Tag Archives: life

Medicine Maxims

THE MAXIMS OF MEDICINE

Before you examine the body of a patient,
Be patient to learn his story.
For once you learn his story,
You will also come to know
His body.
Before you diagnose any sickness,
Make sure there is no sickness in the mind or heart.
For the emotions in a man’s moon or sun,
Can point to the sickness in
Any one of his other parts.
Before you treat a man with a condition,
Know that not all cures can heal all people.
For the chemistry that works on one patient,
May not work for the next,
Because even medicine has its own
Conditions.
Before asserting a prognosis on any patient,
Always be objective and never subjective.
For telling a man that he will win the treasure of life,
But then later discovering that he will lose,
Will harm him more than by telling him
That he may lose,
But then he wins.
― Suzy Kassem, Rise Up and Salute the Sun: The Writings of Suzy Kassem


The Good Doctor

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be good, always

A doctor, like anyone else who has to deal with human beings, each of them unique, cannot be a scientist; he is either, like the surgeon, a craftsman, or, like the physician and the psychologist, an artist. This means that in order to be a good doctor a man must also have a good character, that is to say, whatever weaknesses and foibles he may have, he must love his fellow human beings in the concrete and desire their good before his own

– W.H. Auden 1907-1973


Saving Lives

The following article is not mine, but I am reposting it here so that we may be reminded that it’s not only us doctors who save peoples lives. Here’s to the other unsung members of the healthcare profession.

all in a day’s work.. well done

Get up when the alarm goes off, shower, and put on fresh scrubs. Relish the moment, this is the cleanest you are ever going to get today. Eat heartily because nursing is not only for the strong of will but the strong of gut as well.

Feel the odd urge to want to get to work a few minutes earlier. Know that being early will not be acknowledged on your pay slip but will shape the quality of your work. Get to work early, anyway. Accept the endorsements of your coworkers with a smile. Their shift has just ended, do not expect them to be clean, thorough or in good spirits. Smile, anyway. Be patient and give them time and your undivided attention.

Don’t wish for an easy shift. This will lead to disappointment and frustration when the inevitable walks in, which could be anything from the common flu to a multiple gunshot wound. Wish for fortitude and being able to eat on time instead. Check and prepare your equipment and medication conscientiously. This will save you time, and a day’s worth of mental and emotional anguish. You are here to mitigate bodily disasters. There is no other way to go about it.

Quickly assess patients as they come in. Use your intuition. You will become instinctively attuned to the workings of the human body when you keep an open and inquisitive mind. Pain matters. It tells you something is wrong. It gives us the chance to fix, transcend, and heal.

Physical pain is easy. You run diagnostics and give pain medication while figuring out what has gone awry. It’s the other kind that’s hard. It’s the widow weeping in the corner, the bruised child sitting still, and the father staring into space. There is no textbook manual on empathy. Be human, that is all they really need from you. Listen and always try to understand. The people we meet at work are in the middle of what could probably be one of the worse days of their lives. They will not be rational, polite or calculated. Organs fail, systems go haywire, bones break, and people hurt. Know that at any given moment it could have been one of your people lying on the stretcher. It could have been someone you love. It could have been you. Never look away. Keep your head above the water. Tread the fine line between the surreal and the random cruelty of life.

In a nutshell, the healthcare industry is institutionalized compassion. Healthcare workers are the determination of divine goodwill in a man’s world. There is bound to be friction. We operate within a framework and the bureaucracy of that framework. Wade through the turbulent currents of policy and practicality. Never forget your own voice, especially when you discuss issues with your coworkers and superiors. You are a nurse first and an employee second. Sometimes the two will be at odds with each other. Give the former a bigger voice. This is what the strength of will is for. There will be days when you will doubt yourself. This is fine. It means you still care enough to want to be better. The moment you stop wondering and wanting is what you should be afraid of. At its most basic, the greatest challenge of a registered nurse is to be charitable and selfless in a world that is not charitable and selfless by nature.

Strike the balance between precision and compassion. Insert IV lines and defibrillate. Don’t be afraid to pierce skin and draw blood. Keep your hands steady. Saving lives requires a measure of detachment from human sentimentality while sustaining the earnest belief that this person loves and is loved and that it is your job to keep that cycle running.

Most of the measures we take to save lives seem grisly and almost violent. Don’t flinch. Remind yourself every time that you are doing them kindness. You will get better at this as time goes by. There are some things you can only learn from repetition. The unpredictability and wanton disregard of change has never seemed so palpable as that in the small window of opportunity in a crisis. Time is critical. Life is fragile. People fall apart so easily. The body can stop trying in an instant. Hope for the best and prepare for the worst. Close curtains. Recognize your own powerlessness when the end comes. Sometimes, the best form of kindness we can give to another person is a dignified death. Remove tubes with care and wipe away body fluids. Dress open wounds. Cover the body with a sheet.

It is a curious position to find one’s self in: Close encounters of the wondrous and harrowing kind make us acutely aware of how terrible and extraordinary people can be, how terrible and extraordinary things can happen, and how terribly and extraordinarily we can do. Being within arm’s length of other people’s tragedies is a privilege reserved for the courageous few. In that singular moment we hold in our hands the power to save. Do the kind of work that will make you proud by day and sleep well at night.

Make your presence count. The only way to save a life is to go beyond your own. In saving others, we save ourselves.

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[NB: The following appeared on the opinions pages of the Philippine Daily Inquirer April 18, 2013 issue, the online version can be found here. It was written by Isabel Manalastas, 25,  an emergency care unit nurse at Manuel J. Santos Hospital.  All copyrights remain with their respective authors and the Philippine Daily Inquirer where this article first appeared. no copyright infringement intended]

Junior Intern On Duty

[NB: the following is an original article written by a batch mate  in medical school. We would like to thank the author for giving us permission to post the article  in this blog. ]

Maundy Thursday. April 8, 2004. 10:30 pm. 

It was my first week as a junior intern in UERM. I was doing my rounds in the Medicine pay section monitoring my patients’ vital signs when I got a message from the nurse that there was a patient who was transferring from the charity wards. He was JM, a 45-year old male, who came in due to bipedal edema of several weeks duration. He was previously diagnosed with Congestive Heart Failure, a condition wherein the heart could not pump enough blood to supply the body, causing him respiratory distress.

I did not attend to him right away as I was busy recording the vital signs of the other patients I was monitoring.

Maundy Thursday. April 8, 2004. 11:00 pm.

 I was in my station, 3 North 1, when Dr. Uy, the cardiologist of JM, together with Dra. Escasa, the medicine resident on duty, arrived to do their rounds. Guilty of not having seen the patient before their rounds, I was hesitant in handing them over the patient’s chart. I had no choice but to present it anyway. As they were discussing the case of the patient, I ‘slipped out’ to monitor the other patients assigned to me. However, Dr. Uy noticed that I, the junior intern assigned to his patient, was ‘missing’ and called my name. I reported right away. He asked me, “Have you seen the ECG tracing of this patient?” I answered honestly, “No, sir.” He showed me the ECG recordings and asked me to interpret it. I could not say a thing. Reading an ECG, a must know, was my Achilles’ heel. He was very kind for not humiliating me in front of everybody.

He then asked me, “Have you heard the patient’s heart sound?” I said no. He asked me to listen to his heart and come back and tell him what I heard.

I entered room 308, where the patient was confined. I saw an obese, dark-complexioned man lying on his bed. He was gasping for breath. A nasal cannula of an oxygen tank was attached to his nostrils. He was in moderate respiratory distress. He was sweating profusely and his skin was cold and clammy. His nail beds were cyanotic.

I lifted his shirt and placed the bell of my stethoscope over his chest to listen to his heart. I could not hear any heartbeat because his breath sounds were louder than the latter, thus, giving me a ‘noisy environment’. I used the diaphragm of my stethoscope but his heart sounds were overshadowed by his breath sounds. I did this for more than five minutes but I could not hear any distinct heart sounds. Then I went out of the room and reported back to Dr. Uy. I told him I could not hear anything so I could not describe his heart sounds. He accompanied me back to the patient. He auscultated the patient then he let me listen through his stethoscope. He told me to listen to the gallop sound. A normal heart sound is “lub-dub… lub-dub…” His was very rapid “lub-dub-lub-dub-lub-dub…”

Maundy Thursday. April 8, 2004. 11:50 pm.

The patient was a time bomb waiting to explode. I was beside Dr. Uy when he was explaining the condition of the patient to his relatives. Sooner or later he was going to have an arrest – he was going to die. That was the reason I have to monitor his vital signs hourly.

The relatives were faced with two choices if ever he went into cardiac and pulmonary arrest. Choice A was simple: Do Not Resuscitate. Choice B was to intubate him now so to avert a respiratory arrest and place him in the Critical Care Unit. His relatives were not sure if they would be able to afford his 100-thousand weekly hospitalization cost if ever he was placed in the CCU.

They were undecided.

Good Friday. April 9, 2004. 12:30 am.     

The patient was observed to have yellowish penile discharge. Pauline, a fellow junior intern who would help monitor some of my patients whenever my load was overwhelming, and I were assigned to get the tip of the patient’s Foley catheter for gram staining and culture. We were also instructed to put on a new catheter to monitor his urine output accurately. I was kind of excited since I had not done this procedure in my first week of being a junior intern. It would be my first time.

When the materials were ready, we entered the patient’s room. She told me that I was the one who was going to do the entire procedure, as she would be there only to assist me. I put on my gloves and told the patient that the procedure would be not comfortable. We were able to get the specimen and re-insert a new Foley catheter without much difficulty.

I also pushed Furosemide 80 mg IV, a diuretic, to help the patient urinate and lose much of the fluid he had retained which was contributing to his respiratory distress and edema.

Good Friday. April 9, 2004. 1:15 am.

I checked the patient’s vital signs which had not changed much. His BP was still 120/80 mm Hg, heart rate was more than a hundred, and axillary temperature was 36.5˚C. However, he was tachypneic as his respiratory rate was already 56 cycles per minute. His urine drainage bag was empty. He was diaphoretic – his two pillows and bed sheet were wet with sweat. I told myself that Dr. Uy’s assessment was correct, this patient was about to die soon.    I urgently referred his condition to Dra. Escasa, who promptly ordered another Furosemide 40 mg IV push.

Good Friday. April 9, 2004. 1:30 am.

I went to his room to check if he had urine output. There was none. “Did I insert the Foley catheter correctly?” I asked myself. Even his relatives called my attention to check if it was connected. I told them it was in place. I was sure that it was in his bladder. Pauline confirmed it. But the zero output despite the administration of two doses of diuretic agent made me wonder why he had not any urine in his drainage bag. I referred this matter to my senior intern.

Good Friday. April 9, 2004. 1:45 am.

A relative went into my station and informed me that the patient wanted to be nebulized. I checked his breath sounds but I heard no wheeze. I just explained to him that the reason he was having difficulty of breathing was not due to constriction of airways, which could be relived by nebulization. He was gasping for his breath because of pulmonary congestion. I told him that his heart could not pump blood efficiently so there was backflow of blood into the pulmonary arteries. It was causing fluid build-up, impeding proper expansion of his lungs for oxygenation of blood.

Good Friday. April 9, 2004. 1:55 am.

As I was going to leave the station to monitor JM, I saw Dra. Escasa approaching. She was now opening the door of room 308 and I immediately followed. As soon as we entered the room, the patient collapsed!

I sensed panic but I kept my presence of mind. I pulled the patient’s bed so I could go to the patient’s left side as Dra. Escasa was checking his heart and shouting instructions to the nurses, “Bring in the intubation and suction machine now! Call ECG technician now! Page Dra. Mabilangan now!”

A bloody frothy discharge came out from the patient’s mouth. She told me to do chest pumps so I immediately climbed onto the bed and knelt on his left side and performed chest compressions.

I could hear the relatives crying outside the room as the paging system announced repeatedly: “Dra. Mabilangan 3 North 1 NOW!” Dra. Mabilangan was the Chief Resident of the Department of Medicine. Announcing her name to go to 3 North 1, my station was a code that someone was being resuscitated. Seconds later she was inside the room. Some residents and senior interns were already helping Dra. Escasa in intubating the patient. A group of male junior interns were also outside waiting for their turn to do CPR.

The ECG technician also arrived and instantly placed the three electrodes to the patient. An ECG tracing showed that the heart was still contracting but failing. Epinephrine was administered while the residents and senior interns were intubating the patient. Chest pumps were resumed and after 20 or more pumps, I felt exhausted and I shouted, “Change!” Gio, the junior intern next to me, occupied my space and continued pumping. There were five of us alternating in giving him chest compressions.

A repeat ECG tracing done showed flat line – his heart was not beating anymore! Finally he was intubated but auscultation of the chest and abdomen showed the tube was in the stomach and not in the lungs. First intubation try was unsuccessful. A nasogastric tube was simultaneously being inserted to decompress his abdomen. It was now Yay, another junior intern, who was giving CPR as I pushed the sixth dose of Epinephrine.

After thirty minutes, ten doses of Epinephrine, countless chest pumps, a dozen flat ECG tracings and several intubation attempts, JM was pronounced dead by Dra. Mabilangan. All residents, senior interns and junior interns, exited one by one.

I remained inside as he was still my patient and my responsibility. He was the first person I had given chest compression, hoping that my effort would give him a new lease on life. He was the first person I had seen dying. All throughout his last moments, I was beside him. I silently prayed for his soul as I left the room to give privacy to his grieving relatives.

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About the author:

Arbee Bascuna, M.D. is a graduate of the UERMMMC College of Medicine Class 2005 and is currently taking up residency training in urology at the St Luke’s Medical Center.


Borrowed Dreams

[Previously posted as Recycled Dreams in the Aesculapian Vol. 40, No. 2, modified and updated for this blog post]

Kung saan ka masaya, te suportahan taka…                                                                                                                                                             

image credits: yourjustine.tumblr.com/

The line above (loosely translated from Ilocano: whatever makes you happy I will support you) is from an old PLDT TV commercial advertisement circa 2001 where a father, a Doctor apparently, reassures his son, who was taking up Medicine at that time wanted to shift to Fine Arts, that regardless of what he wanted to become he’d still support him. Personally I liked the print ad version better. But this article isn’t just about the ad, but rather it’s about what we can learn from it.

Flashback to the time when I was just a kid and people asked me what I wanted to be when I grew up I always had a ready answer: I wanted to be a scientist. What kind they asked still and I’d say just a scientist. What was I to know, I was just a kid right? Now fast forward a few years later, it was the time just before graduating from college. Like so many others of our class I mulled at what lies ahead for me. If I wanted to I was offered the chance and position to go into research and become the scientist of my childhood, but I decided to take on another career path, where most of my classmates were also heading — I was to pursue a medical course. And mind you it’s not because I bumped my head on the wall that I got this idea. I guess it was part of me all along and I just didn’t realize it.

So when I was interviewed here at UERM and asked why I wanted to study Medicine for lack of a better answer I uttered the most over used and abused cliché “Because I want to help my fellowmen” and the interviewer seemed unimpressed. He then proceeded to ask me, again, why I wanted to become a Doctor of Medicine and I said that it’s my dream, and that I didn’t want it to remain just another dream.

And like any medical student will probably tell you, I worked, studied and persevered to fulfill the dream that I can honestly say is mine. I wasn’t forced, coerced, and most definitely not bribed to becoming a doctor. It’s my own choice.

Unfortunately I can’t say holds true for all of us. Like the father in the advertisement, and most other parents who are professionals, there is the tendency to want to pass on the dream, to follow in their footsteps, and ultimately continue their legacy. I know of a friend who is taking a medical course only because both his parents are doctors, his uncles and aunts are doctors and apparently, as logic would place it, so should he. In the long run, he will just continue the tradition of being another doctor in the family. It’s a good thing that he did not take his studies half heartedly, and embraced the dream as his own, otherwise he’d probably end up a mediocre, a doctor who never wanted to be one, in stark contrast to those who really want to become doctors but could only dream of it. Such is life.

Mulling over these thoughts of mine, I dream again. Perhaps if and when the time would come when I have a family of my own, I will allow my kids to live and choose their own dreams as my own parents allowed me to live and choose mine. Their dreams doesn’t necessarily should be a duplication of mine, but if ever he does tell me what he wants to pursue, I’ll probably look back at this article, smile and say kung saan ka masaya te suportahan taka.


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