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A Walk Down Memory Lane
March 15, 2006
After two years of continuous work, I was able to enjoy a really good breakfast one rainy morning. It was not because I was having my favorite sausages and eggs. It was because I was having it at home in Bacolod, and I was not reporting for work that day, and I was preparing for a trip to Iloilo to visit the West Visayas State University College of Medicine. Only after two years of working 80 hours a week, did I get that chance to take a short vacation.
Before I embarked on such a vacation, I made sure that all of our study patients are stable. One patient has developed anemia, which required correction. We ordered transfusion of two units of PRBC. A second patient developed a rectovaginal fistula probably secondary to cobalt treatment. We sent her for colostomy. A third patient developed urosepsis. We started her on ceftazidime and referred her to the nephrology service for co-management. She was found to have azotemia secondary to obstructive uropathy. The nephrologist shifted to a fourth-generation cephalosporin, cefipime. After one week of treatment, the patient did not improve and still presented with febrile episodes. We sent her for nephrostomy and requested a urine culture and sensitivity, which later revealed Pseudomonas aeruginosa resistant to cefipime but sensitive to ceftazidime, a third-generation cephalosporin. The nephrologist was surprised. We shifted back to ceftazidime and the patient started improving. It was time I took a short vacation.
After spending a few days in Bacolod (playing with my one-year-old nephew, who is now starting to walk independently, and feasting on chicken and pork "inasal" of El Camino and several fresh fish from "Pala-Pala"), I took a trip to Iloilo on that rainy day. There was no Super Cat or Bullet Express anymore. Instead, there was Weesam Express 5, which leaves at 8:00 AM. In an hour, I was already at the port of Iloilo. I took a cab to WVSU-COM and in a few minutes, I was standing in front of Roxas Hall. It was six years ago since I last set foot on that place and it already seemed a very long time. Hector, the medical technologist in the college, was outside the building and was surprised to see me. He used to coach our basketball team. I went inside. The staff at the Registrar's Office was still very accommodating. The faculty who happened to be there were Dr. Medez, Dr. Marte (if only he did not have class, we would have visited our old hangout for some beer), and Dr. Hubero, who remarked that my beer belly is a sign of success! I had a short conversation with the dean, Dr. Villareal. She gave me a good career advice and wished me luck. I did not stay long at Roxas Hall because I still had to visit my grandma in Villa, where I left some of my stuff from medical school.
Before I went to Manila to work, I placed my stuff from medical school in a box and left it with my grandma. I opened the box again when I visited her. It contained textbooks ranging from Nelson Pediatrics to Schwartz Surgery, several reviewers, and several papers including ER charts from the University Hospital. I also found my ID, my Order of Asclepius pin and some pictures of our Boracay getaway. It is nice to have this kind of break from work and be able to cherish your memories of the College of Medicine.
I was able to retrieve from the box a few old issues of the Vital Signs. The editorial board showed I was once a news editor and once an associate editor. I would like to share one article I wrote. It was published in the October 1998 issue of the Vital Signs. It was about my experience the summer right after my second year in medical school and at that time I still knew nothing about clinical skills.
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A Peek at the Clinics
I wanted to watch a more realistic episode of the ER, but not on ABC 5 and neither employing virtual reality technology. I just went to a place where real things happen right before your eyes without commercials. Later, I realized I needed the commercials. However, they can actually never exist in a place called the emergency room.
Actually, I just wanted t take a peek at that place but a pretty familiar face asked, "Aren't you going to insert IVs, NGTs and FoleyCaths?" He was the EMS chief of WVMC and he was no other than Dr. Maximo Nadala, the same person who heads the Department of Surgery of that institution.
So afterwards, I thought I was really making a big mistake. I was going too far and I was not prepared for it. Come to think of it, I had to go on an On Duty-From Duty-On Call rotation. No more weekends, no more holidays. But, did I have choice?
The first few days of duty were really quite difficult. Imagine inserting your first IV line in front of the senior surgical resident and Dr. Nadala himself. But later, things were easier that you would sometimes go for blind IV insertion either because you don't really see or palpate a vein or you're just too sleepy to find one.
Then you start inserting FoleyCaths. Sometimes you would blame it on too much Betadine because it's just too slippery to insert the catheter only to find out later that the patient has benign prostatic hyperplasia. So, you forget about the FoleyCath and order for an NGT. Yes, an NGT and you insert it in the urethra. It might not still be successful. So, you call the surgical resident to help you with a suprapubic insertion. You should see the relief in the patient when his bladder is decompressed.
Then you proceed with NGTs. They say that when you are to insert both a FoleyCath and an NGT, you insert the FoleyCath first. Quite rational, it's much cleaner there. Anyway, it's easier inserting an NGT considering the posterior anatomical location of the esophagus. But what if it was anteriorly located? Most would end up in the lungs! But then, intubation would be much easier. Where would you place your tracheostomy? At the side of the neck?
Then Dr. Nadala would say, "During our time, we already inserted IVs, NGTs and FoleyCaths." And I would tell him, "We already inserted chest tubes and CVPs." Thanks to a number of trauma patients who required evacuation of a hemothorax. Thanks also to referrals from the Department of Internal Medicine of patients with pleural effusion. The residents would say, "Just direct the tube superiorly and posteriorly and you won't puncture the lungs." So that was when we started puncturing, it was not the lungs, but the pleural cavity.
There was no way out. We had to rotate with the Department of Surgery. But minor OR days were fun. You see 10 boys waiting to be circumcised and there were 3 surgical residents and 2 of you. The residents would not expect you to assist them. They don't need you. So, you get 2 boys each and do things on your own. And that's not all. There's one waiting for an excisional biopsy of a breast mass. You prep the skin and make your incision of choice. Then the resident exposes the mass for you to excise in 2 minutes. So that was fun. And there's another one for removal of a large sebaceous cyst at the buttocks. If you're not careful, you'll burst the cyst open at the buttocks and it spurts right into your face. But you should stay put and just wait until it's over.
You don't just learn these basic skills. A patient comes in DOA because of electric shock and the resident asks you what the cause of death is. Or another patient comes in with multiple gunshot wounds and they would ask you the difference between an entrance wound and an exit wound. And this was before we ever had Legal Medicine as a subject. A 5-year-old child comes in because of abdominal distention, perhaps a case of Hirschsprung's, and the residents would be talking about a Swenson, a Duhamel, or a Soave. During pre-op/post-op conferences, they would talk about a Whipple procedure. Or over a bowl of "arroz caldo," someone would ask you the stages of acute appendicitis. So, you had no choice but to study with them. Anyway, there was food everywhere, you'll never go hungry. It's through the compliments of either the consultants or the pharmaceutical companies. You can get to relax in an air-conditioned office and watch a basketball game if you want. Just be prepared for ward and ER calls.
But this isn't just your life in the clinics. You see, when you're about to sleep at 4 in the morning, a resident asks you to perform cystoclysis and this would sometimes take more than an hour. The sun would be up by that time. Or maybe at about the same time, a trauma patient comes in and all you see is a 7.5 cm lacerated would on the head and you suture it only to find out later that the patient expired because of subdural hemorrhage. Or a 2-year-old comes in at the ER because of a vehicular accident and you can't do anything because the folks cannot afford a CT scan so you would just expect another mortality the next day.
Life's like that, they would say. Sometimes, we can do something. At other times, we can't do anything at all. In the process of learning, we realize that in the place called the emergency room, we are only instruments of His will.
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Good luck to those starting junior internship on April 1, 2006.
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Views expressed on this column and any other by-lined articles on this site are the authors' own and do not necessarily reflect the views of the organization or its members.
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