Category: medicine

Broken Ribs But Not Broken Spirit

My own Popo and I. Last pic together. 2022.

I woke up at 3 am thinking about the 93-year old lady whom I discharged the evening prior, wondering if she’s doing okay.

Popo G (‘Popo’ means grandmother in Chinese) has a blue cap on her head, covering her face, shielding her from the bright fluorescent light of the exam room in the ER. Her family brought her to the ER because she’s been complaining of right-sided back pain since she fell off her bed the day before. She stares at me blankly when I greet her in her native tongue, Cantonese. Her daughter at bedside tells me she’s very hard of hearing, which explains her lack of reaction. In hindsight, I wonder if her stoned expression and subdued manner was because of the oxycodone she was given earlier. As I get to learn more about her later, her personality is nothing like this calm, subdued woman sitting in front of me, and she is able to hear me and others well enough to yell back with full strength. At that moment though, that isn’t what happens. I try hard to communicate with her, both yelling next to her ears, as well as using the tele interpreter on max volume, but all she does is stare at us with a blank expression. It’s as if there is a 6-inch fiberglass wall surrounding her, blocking out all sounds. All she says to us is, “I’m deaf!”

Popo G’s fall resulted in three consecutive rib fractures on the right side. Thankfully, there is no pneumothorax or flail chest, and nothing else was broken or ruptured. She was referred to me for an admission, mainly for pain control, and a physical therapy consult to ensure she’s safe enough to be discharged home, or if not, to go to a rehab for a short stay. It’s a straightforward enough case, and I admitted Popo after my failed attempt to communicate with her. I never thought that 3 hours later, I’d suffer the wrath from her for the plan to admit her to the hospital without her permission.

I get a message from her nurse Q, who informs me that “patient is threatening to jump out of the window if we try to keep her in the hospital”. I’m surprised by this, given that no matter how loud I yelled next to her ears earlier, she didn’t seem to respond or acknowledge that she heard me. How is it then, that she’s now able to express such threat? Q says they use the help of the tele interpreter to communicate with her. I’m intrigued, and I have to see for myself, this drastic transformation of character from hours ago. When I get to the bedside, this thin-framed but not-frail nonagenarian is sitting at the edge of the chair next to her bed, with her two daughters and a son-in-law at bedside, the tele interpreter, and her nurse next to them. Popo G seems to be in a fight-or-flight mode, or maybe just in a fight mode, and when our eyes meet, I feel the burn all the way through my eyes into the back of my skull. I’m both intimidated and amused at the same time. She reminds me of my own grandma.

What happens after is a long multi-way conversation and negotiation between this sprightly woman, her grandson who is a psychiatry resident out-of-state (on the phone), her family at bedside, the tele interpreter, the nurse, and myself. Popo wants to go home; she insists that the pain is nothing unbearable; she’s never been sick her whole life – and she reminds us she’s been around for almost a century – why are we trying to keep her in the hospital now, and how dare we make that decision for her without her permission! Family members seem to be okay with whatever decision I make for her, which aggravates Popo even more. Grandson says if I think Popo is safe for discharge, he’s okay with that, to which I tell him, to the extent of her three non-displaced fractures without other complications, she’s stable for discharge. That said, as is for any elderly patient who lives alone, there will always be some safety concerns given their high fall risk. Nurse Q on the other hand feels patient should stay, because she hasn’t been evaluated by PT, and thus is very unsafe to be sent home just like this. She adds that patient may need to be evaluated by psych given her threats to jump out of the window.

While it’s not wrong that there are some risks in sending nonagenarians like Popo G home after a fall, the risk of recurrent falls won’t change or abate whether we send her home today or the next day. In this case, she’s able to ambulate independently, her internal organs are intact, she tells us her pain is tolerable. She’s also shown us that she won’t give in without putting up a fight if we insist to keep her. First, there’s the question of whether it’s ethical to keep her against her wishes. One cannot assume the lack of decision-making capacity just because a person is old. Old in age does not equate senility. Even if we manage to convince her to stay, are we sure we’re helping her and won’t cause more harm to her? How many times have we seen unnecessary admissions for benign diagnoses such as constipation or simple urinary tract infection in elderly that was supposed to be kept overnight observation that turned into a long drawn out admission due to hospital-related complications?! Lastly, the threat that Popo G verbalizes? Should we take it seriously verbatim or is it her way of expressing her anger and frustration for having her freedom of choice taken away from her? Here is a woman who feels she’s about to lose her dignity and independence the moment she allows us to keep her in the hospital. She’s making her last pitch to fight for her freedom.

After discussion with her family, I ask her daughters to take turn sleeping over at Popo G’s house for the next few days just to keep a watch on her, which they gladly agree to do. The son-in-law will also work on lowering her bed and get her a walker in case she needs it. I send her home with some pain meds in case she truly is in pain and needs it, but emphasize to her the side effects, and to use it with caution. I tell them what to look out for, and to come back to the hospital if she has any new symptoms or worsening pain. Everyone seems to be happy and agreeable to the plan, everyone except Nurse Q. From the corner of my eye, I saw her slight dismay, and her sarcastic manner when speaking to me tells me she’s not at all convinced this is the right course of action. Too bad, I thought to self, I can’t please everyone.

The rest of my shift went by uneventfully, I got home and went to bed. Didn’t think much of it after Popo G and her family left. And so, it comes as a surprise to myself when I jolted up in the middle of the night thinking about this incident. Somehow Nurse Q’s response bothered me. I find myself wondering whether I did right by my patient. Have I been careless to send Popo home? Will she be okay at home? What if she suffers another fall, and this time break another bone? Should I have made sure she stayed the night and have physical therapy evaluate her before sending her home?

No matter how I think about this, I still arrive at the same decision. I just regret that I wasn’t able to convince the nurse to be onboard with the decision. I hope Popo G heals well from her rib fractures, and that she lives a long, long life without any fall or hospital encounter. I know she will be alright. Her sassiness and feisty self will keep her going for a long time.

As I drift back to sleep, I think of my own grandma. How I wish she was around a little longer.

Memories of Pre-Covid ICU

Found this note deep in the Draft section. Didn’t post it then because the pain was still raw. And so I kept it contained. I’m good at that, hiding emotions so people can’t see, can’t tell. All is well- on the outside. Nobody knows what goes on beneath the smiles. But years have passed, and it’s long enough that I feel like I can share now. So here it is.

—

Every beep and blip means different things in the ICU. There’s the cardiac monitoring alarm that goes off when oxygen level drops; the tone gets lower and lower, it’s inversely proportionate to my heart rate. Then there’s the beep for blood pressure falling lower than what we’d like. And another one that indicates arrhythmia. The ventilator alarm- intimidating and authoritative, as it should be. The IV pump that got stuck- this one reminds me of a screeching mandrake, and gets me worked up no matter how calm I was before that. The door-is-not-closed alarm – equally annoying, which IMHO is intended to wake sleepy residents up during the hours-long rounds. The one alarm, that should be attention-grabbing, fear-mongering, that should be sending a sign of impending death, is surprisingly soft and gentle- the code blue alarm. Makes no sense at all. But just like life in the ICU, logical sense is a luxury that those contained in it cannot afford.

It takes some getting used to before all these blips somehow managed to mysteriously harmonize into a Chopin-like piece, where you could hear them in your dreams (and not in a nightmarish kind of way). You wake up, go to work, come home, bringing the tunes and everything in between, home with you, go through the motion of doing what you need to do to survive, pass out on the bed. Day break- rinse and repeat, like clockwork. It becomes a comfortable rhythm that you do not question much, just going with the flow, lest you fall in between the cracks and get stuck or get hurt. And yet, sometimes, try as you might to avoid pain, it has a way to find you. 

This woman was unlike the others I took care of. Instead of graying hair and wrinkled skin, she had what most who ended up in the ICU had wanted- youth. She embodied a full body, well groomed, and in all her 5′ 7” figure, it painted a picture of a woman living a rather good (or at least average) life. Painted nails, trimmed eyebrows, and pubic hair. Little did she know, that her life would take a huge turn that day. All the hopes and dreams a mother has for her child would dissipate in an instance. It was there one moment ago, and then all at once- not at all. Zilch. Death is coming for all of us. You just don’t know when. 

That morning she wasn’t feeling well. She didn’t look quite well. So Mom brought little Brian to pre-school. Maybe if she felt better later she’d go pick him up. It was just another day for everyone, and everyone got along their usual business. Coffee, newspapers, chores. By lunchtime, Mom decided to check on her.  Not in bed. Where could she have been? The black Mazda was still parked outside; view from the upstairs windows reassured Mom that she’s still at home. Unless the Boyfriend came to pick her up. She thought she’d check the bathroom, just in case. A mother’s instincts were never wrong. There. It was there that the worst nightmare a mother could ever imagine started unfolding. The body that lied on the cold hard tiles next to the toilet. Still as a statue.  

There was no telling how long she was ‘down’ for. But nothing was looking good for her.

I tiptoed around the young woman much younger than me, checking her ventilator settings, making sure all the tubes were connected and functioning properly, while her mother lamented to me about how young she was and how unfathomable that she was in this vegetative state when she was still ‘normal’ the day before all this happened. Was she aware that we’re here in the room with her? Could she hear us? By the definition of brain death, I guess not. Still, I wonder if her spirit was there with us. She had been on the vent for more than a week now, being kept alive because her family needed time to process what had happened. I can only imagine how hard it is for the family. It was hard even for me, a total stranger, who waited for her in the ER ready to carry out our responsibilities, performing life-saving tasks and administering medications. Alas, it doesn’t always work; sometimes we lose patients too. Inevitably.

Hers was a story of trusting the wrong person. No one really knew what happened; but the deduction from bloodwork and family’s story was that she took what was thought to be marijuana, but which was likely contaminated with some synthetic or impure ingredients that led to her demise. In the two weeks I was taking care of her, I’ve gotten to know her family. One woman introduced herself as my patient’s second mother, because she practically raised her. She asked a lot of good questions, questions I was much more comfortable answering, the technical questions. But when she asked whether she’d ever wake up… there’s just no good way to break bad news. No matter how many times you’ve done it, it is still hard. Yet the most tragic part of it was she was kept alive until nothing can be done anymore. Her blood pressure continued to drop despite being maxed out on all pressors, all the chemistry labs were incompatible with life. When that happened, no family was there with her. That to me was the saddest part.

I do not know if other residents or doctors think or feel the same. But I felt somewhat responsible for that, even though I know I had no reason to. I felt a twinge of failure- failure for not being able to convince or persuade the family to let her go, and say their final goodbyes together at bedside before sending her off. That pained me, in a way that I couldn’t really express or share with anyone. Perhaps that is why I still think about it even now.

Foot Note: Details and names from the story above were made up or changed to protect their privacy.

—

As clinicians, we have the tasks to not only take care of patients with our tools of trade, but also to take care of their family members. In some ways I’d argue that the latter is even more important and could have long-lasting impact in their lives. How you say, what you say, matters to the recipient, because it directly affects how they feel and think at that critical moment. The ability to do so is what sets a stellar clinician apart from the rest.

I wrote that piece 3 years ago, about 3 years after the incident had happened. I still think about my patient sometimes. Since then, there have been patients like her (though thankfully not all are tragic stories or with similar outcomes), who managed to etch themselves in my mind, where during the quiet lull of moments would resurface, and I would revisit them. It’s a good reunion, albeit only in my mental space.

Pneumothorax

One of the toughest rotations during my residency was the month of oncology rotation at another hospital. Albeit the long hours and exhaustion, I learned so much, not just the medical knowledge, but also about patients, the human aspect of things, of life, and death. Many of those stories – and people – stayed with me, even after all these years. But there was one that I remembered today, and wanted to share.

It was one of those busy days with a few pending admissions, sick patients in the ward requiring attention, family wanting updates, and me trying to finish my notes. I must’ve seemed like a battery about to die, blinking the ‘low power’ light, and going into power-saving mode, when someone called out to me. A middle-aged man in blue scrubs, sitting a few computers away, said, “Hey, come over here! Look at this- what do you think?”

I sighed inwardly, thinking to myself, I have no time for this, but didn’t want to appear rude, so I walked over. Took a peek at the screen, and there it was – a chest x-ray staring back at me. I took a closer look, and realized why he wanted to show me this. The right side of the lung was almost completely collapsed. I marveled at it for two seconds before asking him about the patient. He smiled, and told me that the young man did well after they did a needle decompression at bedside followed by chest tube placement. He then continued without missing a beat, “Amazing, isn’t it? Medicine is full of impressive stories and rescues like this. When you see one, don’t hesitate to share with others.” He then went on for a bit, most of which I don’t remember now, but just before he left, he left me with a sentence that went something like this: “It’s important to look for things that impress you, only then will you find ways to continue being inspired, and keep the fire burning for medicine.” And just like that, he walked away waving goodbye.

I never found out who he was, and I was pretty sure that patient with that x-ray wasn’t in our ward. I’ve often looked back and wondered what prompted him to share with me that x-ray and story, and why he said what he said to me. Perhaps I looked like I needed it. At that time, I was almost done with the rotation, and was feeling all kinds of exhaustion- physically and emotionally. I was starting to shut everything out to prevent anymore emotional pain; I was operating on auto-pilot to get through the day. That day I was feeling down, and perhaps he sensed it. Regardless, even though I’ll never know why it happened, his words stayed with me all these years, and I truly appreciate it. His advice came in a timely manner, for it did more than just inspired me; it gave me comfort, and it reminded me of why I went into medicine.

On that otherwise normal day, I am thankful for the few minutes of interaction with him. I could never thank him in person, but I hope he knows it meant the world to me. Since then, whenever I have a tough day at work, I remind myself of what he said. It is, after all, still a privilege to be in medicine.

Another Milestone

It’s true what they say- the days are long but the years are short. I vaguely remember posting about the start of residency, promising myself I will write more (but I never did), and now, three years later, I’m done with residency! Where did time go?!

It’s a strange year to be in medical training, and to graduate in. The pandemic, and more recently a string of unfortunate events that led to the resurgence of BLM movement, have impacted every aspect of our lives. Our graduation ceremony was held via Zoom, which was weird in some ways, but fun in others. Definitely different, and it came with some perks. Many of our friends and family were able to witness this special day with us, which in normal circumstances they couldn’t have, so it was somewhat a blessing in disguise. We had more attendance/participants (88 at its peak, many of whom had 2 people viewing from a single device) than we would have if it were a live event. I loved seeing some of my classmates all dressed up in front of the camera, and their families doing the same as well. Some of our attendings joined us as well. Most people had their mic off, so you’d see silent applause after all the speeches and awards. We had our mic turned on for parts of it, so the 3 of us did the sound effect of applause. At times it was a little distracting seeing people walking around, eating while watching, or even driving, but I loved it all!

Dr. Cmar, one of my favorite human beings, our ex-PD (program director), someone I’m proud to call a mentor-friend, gave our commencement speech, all dressed up at the top half – in tie, white coat – but with flip-flops and shorts at the bottom half. Apparently this is the new in-thing to do in the Covid era! 😀 In any case, his speech was on-point, addressing the current events, and reminding us that it is vital we continue to address the health disparities and be part of the change that is much needed. He also reminded us that whatever we do as a physician, to not only focus on our patients, but also take care of ourselves as well. His entire speech was entertaining, peppered with humor and sarcasm, but not at the expense of substance. I’m so glad we recorded it, because I know I’d want to rewatch it every so often in the future, for all the wisdom he imparted.

The speeches from the graduating classes (PGY-3 and the prelim) were just as great. Amit has his own style of humor, and as always, so humble and nice, thanked everyone for being part of his work family in the past 3 years. Mac did the same, being his humble and funny self, shared what he’s learned over the past year of internship. I couldn’t agree more with their sentiments of gratitude and humility for being here, surrounded by mostly good people who are caring, generous, and willing to step up and help others in times of need.

Personally, I have so many people to thank- not just those I met during residency, but also all the people who made this possible for me. My mentors from med school and research days, my parents, my adopted parents, friends, relatives- people who believed in me even when I doubted myself most. I couldn’t have done it without them, and I will always remember their kindness and support. Hopefully I can do the same for future aspiring med students/doctors as well.

To all my classmates who graduated, thank you for this amazing experience and company! Wishing everyone best of luck in your future endeavors!

Here’s a screenshot of the graduation. I was too busy trying to ensure it runs smoothly, so this was the only screenshot we got. Better than nothing!

Taboo

Preamble

I’ve been saving this draft I wrote long ago towards the end of my fourth year of med school, uncertain if I should share it. Was worried that I’d get in trouble for sharing something like that. It’s probably unlikely, given that I’m not sharing any identifiable information about the patient or the personnel taking care of the patient. Plus, it’s been so long ago… I doubt anyone other than myself remembered this incident. I’ve considered deleting it and just move on, but some things are hard to let go, and this is one of them. Sharing it now because it was so hard to talk about it when it happened then. Perhaps sharing it here now will allow me to see it in a new light, and put it to rest. So… here goes.

—–

My Emergency Medicine rotation was a memorable one, one that gave me some of the best and worst experiences in my clinical years as a med student. One particular incident left a deep impression on me, and I had to pen it down while it’s still fresh in my head. On one of our on-call nights, my friend and I returned to the ED (Emergency Department) from a quick dinner break, only to find the red zone to be almost empty save for this one patient with the attending and a house officer huddling around him. The ED was divided into 3 zones – red, yellow and green (like the traffic light) – and patients were triaged to a zone depending on the severity/urgency of their condition: red being the most urgent/severe and green the least like a cold or a minor cut, with yellow in between with the potential of escalating to the red zone. As most med students can attest to, we usually like to be where the ‘action’ is, if not actually making ourselves useful during such occasions, at least watching and observing to learn a thing or two. And on that fateful night, a thing or two we did learn, indeed, albeit not what we expected.

A 60 year-old pedestrian was hit by a motorcycle, and was found unconscious on the ground for an unknown period of time. Upon arrival, he was found to have GCS of 8, with an active bleeding somewhere in the oropharnygeal region. He had no external wounds, no broken bones. His condition warranted a tracheal intubation to secure his airway before being sent for a CT scan of the head to rule out an intracranial hemorrhage. Unfortunately, none of these happened and he was not intubated until two hours later. Meanwhile, this man was bleeding quite profusely and we were tasked to suction the blood out of the cavity, as they tried to intubate him. I watched helplessly, worrying about him bleeding out. At the rate that he was bleeding, I was almost certain the blood being transfused could not keep up. It took another two hours to send him for the CT scan, because while all this was happening, his abdomen became increasingly tensed and swollen. The consensus was that there might be internal hemorrhage, but they couldn’t seem to agree with the next step. It was between sending him for head CT only, or whole body CT scan. At this point it was close to midnight, the red zone started to get busy, the surgical residents who were called for consultation were reluctant to bring the patient to the operating room for an exploratory laparotomy to potentially stop the hemorrhage in the abdomen. Deliberate discussion took place, and then some, and in the end they decided they wanted a whole body scan. As all those were happening, patient’s BP kept going down, his pupils fixed and dilated, and all we did was keep giving fluids and blood products. Bad luck had it that the CT machine in the ED wasn’t working, so he had to be brought to the radiology department at another site, which was a long way away. It took us at least another 30 minutes to gear up before we were finally on the move to the other side of the building. Alas, as soon as we got there, the man coded, test was aborted, CPR was started while we wheeled the patient back to where we were 10-15 minutes ago.

It was of no surprise that this man died after an unsuccessful resuscitation; and everyone carried on with other tasks and patients as if it was just another death. Everyone except me. I was bewildered, stupefied, but most of all I felt helpless. Perchance when he came in he was already a lost cause, perhaps death was inevitable with the severity of his injuries, but we didn’t know that for sure. Even if we did, shouldn’t our job be to do our best to save his life, the emphasis here being ‘to do our best’? I was upset not just because a person died that night, but that in every step of the way I felt we as providers could’ve done so much better. I didn’t (couldn’t) understand why everyone acted as if it was just another green-zone case, why there was zero sense of urgency, why certain decisions were made (and took so long at that), and why everyone appeared to be emotionless and moved on so quickly. Throughout the entire time no one contacted his family members, no attempt was made, or at least none that I know of.

I tried to understand what happened, and what could’ve been done differently to prevent this from happening, but I was stumped. This to me should be a case to be brought up during Morbidity and Mortality meeting, but when I asked the attending about it at the end of our shift, her reply to me was this, and I paraphrased: “… you will see things that are done correctly, and things that are handled poorly. Good and bad decisions, and behaviors/attitudes. Just learn the good ones, and ignore the bad ones…” For the second time that shift, I was baffled. Sure, yes learn the good and leave the bad behind. But what about the patients?! By not doing anything, aren’t we silently consenting to the wrongful actions or behaviors? Does that not make us complicit? That morning I had trouble sleeping. I felt I’ve failed the patient, and I couldn’t get rid of the guilt. As I eventually dozed off, I think I died a little inside.

—–

Afterthought
I still think about this man once in a while. I wonder if it’s just me being the med student who was ‘young’ and ‘innocent’ and this was some kind of rude awakening to ‘how things are’ in real life. An initiation of sorts. Because how else do you explain why everyone who was working there acted so nonchalantly and went about their business? Maybe they felt something too, but had to hide it to be able to function. If everyone dwelled, then no work could get done. Maybe it’s the culture to act tough and move on. Maybe like me, initially it got to them, but after a while if this kept happening, they just had to wall their emotions off, toughen up and learn to shut up and move on. Maybe they all felt helpless at some point, but believed that nothing could be done to change this and so they just accepted the way things were and learned to live with it. I don’t know. These are just my speculations, because we weren’t allowed to talk about it. Because pointing out some behaviors, actions, or decisions that might be questionable is forbidden, I didn’t get to understand the root cause in that context. I doubt they really understood it either. It’s such a taboo that you just learn to sweep everything under the rug and do your thing. If you want to survive, that’s the modus operandi. 

My writing this and sharing it here wasn’t intended to criticise or to let known how bad things are back home. Situations like these happen everywhere. The point is, there is a need to talk about it, to discuss and address the issues so that we can improve. Pretending as if it didn’t happen won’t prevent it from happening in the future, and then it’s just going to happen again, and again, and again… We owe it to our patients to do our best, and make sure we do not repeat mistakes that can potentially cost lives. Primum non nocere, in English, means ‘first, do no harm’. To do that, we’ve got to set aside the ego, and be willing to take the first step to talk about things that went wrong. I do not know if things will ever change back home, but I sure hope it will. One can only hope. 

A Wrong Diagnosis

If you ever had that passing thought that “things couldn’t go any worse than this right now“, my advice to you is: please, stop. Stop that thought right now and switch it to something else, whatever that may be. Think of mockingbirds, ice-cream, the cute guy/girl you saw yesterday, your pet. Anything. Anything but that. Experiences prove, time and again, that every time that thought comes into mind, things will inevitably become worse. You may say, well maybe that’s just my selective recall bias, an anecdotal fallacy, and not truth. Fine. Have it your way, but don’t say I never warned you.

For the past few weeks I’ve been obsessed with rashes. Found every article I could and read about the differentials, examined for hours the images of each rash, read more than once about varicella, scabies, PLEVA, and a few others on the differentials. I’d wake up in the middle of the night from the itch, reached out to my phone and looked up other causes of rashes, or read up on one of the many skin diseases. I really shouldn’t be going down the rabbit hole when I should be studying for boards, but I can’t help it!! I can’t stand not knowing what it is and why it’s getting worse when it should be better! Arggghhhhhhwwarrrrghhhuuuurgggh!!! [That’s me turning into Hulk, in my head.] 
So. As you can tell from the title of this post, turns out the rash wasn’t chicken pox after all. Here’s what happened. 
About two weeks after it started, when it didn’t get better as expected for varicella, but in fact got worse, I started questioning the diagnosis. I would’ve got to the bottom of it all sooner if I wasn’t so reluctant to see a doctor, or if I didn’t hold on so tightly to the wishful thinking that it is the easier, simpler diagnosis. Because even though it’s absurd that one could get varicella twice, it’s still a shorter course of disease, self-limiting, and- I was banking on the probability of it being milder since it’d be a recurrent infection. I was really hoping it was “just” that, and be done with it. So when the rash started to spread, I convinced myself that I’m seeing things, that it’s all in my head. Sigh. “For someone who studied so much, this type of reasoning was downright stupid,” I can almost hear my dad say that to me. 🙁
And so it got to a point where I just couldn’t lie to myself anymore and had to go to the university health center to get it looked at. The doctor being uncertain of what it was, referred me to dermatology. And with just two words, a huge portion of my anxiety melted away: pityriasis rosea. UGHHH. Really? I never thought bout it because there’s no herald patch! And no christmas tree pattern as well! Here’s another lesson learned, just because something is pathognomonic of a disease doesn’t mean the absence of it precludes the diagnosis. I guess my frustration was noticeable, when I asked the dermatology resident: “How on earth did I get it?!” To which he calmly responded, as if trying to placate me, “It’s nothing that you did or could’ve done to get this. It’s a really common disease and a lot of people get it, but we still don’t really know why it happens or what causes it.” Great. Just great. Isn’t this the majority of the case for almost 80% of the diseases out there?! That we don’t know what the heck we’re dealing with most of the time.  If I weren’t in the medical field and could understand the unpleasantness of having to tell a patient that, I’d have rolled my eyes and stopped listening. But I get it, so I didn’t pursue further.  Yes- I get it now, more so than ever, because now I don’t only understand it from the physician’s point of view, but also from the patient’s. I know how it feels to be on the receiving end of that statement- and it sucked. 
Sure, I understand that a lot of medicine is still in the grey area, and that there are a lot that have yet to be discovered. But the simple truth is that logic never does make anyone feel better. It also makes me realise something about myself, which is probably also the nature of most human beings: that we always attempt to explain everything that happens to us (that’s how the age-old adage of “everything happens for a reason” reasoning came along, isn’t it? To make us feel better?), and we also try to do so in a way that attribute the cause upon something other than ourselves. In other words, we’re always inclined to blame it on something else, anything but ourselves or our own deed. But when push comes to shove, we’d take the blame too, as long as there’s a logical reason to it. We don’t handle the “unknown” very well though. Indeed, it’s the shrugged “I-don’t-know-why-it-happened-it-just-does-and-I’m-sorry” explanation that makes us feel the worst. But why??? Why did it happen to me? What have I done to deserve this?!  Those are the thoughts that would plague one’s mind, because one usually cannot fathom how a bad outcome could befall oneself when one has done everything by the books. Think of all the people who got lung cancer but never smoked a cigarette or anything in their entire lives. Or substitute it with any cancer that happened without a known risk factor in someone who had lived a perfect life up till that point. Think about the 30-something neurosurgeon who was about the complete his decade-long training only to find out he had terminal lung cancer. It’s atrocious! How vile to have been sentenced to such fate when a 90-year old man a stone’s throw away was probably happily puffing his cigarette celebrating his 70th-pack-year! But what can one do but throw up his hands and surrender to this thing called Life??! 
And when the initial emotions has passed and the dust settled, how does one cope with this kind of horrible outcome? Ironically, one tends to circle back to the “everything happens for a reason” argument to cope with it, or chose to accept and entrust one’s faith to the higher beings. That, or one could go into self-destruction mode and start hating everything and everyone with the “fuck god, fuck the disease, fuck the world” mentality. 
Now I’m not being melodramatic, I don’t have a terminal illness, I just have a skin condition that is also self-limiting, albeit one that will last 6-8 weeks. In the bigger scheme of things, I am thankful for being alive, for having “just” a skin disease. But being unwell is hard, especially for someone who’s spent most of her adult life working towards being the person who provides care. Now that table has turned, it’s a hard pill to swallow. I don’t want or like to be reminded that I too am mortal, that I’m completely susceptible to any disease, and that the medical degree earned is not an immunity to any or all sickness at all. Alas, I, and all the other physicians who may share my sentiments, are just humans too. We too can die, can get heart attacks, dementias, stroke, or [insert your disease of choice here]. It’s a silly, not-worth-mentioning known fact, but we don’t really think about it until we have to. (One could argue that some deliberately avoid thinking about it, but that’s a topic for another day.) The truth is, we all have to face mortality at some point, and we will all do so on our own terms. One way or another, eventually. (Unless you happened to be in a plane that miraculously disappear into thin air. Then sorry, no time for you to think about dying and death because your brain cells and every bit of you will be blown up into ashes before you could even conceive of what just happened.)
I write this before I had the chance to read Atul Gawande’s Being Mortal, or Paul Kalanithi’s When Breath Becomes Air (that’s the neurosurgeon who had terminal lung cancer I mentioned above), even though those books are just sitting on the shelf two feet away from me. When I’m done with exam, I’ll read them. Perhaps I will have additional thoughts on mortality then. But at this moment, as I’m writing this pondering upon mortality, grateful that I’m alive yet slightly (only slightly) resenting the cards I’m dealt with, I still think it’s a good thing over all. I see some good coming from it, not because I’m a masochist, but because through this ordeal I had a taste of being a patient, of being unwell, without having to go through chemo or radiation (or worse- to die!).  Empathy and compassion often grow exponentially from first-hand experience. So hopefully this experience will help me be a better doctor. Then again- one could only hope, eh. 😛 
Peace. xoxo.

Afterthoughts

“Welcome to the real world, where people only want answers — correct, accurate answers. […] In life, there is no partial credit for being half right. If you want to accomplish something important, you have to be totally right — and be willing to face the consequences if you are not.”  

Excerpt from When the Air Hits Your Brain, by Frank Vertosick Jr., M.D. 

It’s funny how I’d always come across something that is so relevant to what I’ve been thinking about at that moment, as if the universe ‘gets’ what I’m thinking and is sending a message back at me. Those words from that excerpt pierced right into my heart, and mind. It’s probably a gradual process, but at some point during my clerkship rotations, I realize this: every passing day I am inching towards that real world- a world where physicians are expected to be perfect all the time.

Some time last week, I was in the neurosurgery morning conference, and the head of department talked about how patients are increasingly demanding, and they would harp on the one mistake that you’ve done, and would not let it go. To some, it doesn’t matter if you’ve done many things to help them or their family member; as long as there is one mistake, that’s it. They will come after you. It’s even more so in the field of neurosurgery than any other specialty – and for good reasons too, of course. But he brought it up to remind everyone that we are being watched – all the time. And so, pandai-pandai lah. 

Just finished neuro clerkship. Moving on to pediatrics. It feels like just yesterday that I did psych, but in actuality I’ve done psych, surgery, and neuro! Half-way point. 3 more rotations to go before year 3 ends. How time flies.

Untitled #2

Of late I count my days by whether it’s headache-free or headache-filled days, and lemme tell you it’s no fun at all to have the latter be the majority of them. Don’t understand why this is happening; some says it’s stress, but I really don’t feel stressed at all- truth! Yet this past week the first thing I do as soon as I woke up is to pray hard that I won’t have headache later during the day. It probably sounds like I’m whining about something petty, but if you’ve ever had tension headaches or migraine before, you’d know this kind of pain can be quite debilitating- in short it’s nothing you’d wish for on anyone (unless you really hate them lol).

Apart from the headaches though, days have been filled with interesting (sometimes bizarre) conversations. Some people have delusions that are not that out of line from what we know as social norms, and I guess it’s understandable- in most cases it’s their coping mechanism, their way of handling what they considered as brutal reality, and they needed a way to deal with it. You hear views about life, about religions, about universality of all religions, about love, about ‘the other world’ etc.  Some of the things they said were quite mind-boggling, whilst some made me think (when I don’t have headaches that impair my cognitive function, that is). Psychiatry is so much more about life and the real world out there for different kinds of people, most of them not the average people we surround ourselves with; it’s becoming more interesting and less intimidating as the day goes by- it really just depends on how you choose to see things. Our professor told us, before we went out to the wards, “whatever it is, just take it easy,” and I think that’s the most apt advice to give. 
Today there’s this guy who wasn’t his usual self as the past few days. He made an analogy about him being a meek lion. “but just because I’m meek doesn’t mean I’m weak,” and he claims to be an empathic and simple person, but when pushed to a corner, “I’ll ROARRRR!” And he also made a comment that’s worth reflecting upon- “who do you think you are to want to help me? how can you help me? tell me, how are you helping me right now???” Indeed. Sometimes we doctors think we know better, and we prescribe meds intending to “help” them, but is that necessarily the best thing for the patient? Do we really know better than them about themselves and what they need? Do we? I have no answer to that, but I think that’s a fair point that he made, and it’s worth spending some time thinking bout it. Just a food for thought I guess. 

Movie Reflection: Something The Lord Made

Synopsis
The movie is about a white surgeon Alfred Blalock‘s partnership with his African American assistant, Vivien Thomas, in developing Blalock-Taussig shunt, a surgical procedure that saved the lives of babies who had blue baby syndrome. In essence, the shunt was made as an anastomosis of the subclavian and pulmonary artery, to provide oxygenated blood to cyanotic babies. (For those who are not medically inclined- it was a breakthrough surgical procedure done to provide oxygen to babies who couldn’t survive long after their births due to the lack of oxygenated blood, and so it was kind of a big deal.) This movie tells an extraordinary story about an ordinary man whose role was pivotal to this invention. Vivien Thomas was an African American guy who had never gone to medical school and was previously a carpenter apprentice – and what’s more, all this happened in a time when racial disparity was as deep as the Mariana Trench. The movie was a recount of the historical event, but took on more of Thomas’ perspective, and it zoomed in on the complex relationship between the two men, how close they were when they were working together, yet how distant they were in social settings when they were out of the lab. 

Reflection
There are those movies that inspire you, and then there are those that inspire you. This is one such movie. Let me start by saying, if you haven’t seen it, I highly recommend you to do so- it will be time well spent, I promise. It’s a story worth telling mainly because it was a story about a man who worked hard and shone through even when the circumstances were not in his favor. A story about an underdog who won the day, except it’s many times better- it was a significant milestone in the history of modern medicine; it saved millions of lives; and it marked the beginning of pediatric cardiosurgery. 
One of the things I loved about the movie was that I think it did a very good job depicting the era during which this relationship/partnership (between Blalock and Thomas) took place- the environment, the people, and the socio-cultural interactions between the races (and also amongst the people of the same race). There was a lot of subtleties, like how his own people who were working in the hospital were curious/suspicious/envious of Thomas when he got to wear the lab coat; like how Thomas saved up for his medical school only to find out it was all gone when Depression hit America. It must’ve been frustrating for him, no doubt. Yet in a way it was serendipity- if he had gone to medical school, he wouldn’t have continued working for Blalock, and this great work of collaboration wouldn’t have happened. Not saying that the invention wouldn’t have happened, but it wouldn’t have been the same. And then there was the conversation between Thomas and his brother, about the Brown vs. Board of Education – another significant event in the African American history in which it was deemed unconstitutional by the U.S. Supreme Court for public schools to separate the black and white students. It may be easy to dismiss it today, but it was really a huge feat back then, and it painted a clearer picture of the times that they were living in. Other things were like how there were separated washrooms for the blacks and whites, how they could only enter the hospital through a separate back door etc. People probably don’t think about it now, but it was a great reminder of how things have changed so much since then, and for the better.
Thomas’ diligence and creativity was inspiring; when he was in the lab you could tell that he was in his element. The lack of appreciation of his contribution did not sit well for him, and at some point he gave up and moved on to something else for a change, but then he went back to it after all. Was it because as frustrating as it was, he understood the circumstances, and made peace with it? Or was it more of a resilience to fight back in his own way, the way he knew how- by doing what he does best and show the world he will not be “defeated”? I don’t know. Perhaps it’s a little of both, and his passion for the work he was doing.
There is also another person I thought was worth mentioning- Dr. Helen Taussig, the other doctor who also worked on this shunt. In fact it was her who went to Blalock to ask for assistance. She was one of the first female doctors in a time when medicine was a male dominated field and females did not enjoy the socioeconomic status that we do today. It was tremendously tough for her to become a doctor; on top of that she was dyslexic to begin with, and became deaf in the later part of her life. But all these did not stop her from being an amazing physician who learned to lip-read to listen to her patients, and to listen to her patients’ heartbeats with her fingers in lieu of a stethoscope. And even though her male colleagues sneered at her idea that something could be done for the blue babies, it did not discourage her to pursue it till the end. For all those reasons, I just think she’s awesome. Hats off to her!
Anyway. Thought it was a great story told beautifully, and I probably didn’t give it enough justice it deserves, so if you have the chance, do watch it. Peace. 🙂 

A Book Review

Such compelling words! I certainly don’t want to be killed by the ignorance of my doctor, and more than that I don’t want to be the doctor whose ignorance may kill others. The title kinda piqued my curiosity, but I should’ve known better- that such compelling words is part of the marketing strategy. And yet, I read on, because I was too curious to know what he had to offer. Why, indeed, are we taught in medical school that as long as we eat a balanced diet, we don’t need nutritional supplements? Why is it generally frowned upon in the medical community?!

The book talked about how our body has its own natural healing power, and that the common threat of all diseases is the excessive oxidative stress that our body just can’t handle anymore. It then went on to give anecdotes about how taking nutritional supplements helped the patients come around- some were healed by it, some saw dramatic improvements. The book gave a pretty detailed description of the various disease processes, in the simplest way that anyone can understand without needing a lot of medical knowledge. The author also stressed that nutritional supplements is only complementary to whatever treatment that the patients were receiving, and it is by no means the only thing that the patient should take in order to be well again – a very important point because some people might have misunderstood the author thinking that just taking multi-vitamins is enough and will heal them completely.

I can see how non-medical people can learn a great deal from this book. It was probably more than an eye-opener to them- it would’ve totally convinced them that nutritional supplements is the way to go. For medical students or medical professionals, it offered a perspective other than what we were taught or what we were accustomed to. I can’t say I was enlightened by the book, but I give the author credit where credit is due. This book is primarily for general public to know their body a little better and to understand the disease processes that plague many of them, and ultimately it is a book written to encourage people to start taking care of their health- by taking nutritional supplements. For that, I think it’s done a tremendous job convincing people.

So. Just for fun, I’d rate the book a 3 out of 5. The title of the book, in my opinion, is exaggerated. But it did its job- it made you read what he has to say! It also did its job convincing you to start searching for the most trustworthy nutritional supplements the market has to offer, at which point you’ll come to realize that he was on the medical review board of the nutritional company called USANA (he’s moved on to ARIIX last year). The fact that the entire book sounded like a marketing tool also irritated me a little. (OK fine, it is a marketing tool.) It got a 3 out of 5 from me only because my personal view isn’t too far off from the author’s, in that I do believe nutritional supplements is beneficial to a person’s health, although there are many other factors at play too. In conclusion, unless you believe otherwise, I’d suggest reading something else that tells you things that you don’t already know! Go read something more fun, like the discovery of insulin. or 1Q84. 🙂

Away from Mother Ship, Venturing Out

So, very early on in our medical training, we’re taught communication and general history taking skills as well as physical examination skills with the help of simulated patients. Now after about 3 months of that, it’s time to put them in actual use. Well, kind of. We’ll be venturing out to the “real world” as we’re posted to our designated clinics once a week for a 3-hour session, observing and learning from our preceptors. Hopefully it won’t be all observing but that we’ll also get to do stuff too. I personally want to work on my history-taking and interviewing skills, and all the other basics. Mmm can’t wait. It should be fun!

As we prepare ourselves for the adventures and challenges in the next year or so that we can only imagine, one of our professors shared with us the following video from TED. It conveys a simple message, which is to stress the importance of a doctor’s touch in a patient-doctor relationship. Couldn’t be simple enough, yes, and perhaps it may seem like an ordinary, redundant point to make, but in reality it may be under-appreciated or under-practiced in this fast-paced technologically-driven world that we live in. And so, I just thought it’s a good reminder for those of us who will be embarking on our new adventures soon. 🙂  Good luck everyone!