wish I could do a lot of the pointing myself, too.

* * *

In the International Herald Tribune, a month-old article warns about the developing resistance to artemisinin-based drugs. Working in Mindoro has definitely opened my eyes to this disease. I appreciate any new information I can get about treatment and management.

Malaria patients in the intensive care ward of the provincial hospital
in Battambang, Cambodia.(Thomas Fuller/International Herald Tribune)

Spread of malaria feared as drug loses potency

The recent studies show that artemisinin-based drugs are becoming less effective in removing the parasite from the bloodstream. While a few years ago it took the drugs 48 hours to clear the bloodstream of parasites, it now can take 120 hours.

Although this has only been noted in Tasanh located near the Thai border of Cambodia, it certainly heralds things to come. Malaria must be eradicated, eliminated before drug resistance spreads.

Artemisinin-based drugs such as artemether are used to treat Plasmodium falciparum-confirmed malaria. Falciparum is one of four types of malaria and is endemic in the Philippines. It is unfortunate that it also happens to be the most virulent.

In the Philippines, artemether is commonly used in combination with lumefantrine. Drug combinations allow for faster treatment and may slow transmission of the disease. It may also decrease the rate of developing drug resistance.


Read on the evidence of Artemisinin-resistant malaria in the The New England Journal of Medicine. Other articles on malaria are also in the same issue of NEJM (Dec 11, 2008).

shifting

I just got back yesterday from another 10-day stint at a provincial hospital. As I lay in my bed completely maxed out all I could think about was that I was happy.

During my stay in the hospital I kept thinking I should keep a log of the cases I see. Common cases such as acute gastroenteritis, intestinal parasitism and pneumonia might not warrant too much attention. On the other hand, I certainly would like to look further into malaria, extensive PTB, TB meningitis, rabies infection, tetanus, sepsis, stroke and MI, and how to manage and recognize these diseases with limited resources.

X-rays and peripheral blood smears are readily available in the hospital. Ultrasounds can be scheduled or done on-call. Blood cultures are not available. For a 12-lead ECG you have to call private diagnostic centers in town for the technician to come to the hospital and do the ECG. Most of the time they are not available in the middle of the night. For a CT Scan you have to send the patient to Batangas. To get to Batangas the patient has to take a 40-minute drive, a 2 1/2-hour boat ride plus another 20-minute drive - a trip that not all of them might survive.

But I am not complaining. I cannot complain. At this point I am giving the best that I can give. It may not be the best care the patient can get elsewhere, but it is close to being the best they can get at that hospital.

People travel six to seven hours for a consultation. Some take a 4-hour trek down the mountain to bring their ailing children. You cannot blame these people for not coming to the hospital at the first sign of disease. You cannot blame them when they arrive at the hospital dehydrated, weak-looking or in cardiorespiratory distress. I know something has to be done to improve the health system. But at this point I am only capable of making do with the available resources.

This does not mean I am satisfied with what I'm doing. I know something more can and must be done. But I need to study more, train more and get more exposure to know what else can be done.

It is too early in my medical practice to make big changes. But it doesn't mean I'm not trying to make small changes.

Tired as I am, I'm looking forward to my provincial hospital shift next month.

Posted by lefthand at 8:22 PM

annuals

I had no idea a couple of days doing annual physical exams for a company could be so tiring. I've seen more patients in one day before, but there's something about having to deal with all those stressed-out individuals in a hurry that is both emotionally and physically draining. Of course working from 7 am to 5 pm, with only a 20 minute lunch break could be one reason why I was so tired.


Here are just a few short notes:

1. I was correct to expect better dressed individuals there so I made it a point to dress up also.

2. With physical appearance a vital part of their business they also seemed more conscious about fitness and health.

3. I had expected that because of the stress level of meeting daily quotas and deadlines, more employees would be turning to smoking and drinking. As it turned out a greater number opted physical activity as stress busters. This included brisk walking, running, jogging, cycling and working out at the gym. I was surprised to note that most were involved in basic physical activities rather than more competitive sports.

4. As part of the OB-Gyne history I had to ask about recent sexual activity to determine if I could do a Pap smear. As the women themselves commented, corporate sex was "sex on schedule". That would be sex on a weekend or a Friday night when they didn't have to wake up early for work the next day.

5. The women higher up in the corporate ladder always wonder why I don't have an assistant helping me out when I'm doing Pap Smears.

6. Educated people ask educated questions.

7. Educated people who ask educated questions get comprehensive and educated answers.

8. Educated people take doctor's advice more seriously -- that is, if they think the advice suits them (read: convenient). Otherwise, they are as stubborn as a mule.

9. I've never had to explain as much about lifestyle modification as I had in two days. Same goes for the effects of coffee and tea.

10. Doctors aren't being intrusive if they ask too many questions. They just want to be sure they will give the patient the best possible care always.

first look

When an opportunity to mix travel and work arose I jumped at it. I shrugged off comments about trying to find work closer to home. I let complaints about my not getting a permanent job fall on deaf ears. After five years of barely getting out of Quezon City I wanted some R&R and a chance to explore more of my country.

Day 1: It was a little after five in the morning when I took the10-minute drive to the pier. I had barely slept. My sleep-wake pattern was still a mess and I was unable to adjust it days before I was set to leave. I was planning to sleep through the 2 1/2-hour boat ride to Occidental Mindoro but the cold and windy morning woke me up. I was expecting some high waves as we hit the open sea but the ride was calm enough. I did not have a minute's worry.

The van ride to Mamburao took 40 minutes. The concrete road cut along the verdant greens of farms and rice paddies. There were stretches where only one lane was usable, the other lane was used for drying grains and corn. A good five minutes sometimes passed before the van came across another vehicle. The drive was both calming and revitalizing. It was truly a breath of fresh air compared to Manila.

The hospital is squat and white. At first glance it was almost intimidating. I had expected a rundown graying hospital. Instead I was greeted by a wedding-cake white building roughly a year old.

We got a tour when we arrived, meeting with other residents, getting introduced to the attendings. After a quick lunch we were taken to the Capitolio for a courtesy call with the governor. I sat down, smiled and tried to look professional as I introduced myself to the governor, vice governor and a mayor. As it turned out, someone I was going to work with happened to be the governor's nephew.

It's true what the Lonely Planet guide said. Mamburao is a dusty little town with a bad case of tricycle-itis. Tricycles are the primary mode of transport. There are few jeepneys. Like the vans, the jeepneys only seemed to operate to transport produce or to carry passengers over long distances. After the first ride through the town I was looking forward to exploring it on foot. Later in the day a group of doctors was going for a swim at a beach resort only 2 kilometers away from the hospital. Too tired to do anything but sleep, I declined the invitation to join them and just made a mental note to check it on a later date.

I slept soundly that night. I knew I needed all the energy a good eight hours of sleep would give me. The next day was going to be an entirely different day.

getting the groove of things

Three days was enough for me to get the rhythm going -- that was one 24-hour duty, a from duty status and a day as the OPD officer. It was enough to get my eating right, enough for me to know the general lay of the hospital, and enough for me to know that in the next seven days I would see more cases of acute gastroenteritis, intestinal parasitism and malaria.

It's almost sad to admit that the major diseases I see everyday can be easily remedied by good hygiene and proper sanitation. This may seem a straightforward solution for disease prevention for other locals but I understand a lot of traditional beliefs may hinder the minorities into taking positive action for better health.

A case in point: Most minorities in the ward do not think taking a bath is necessary. On the contrary they avoid taking baths because it goes against their belief. Any illness is brought upon by actions that have angered gods or from the ill will of spirits. A plea for cleanliness and hygiene with a gift of a bar of soap may not always get the desired result. A family given soap to bathe with was found the next day still oily and grimy. Not even their faces had lightened with washing. As it turned out, instead of using the soap for bathing, the family had used the soap to wash clothing.

When you are up against decades of tradition it sometimes feels like you are fighting a losing battle. It makes you feel that for every step forward you take, you take not just two steps back, but three. And then a day comes when you do the morning rounds and find out one boy was actually given a bath. It erases all the frustrations and pushes you to take one more step forward, only to find that you're still two steps behind.

Coming to the hospital I didn't think I was going see so many malaria patients. By the end of ten days I would admit 4 patients with blood teeming with Plasmodium falciparum. There were already three others in the ward receiving treatment for it. These are just the pediatrics cases. Internal Medicine had it's own share of malaria cases. If in urban Manila, Dengue was the disease to rule out for every febrile, flu-ey patient, in rural Mindoro Malaria was what I had to watch out for. I had no idea they saw so many cases. Although most patients came from far away towns I still felt unsafe without prophylaxis.

On a lighter more hopeful note, the workload in the hospital isn't all that heavy for the most part. I enjoyed walking trips to the center of the town and a short tricycle ride to the beach. I hadn't taken a camera with me since I wanted to focus more on the work part of the trip. But standing on the powdery white sand beach at Tayamaan watching two kids tumble into the water as the sun set I could not resist the urge to capture the moment with my phone camera.

Sometimes, life's a beach. All you have to do is breathe deeply.