Death and Lessons from Google

I have a confession to make: I google-stalked someone today.

It all started out like this...

“Code! Code!,” someone screamed even before he was through the double swing doors of the critical care area of the ER I was manning about a week ago. The orderlies and triage nurse rushed through the doors pushing in a stretcher containing the limp body of a young man. As we’re programmed to do, we started resuscitation on the patient. While the code team was pounding away at his chest and continued to give life-saving medication through his vein, I had started the interview with the family to document what had led to the patient’s present condition. It was then that I realized that the patient was vaguely familiar to me. The patient was in his early twenties and he’d been in and out of the hospital for a hematologic malignancy. He’d undergone chemotherapy and radiation but remained sick. The latest development, and this I only found out that night, was that the cancer had already spread to his brain and the tumor wasn’t responding to radiation. I never knew the patient personally and had only seen him once or twice, but his name was familiar.

After about an hour of resuscitation, we had explained to the family that continued resuscitation efforts will be futile. The father was trying to compose himself but had agreed to stop the code. It was over, confirmed by the flat green line on the cardiac monitor. The nurses and orderlies started turning off drips and unplugging equipment. The lifeless body of the young man was perfunctorily cleaned and wrapped in a shroud, in preparation for the morgue. This scenario is not unusual at the ER and it happens almost everyday in the hospital. I was used to it. Just another day at work. It was a sad day to be sure, but just another day all the same.

This morning, some Facebook messages reminded me about that patient. Some of the floor nurses that had been friends with the young man had posted their goodbyes on their closed Facebook group. This piqued my interest and that’s when I started my google search.

The patient was an athlete and a student. I found pictures of him horsing around with friends, a genuine smile on his lips. One photo was of the patient with another friend, in sepia, both of them wearing barongs and looking up smiling at the camera. The pictures were accompanied by a blog entry by one of the patient’s close friends and through it, I caught a glimpse of a vibrant young man, about to begin his adventure in the world. In the article, the friend reminisced about their 9 years of friendship and lamented that he had lost a brother.

After one has done countless of codes and resuscitations, after many failed intubations and seemingly intractable arrhythmias, after handling the patient with stubborn low blood pressure that just wouldn’t go up after 5 vasopressors, it’s easy in Medicine to steel oneself from the realities entwined with one’s patient. It’s easy to detach oneself from all the drama and just focus on getting back a heartbeat or a breath, or even a continuous spike of electrical activity on the EKG. On some level, health care providers need to be removed from the emotion-laden realities of our patients so we can focus on the medical aspect, the main area we are called to address. We need to think and think quick. There is also the factor of seeing something too often that it becomes rote. Death and dying is such an integral part of the hospital, especially as a resident, and especially at the ER.

While each doctor and each health care provider will have a short list of memorable anecdotes about memorable patients, my google search reminded me that every single patient I see, whether at the ER, the floors, or outside the hospital, each one of them has a network of people who love them and will for certain be affected by any decision, wrong or right, I make in the patient’s behalf. In the hustle and bustle of the ER, such an obvious and instinctive thing can easily get lost, buried under piles of academic steel and medical jargon. My patient’s death reminded me that death is painful for those left behind and the grieving process for the family extends far beyond the confines of that little room I man in the ER. For us doctors, tomorrow means more patients to see and help get better. For my dead patient’s family, it means an empty bed and a quiet bedroom, a brother gone too soon, and one more grave to visit.

Clichés and the End of R1 Year

It has become a cliché to say that something you've been waiting for seemed to have arrived sooner than expected. "As if it was only yesterday that we were starting our residency training" is a statement I will not agree with. This year seemed to have passed too slowly and the end could not have come sooner.

I am happy to report that I learned a lot this year, not only about Internal Medicine but also about the more important thing in my profession: interpersonal relationships. I learned that people handle stress in many different ways and sometimes, one needs to let things slide to attain some form of peace. I also learned the value of being quick to apologize and admit error. I quickly averted several potential disasters just by immediately admitting my mistake and promising to do better next time. It's a work in progress but I'm slowly getting a handle on my temper and my impatience with incompetence, as I realize that I am incompetent more times than I care to admit, and in worse ways. Something Dr. Bengzon once said struck me and I think about it every time a patient (or family member) poses a "challenge": our patients remind us of our humanity. We are all impatient, difficult, cranky, and demanding at one point or another. We are all apprehensive about death and disease, albeit in variable degrees. These thoughts help me to maintain my composure, take a quick breath, and move on with my work.

This year, I also learned some good Medicine, mostly from the people who took the time to teach. We all had virtually no time to read Harrinson's so we were mostly learning by leeching: "leeching rounds," as one pre-resident put it. At one point, I was reading ECG tracings from a treadmill stress test and I remembered the time when I was a clerk and I was so impressed by the cardiology fellows who seemed to have read these same tracings as if it were a book, almost efortlessly. My clerkship self would be proud of my resident self, I think.

The learning was there. But the learning came with a huge price tag. Late nights, sleepless nights, missed time with family and friends ... the list is substantial. The way I coped, however, was to always have my long term goals in mind. As another cliché goes, I "kept my eye on the prize." I knew that sooner or later, R1 year would be over and I'd be moving on to more challenging stuff. But I'd be MOVING on and that means, pretty soon, the entire ordeal of residency would soon be over.

The Lord has shown me grace upon grace this year and my friend Angel, just tonight, reminded me of how undeserving I am of the favor I received from Him. He has been my source of strength, my source of peace, and the One who stretched my limits even more when I thought I had nothing else to give. He has given me an excellent set of duty mates (and now great friends) the past few months. He has sustained me through the most toxic of duty nights and has given me wisdom enough that I don't have screw-ups that endangered any of my patients' lives. As an added bonus, I get to do something I love more than medicine: teach. It might well be my only drive to read and study up on my cases.

I may be looking back and seeing things through rose-colored lenses because I am at a high right now: it is my last day as an R1 (and all its accompanying baggage, like DS!) and I had a pretty good dinner (more like excellent, really). But as I remember the year that has passed, it strikes me as being an over-all very positive year. And this makes me extremely happy. If you will notice the description I post about myself in my blog: "An occasional writer whose current preoccupation is getting through medical training unscathed and unjaded." I may have been scathed and stung the past year but I am as unjaded and enthusiastic about my work as the day I first started last year, considering everything that has happened. The ER and hemodialysis (and many more R2 issues) may quite possibly kill the buzz. But I say, bring it on.

First Day Blues

I can't even begin to describe what this day was like. I've been toxic at work before, even more so than I was today. But today was different. I was lost. I guess that's to be expected on the first day of anything. For some reason, I just couldn't get the chart data on to my brain even if I read the patient chart twice or three times. I couldn't understand my notes half the time. I pictured each referral from the nurses like paper piling up on my Inbox tray, and I wasn't able to get to them fast enough. Sigh. I envisioned this blog to be focused on the lessons I learn from patients and the people I interact with. But today, just because it's my first day, allow it to be all about me.

Tomorrow's going to be a brand new day. I just hope I wiped the slate clean this afternoon.

Reflections on the Pre-Residency Experience

I was an Internal Medicine Pre-Resident for 21 days. Today was my last day. Pre-Residency is part of this elaborate evaluation scheme designed by the hospital training committee to screen for applicants that will match well with the training program in terms of academic aptitude, adaptability to the system, and I think most importantly, work ethic. I realize now that in many ways, this is much better than the automated matching system they use in the US. For one, we actually get to experience working for a few weeks in the hospital, in the very setting where we’ll be immersed for the next three years. In the US, all this experiencing is captured into one whole-day visit, during the interview. If you’re lucky enough, you get invited for a second-look.

Pre-Residency allowed me to refocus my mind and my heart on clinical work. I’ve been away from clinical practice for a few months, almost a year, really. It takes a while to get back into the groove. The three-week foretaste allowed me to remind myself of the need to balance the clinical and the academic side of medicine. It brought to fore all the dusty boxes of (what I thought were useless and trivial) medical information I learned from medical school, those phrases I highlighted in books using colorful markers and remembered only for the sake of tests and which I never thought I’d use.

I have never experienced being a resident before. I had an idea of the kind of work the residents did but it wasn’t a complete picture. I was a kid on the outside looking in. The past three weeks gave me an insider viewpoint and what I saw fascinated me. Residents, especially those in the first year, are in a very unique position to CARE for their patients. Their constant presence on the floor gives them the opportunity to develop something more than rapport with the people they admit into their wards; they the golden opportunity to establish genuine relationships with patients. This is something I have set forth as one of my goals when I made the decision to go into Internal Medicine.

For this realization and reminder, I have one first year resident to thank. He was my resident-buddy for about a week. This was enough time for me to witness the way he interacted with his patients and his genuine care for their welfare, something that went beyond facilitating labs and making sure they were discharged alive at the end of a set period of time. This isn’t to say the other residents I worked with were horrible. They were excellent in their own way but this guy went the extra mile. He held his patients’ hands, spent time explaining the case to them and their families, and, short of praying for them, he said “God bless” as he exited the room each and every morning after the routine morning visit. By the time these patients are discharged, this resident not only knew his patients completely, but he also knew the family members and the watchers.

By way of completing my requirements for the US Match, I drafted a “Personal Statement” wherein I outlined the reasons why I wanted to go into Internal Medicine. This essay was a chance for me to organize my thoughts and formally state on paper my reasons for the life-changing decisions I have made the past few years. In it, I wrote this: “At about this time, I had given much thought to what I would do after medical school. I was now sure that I wanted two things: I wanted to build significant connections with my patients and I also knew that I wanted to get the best training available. These premises led me to two things: first, I decided to go into Internal Medicine, and second, I started to look into doing residency in the United States...” And further on: “Internal Medicine is a specialty that deals with problems that usually require long-term care – diabetes and hypertension are not addressed overnight. As such, I saw it as a great opportunity to build long-lasting relationships with my patients.” I may not have gotten a training position in the US, and I believe this is something the Lord ordained, but my reasons for going into IM remain the same.

I post this here as a future reminder to myself. I went into Internal Medicine for all the right reasons. I am sure of it. It is my prayer that the challenges that come with residency training won’t leave me jaded and calloused. This resident allowed me to see that it IS possible to remain caring and compassionate while handling all the stress of residency life. Indeed, I pray that the three years I am about to invest in IM, while training me to be critical and objective, will leave my heart raw and bleeding for the concerns and the suffering of the sick patients that the Lord will bring to my floor, unit, or office door.

Code #1

We were doing our routine rounds this morning when we entered the room of a patient admitted during the night for possible Leptospirosis. He was febrile and complained of abdominal pain but was endorsed to us as one of the stable Lepto patients admitted the night before. As we entered the room, we saw the patient lying on his right side, breathing fast, and was complaining of abdominal pain. This is part of the constellation of symptoms of the infection we suspected he had. We checked out the rest of his vitals and my resident said we might give medication for the abdominal pain and he ordered one for him. We went about seeing other patients and I later found out the medication helped with the pain.

After grabbing a bit of lunch at 2pm, while we were waiting for endorsements at the office, a Code* was sounded. It was our patient. We rushed up to his room and found full resuscitative efforts under way. CPR was administered, along with injections of medications and infusion of fluids. I stood there, helpless, and for the first time that I can ever remember, I was affected by the resuscitation scene unfolding before me. I had never met the patient before this morning and had only briefly spoken with him and his wife. But for some reason, this code was different from all the others. Maybe it was because of the wife crying quietly beside me outside the room. Maybe it was the fact that as soon as I noticed the patient's fast breathing, I knew something was wrong. Whatever it was, I was affected by that picture before me, a middle-aged man, at the prime of his life, previously healthy, just lying there literally breathless, pulseless, lifeless.

As doctors, we are trained to distance ourselves emotionally from scenes like these. It is the only way we are able to think clearly, to do the right thing and give the proper treatment at the exact time it is needed. We need to be objective and critical, and emotions will always affect our judgment. We can feel sad and sorry for our patients, but not when our clear judgments are needed the most. I've seen many codes before, and in fact lost my first laptop when I rushed to one in med school. There will be many more codes in the future. But for some reason, I feel this code will always stick out in my memory, a reminder that doctors need to be human and emotional too, albeit at the proper time.

As my resident was writing post-mortem orders in the patient's chart, a nurse passing behind me at the station said, "just another day at work." For the medical team, perhaps it is. For the family of this patient, not by a million miles.

*For my non-medical friends, a "Code" is sounded in the hospital's paging system whenever a patient "crashes," i.e., loses a pulse, stops breathing, or generally becomes unresponsive. You might be familiar with CPR scenes like these in shows like Grey's Anatomy or E.R, but it is rarely as dramatic.

First Day and On Call

I am at the Resident's Call Room on the hospital floor I am assigned to. It is 30 minutes before midnight. It's the first day of Pre-Residency and, whaddya know, I am on call. I had a hunch it would happen. My resident-buddy and I have finished rounding on our admissions and we've decided to rest for the night, hence the stay at the call room. I now find myself totally engrossed reading about Coronary Artery Disease. I missed hospital work so much that even the idea of having to read 4 chapters of Harrisons (the IM "Bible") sort of excites me. Yes, I am geeky that way.

I'm sure future entries on this blog won't always be this, umm, happy. But allow me just this once to bask in the newness of my situation and the positive anticipation for the adventures about to come my way.
Sent from a BB.

Beginnings

It’s not such a great time to officially start a new blog. As I write this, most of Metro Manila and the surrounding provinces are still submerged in flood water. The typhoon Ondoy (Ketsana) started sweeping through Luzon on Saturday morning, leaving in its wake about two hundred people dead and many more missing. As of this writing, there are still people stranded on their rooftops, waiting to be rescued, without drinkable water or food. It has been two days since the typhoon hit. This is one of the greatest tragedies ever to hit my country in the past few decades.

But the cycle of life continues and I am about to embark on a journey that is the whole point of this new blog.

First, the back story. I have written about this extensively on my main blog, Chronicles of Boredom, and I will preface it here briefly.

The idea of going to the United States for residency training congealed in my head in sophomore year of medical school. I started reading about how the system works and by the time I graduated, I knew what I was supposed to do. After taking and passing my country’s Physician Licensure Examination in 2007, I started preparing for the USMLE. For the next year and a half, I was studying and laying down the foundation for what I hoped was a brief training stint in the US. I had intended to go for the 2009 Match cycle and the whole application effort culminated in a 6-month trip to the US beginning October 2008. I did a month-long observership with a cardiologist in Florida and attended an interview at a hospital in New York. I then waited it out in San Francisco. The Match results came out in March 2009, and I didn’t match into a program. A last-ditch attempt at Scrambling also proved fruitless. While there was much disappointment in my heart, I knew then that I was coming home to a definite path set by the Lord. He meant for me to stay in my homeland and train here. I returned to the Philippines in the last few days of March 2009 and have been waiting for this present moment since.

Upon my arrival, I was sure of three things, although I was initially in denial. First was that I was meant to return home and train here. Second was that I was going to apply to only one hospital’s internal medicine residency program. Third was that I have no idea what will happen after my three years of IM training. I submitted my application to the hospital in early September 2009. I sat for my interview with the training officer and chief residents a week later. A week ago, I was informed that I was accepted as a pre-resident. I’m attending the pre-residency orientation on Wednesday, 30 September 2009, and I am to begin working the following day.

A side note: Pre-residency is something unheard of in the US. It is part of the evaluation/application process in residency programs in the Philippines. The pre-resident works with a current first-year (incoming second-year) resident and learns the ropes. In the process, the pre-resident is evaluated based on his work ethic, ability to interact with patients and co-workers, and his medical knowledge. At the end of a set time, typically a month, the training committee of the program will evaluate who among the pre-residents will be accepted as first year residents. Most programs will allow them to begin working as official first year residents in either December or January.

While I have some idea about the life of a first-year resident (the US system calls this ‘internship year’ but in the Philippines, ‘internship’ is a different process), I don’t really know busy I’ll actually be and how often I can update this blog. But I intend to use this space as a cathartic medium. I’ve always found writing relaxing and it allows me to clear up my thinking. I also didn’t want to mix these entries up with my main blog. In my own little way, I can have a bit of organization too. Finally, I’m writing about my experiences in the hope that someday, somewhere, some first year resident or med student is going to read my entries and pick up a little piece of encouragement, or entertainment, or maybe even wisdom.

Welcome to Chronicles of Medical Residency. I hope that you will join me for this ride.