Elevator Thoughts

 

Day ends. Night duty begins.

I got a referral from Ward Charlie – patient seized – Oh no! What to do! I ran to the elevator thinking of…

My plan: check vitals, check sugar, check GCS score, do neuro physical exam… and then what?

My anxiety is kicking in. This is going to be a long night!

Above is my first 55-word short story entitled Elevator Thoughts.

Thank you very much Philippine College of Physicians and Dr. J. Tabula for introducing this wonderful literary world.

Below is my revision to the above text.

Day ends. Night duty begins.

I got a referral from Ward Charlie – patient seized – Oh no! What to do! I ran to the elevator thinking of…

My plan: check vitals, check sugar, check GCS score, do neuro physical exam… and then what?

Anxiety is kicking in.

Ding! Door opens.

Inhale confidence. Exhale compassion.

Doctor begins.

Day 21 of #100DaysToOffload. Find out more about it here.

In one form or another, each of us had a chance to do a tree planting activity. When we were younger these activities were a form of excursions, school requirement or/and a bonding activity with friends. Its goal is always environmental awareness. On a personal level, it was rarely because of the common good rather a chance to gallivant and explore nature. The altruistic goal becomes a secondary gain.

            This time around the Philippine College of Physician (PCP) had a tree planting activity. I was informed by one of the organizers that the event is a regular activity of the College. This is part of the commitment to help combat climate change. Certainly, trees are necessary to help reduce the carbon dioxide levels in our atmosphere. More importantly it can address soil erosion which has impacts on soil fertility and aggravate floods and landslides.

             From the perspective of the PCP, this is part of their commitment on environmental activism and protection. As an annual activity, this can help the members to be active on environmentalism. It is commendable that even in the face of COVID-19 pandemic, the organization is trying and achieving its organization goals.

            From the perspective of my co-residents, this is a new experience. This is our first time to participate on a tree planting activity sponsored by the PCP. We were excited and happy to be part of the activity. Moreover, we it was a refreshing experience, to have a breath of fresh scenery and fresh air, and away from the hustle and bustle of the hospital. Day in and day out, the residents are in the hospital and without any privilege of force leaves or vacations can cause mental anguish and coupled with the seemingly never ending-pandemic can be a nightmare. We hope that there will be more activities such as this.

            From my perspective, the experience allowed me to be “away from the hospital”. Emotionally, it was an experience that allowed me to visit the mountains again. Fresh air and less people. A reminder of my community days. Aside from the emotional benefit it gave me, it also reminded me of the environmental and social benefit of tree planting. Trees greatly benefit the people living around them by having a positive impact on mental health and wellbeing, reducing stress and encouraging outdoor exercise. This is in addition to the benefits people will receive from an improved environmental quality and improved scenery which comes with planted areas.

            Lessons learned from this activity include the need for outdoor activities. This has been very scares ever since the start of my training. But at the same time, it probably is unavoidable due to the pandemic. However, I think at this point, we have to move forward and learn to live with COVID-19. It is here and probably here to stay. I still pray that there will be definitive treatment and that complications can be avoided. Another lesson learned is that trees can stand the test of time and can even outlive us humans. It can even be a legacy. I remember a tree planting activity done by contestants of the Miss Universe way back in 1994. It was a big deal then. I think the contestants doesn’t even know if the trees did survive. Today, in Dipolog City, those trees line up the driveway towards the airport and the only reminder of the activity is a small placard around the tree stating the name of the planter and the date.

            I hope that the trees planted in Cabaluay will survive. One key problem with tree planting activities is that the seedlings are just planted, and everyone hopes that the seedling will just grow to become a tree. I think in the future we need to have some sort of activity where we can revisit the area where we had the tree planting activity to evaluate. And then if the need arises, add more seedlings in the area especially where the areas that have no growth at all.

            I believe my future plans would still to cater and join the next tree planting activity. And since this is an annual activity and under the PCP leadership, the chances of me joining the next one is high.

Day 20 of #100DaysToOffload. Find out more about it here.

A former student of mine contacted me regarding her medical condition. She was advised to undergo a renal biopsy to help her diagnose her ailment. She was asking for assistance and facilitation for the procedure. With the proper diagnosis comes the definitive management of her medical condition. She was already previously admitted at another hospital so I can just imagine the tremendous financial pressure it is giving her; not to mention the emotional stress involved with her predicament. She already opened up that she doesn’t really know if she can afford the procedure but because of the kindness of her classmates and friends coupled with her desire to be better, she is pursuing the procedure.

Academically, a renal biopsy is an invaluable tool that has become the gold standard for the diagnosis of pathologic kidney diseases since the early 1950s. Throughout the years, immunohistologic and ultrastructural microscopy techniques have improved and provide more information on the cause and classification of kidney diseases than that available from simple light microscopy alone. Kidney biopsy has become a preferred method to obtain critical information that can be used in conjunction with serologic, urinary, and genetic testing to diagnose a variety of kidney diseases, both acute and chronic.

During my medical student days, I did not have the chance to observe this procedure. This could be because of the 2013 Zamboanga Siege. I was an intern during those turbulent days and much of the academic learning and experience were compromised. Thus, because of my case, I was excited and inspired to read and prepare. I had to read on lupus nephritis as well as glomerular diseases which was good since I was still unable to read on them in Harrison’s. Also, the last time I had the chance to do a core needle biopsy was during my medical school days so having the opportunity to do it once again adds to the excitement. I was also prepped by my consultant before the procedure.

I’ve learned how to coordinate the radiology department, pathology department and my Nephrology consultant. It was daunting and stressful at first. I realized that this procedure required me to prepare a schedule that fits all the availability of the valuable actors for the procedure. This also gave me the chance to establish rapport to other specialists. The radiologist interventionist also gave me a list of the materials that he would need or use during the procedure. This is to my advantage at least I did not anymore research for the materials needed for the procedure.

I was assigned to do the 3rd puncture for the biopsy by my consultant. The first two were for me to observe and visually learn. During the procedure, my hands were steady but there was also an apprehension if I would cause any hematoma for my patient. Luckily, there was not and she only experienced minimal pain.

In the future, for every procedure whether familiar to me or not I should endevour to investigate the indications and contraindications of the procedure. It is uncommon for me to have special procedures in our department therefore whenever the opportunity arises, I should allow myself to read and experience those procedures. Armed with the internet, web crawlers and search engines I’m pretty sure relevant reading materials and journals are available for me to read. All it takes is the desire to search. I also would like to have more reflection on these special procedures and at least set a deadline within two weeks.

It is a privilege to be of service to my patient, former student, and now my facilitator for learning on glomerular diseases. Before she went home, she gave her thanks but I also thanked her for the opportunity to learn. And I reminded her that this situation may be just a small trial for her compared to her destiny in the future – to be a doctor for all. I sincerely hope she gets better.

References:

https://www.ajkd.org/article/S0272-6386(18)31102-8/fulltext#secsectitle0025

Day 19 of #100DaysToOffload. Find out more about it here.

Coronary angiography is defined as the radiographic visualization of the coronary vessels after injection of radiopaque contrast media. It is most commonly performed with specialized intravascular catheters. The procedure is usually included as part of cardiac catheterization, which may also involve angiography of other vascular structures, such as the aorta and left ventricle.

The purpose of coronary angiography is to define the coronary anatomy and the degree of luminal obstruction of the coronary arteries. It is most commonly used to determine the presence and extent of obstructive coronary artery disease (CAD) and to assess the feasibility and appropriateness of various forms of therapy, such as revascularization by percutaneous or surgical interventions. It is also used when the diagnosis of coronary disease is uncertain and coronary disease cannot be reasonably excluded by noninvasive techniques.

Reading this definition from the ACC/AHA Guidelines for Coronary Angiography, if I were still a medical student reading this might have inspired me to sleep or the concept would have been abstract.

The angiogram and angioplasty procedure was a real experience for my mother. Looking back, I was not interested with the indications for the procedure. This is an expensive procedure that had to be done away from Zamboanga. I just wanted to learn about the risks and consequences of the procedure for my mother and if it could save her from the agony of chest pain. Conversing with my mother’s interventionist was a learning experience but it also felt like a blur. I was a significant other then not a learner or a resident.

Fast forward into present time and I’m now an Internal Medicine resident and I was tasked to transport a patient for an angiogram. I was instructed to return after the transport to my post.

Instead, I was asked by my consultant to scrub in and observe. I was happy for the opportunity. I got to learn about the potential radiation exposure which made me a bit worried. More over, I got to assist with the procedure and got to insert the guide wire for the angiogram. I was able to appreciate the live movement of the dye during the procedure and see the actual stenosis first hand. I was able to appreciate the Left Anterior Descending (LAD) artery and Left Circuflex (LCx) Artery. Years ago, these arteries are just names that I had to memories and locate in an image of a heart. And as you would expect, you tend to forget this type of information.

Therefore, I should have reviewed the anatomy and distribution of the coronary arteries prior to the procedure. Although I’m not a very visual learner, I’m more of an auditory learner, a review would have further prepared me for the procedure and thus could have made a more engaging interaction with my consultant.

I am lucky to have assisted in the procedure though. Among my co-residents, none of them had the opportunity to assist and I hope they will also have the chance to assist in one. In my future interaction of patients who will be undergoing the procedure, when describing the procedure I will be able to describe it not from just reiteration from a textbook alone but from an actual experience as well.

As part of my deficiencies, I must review and take not of the indications for a coronary angiography according to the Harrison’s book. I was able to encounter and read the indications but a review of this literature is most likely to be a fruitful encounter.

As what Scarlett O’Hara said in Gone With the Wind, “After all, tomorrow is another day.” I will have my opportunity again to learn tomorrow and be better.

Day 18 of #100DaysToOffload. Find out more about it here.

Two days before my Infectious Disease (IDS) Rotation I had a nightmare. I dreamt that my wife complained of shortness of breath and cough. Her breathlessness and suffering seemed so real that it made me wake up instantly. I then realized that the coming days would most likely give me anxiety for fear for my family’s safety.

During my infectious disease rotation, I had to make peace with myself and I prayed earnestly for divine protection. At the start of my residency, I prayed less and missed masses often due to the demands of my schedule. The advent of the pandemic brought many changes in our lifestyle and way of life. One advantage is the masses are now accessible through Youtube or Facebook live. Through these mediums I was able to regain my peace of mind and at the same time be more prayerful.

The rotation reminded me two things, firstly, to accept the things I cannot change and to do my best to change for the better the things I can. Death is inevitable for all humans but the dignity to death must be pursued and given to all patients.

I’ve learned from my rotation and interaction with my consultants and patients the effect of positive outlook and that sheer will to get better has an impact. There were also days that the medicine for covid-19 were unavailable due to global shortage. Some patients sadly died while waiting for treatment.

This is one of the highlights of my covid-19 isolation ward rotation. I saw the healing hands of physicians, not just the medicines, and I saw the heart of physicians when they did their rounds to their patients. I even saw a physician praying and singing to patients. Singing lightens the mood and praying makes us aware or remember that there is a healing power that come from God.

It is my plan that in the future I will advocate to have caring hands and faith in the Lord. Of course, I endeavour to be a competent physician. More than anything else, I think I’ve learned a small fraction of the art of medicine. Thank you dear consultants and patients for the opportunity.

Day 17 of #100DaysToOffload. Find out more about it here.

It is probably an understatement to say that life with juniors during the residency training is a milestone in the profession. This past few months has been a period of adjustment for us, “senior” residents in the Internal Medicine Department. As a starting department, birthing pains are common and definitely expected. It is still, however, a headache...a load of headache.

These past few months have been terrible for me. It even lead me to doubt my compassion, competency and knowledge in the field. Certainly, I'm no expert, far from it. However, this feeling of inadequacy is stifling and suffocating. I do believe that this is not my own doing but rather of external forces. It may be because of undue expectations from me by my juniors or their superfluous idealism misplaced at the very least. Or worse, their self-inflated egos may have reached critical levels. I know this type of person. I have seen them in medical school and I always avoided this type of toxicity. Excellence does not need to trample other people.

My analysis, the junior may be too competitive and feels like I'm a target or an anchor for his competitive drive. Lord, have mercy! I'm in a point in my life where tranquility and learning is more important than the appearance of expertise. My competitive drive and compass is anchor on myself growing and learning. Can't he/she/it just compete with itself?

I realized I have to beat him/her/it with his game. And hopefully, the positive thing that will come out of it, is a worthy opponent.

It's a good thing we have this outlet called writing...er...blogging.

Day 16 of #100DaysToOffload. Find out more about it here.

During our usual critical appraisal and research updates, I had a light bulb moment. I was thinking about Pubmed and how it provided me with a lot of access to journals and information. It definitely helped me grow in my journey as a resident and physician.

I asked myself, if Pubmed and Pubmed Central are the same entities. Of all the things I have to think about. I had to ruminate on this.

I've always thought that Pubmed and Pubmed Central was synonymous. I didn't even bother to research or was even curious until today. I just thought that Central was just the last name of Pubmed.

Briefly, Pubmed is a free resource supporting the search and retrieval of biomedical and life sciences literature with the aim of improving health–both globally and personally. It was developed and is maintained by the National Center for Biotechnology Information (NCBI), at the U.S. National Library of Medicine (NLM), located at the National Institutes of Health (NIH).

Pubmed Central (PMC) on the other hand, is a free full-text archive of biomedical and life sciences journal literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). It serves as a digital counterpart to the NLM extensive print journal collection; it is a repository for journal literature deposited by participating publishers, as well as for author manuscripts that have been submitted in compliance with the NIH Public Access Policy and similar policies of other research funding agencies

Sounds the same to me.

Upon further digging, I was able to find some resource that really states they are two different systems although maintained by the same institution.

Bottom line, PubMed citations come from 1) MEDLINE indexed journals, 2) journals/manuscripts deposited in PMC, and 3) NCBI Bookshelf. Which means PubMed has a greater scope for researching articles.

I think the lesson here for me is that sometimes, what we take for granted as systems in place are themselves worth investigating.

Reference:

1. https://pubmed.ncbi.nlm.nih.gov/about/
2. https://www.ncbi.nlm.nih.gov/pmc/about/intro/
3. https://library.medicine.yale.edu/scholarly-communication/pubmed
4. https://www.nlm.nih.gov/bsd/difference.html

Day 15 of #100DaysToOffload. Find out more about it here.

While researching on Diabetes and deaths related with it, I stumbled upon an updated resource on mortality in the Philippines. Great information worth sharing.

According to the Philippine Statistics Authority, the reported deaths in 2019 reached 620,414. This is an increase of 5.0 percent from the 590,709 registered deaths in 2018. This is equivalent to a crude death rate of 5.8, or about six (6) deaths per thousand population in 2019. This corresponds to an average of 1,700 deaths per day, which translates to 71 deaths per hour or one (1) death per minute in 2019. This report was released last January 5, 2021.

How does the Philippine Statistics Authority (PSA) obtain the data for processing?

Data on deaths presented in this release were obtained from the Certificates of Death (Municipal Form No. 103) that were registered at the Office of the City/Municipal Civil Registrars all throughout the country and forwarded to the Philippine Statistics Authority. Information presented includes registered deaths which occurred from January to December 2019. Cumulative figures for 2019 reflect updated data which excludes fetal deaths present in the processing of regular deaths and may differ from preliminary counts previously published. Fetal deaths as well as deaths of Filipinos that occurred abroad which were reported to the Philippine Foreign Service Posts are presented in a separate report.

What are the top 10 causes of deaths in the Philippines?

Source: https://psa.gov.ph/content/registered-deaths-philippines-2019

The above figure shows the ten leading causes of death in 2019. Among the total deaths, ischaemic heart diseases were the leading causes of death with 97,475 or 15.7 percent of the total registered deaths. Neoplasms, commonly known as “cancer”, were the second leading causes of death with 68,657 (11.1%), followed by cerebrovascular diseases also commonly known strokes with 63,548 (10.2%).

Some thoughts though, I assume that deaths due to myocardial infarction are clumped or group in the ischaemic heart diseases. Not all diagnosed ischaemic (ischemic) heart disease die upon diagnosis although this is a serious medical condition. It would also be interesting to find out the different cancers that make up the deaths under the neoplasm category. I also would like to know what conditions are classified under the chronic lower respiratory tract infections. Lastly, the classification of “other heart diseases” is also confusing. Maybe they also clamp together all other heart diseases not under ischemic heart disease. What could be the top 1 disease under the other heart diseases? Is it congenital heart disease or maybe cardiomyopathy or even pericarditis or maybe even something else?

How about the deaths for 2020?

We will probably know more later this year or early next year.

Reference:

https://psa.gov.ph/content/registered-deaths-philippines-2019

Day 14 of #100DaysToOffload. Find out more about it here.

A moment of relief was felt yesterday. It would mark the end of my presenting, at least for a while until my next one. I've been presenting since December 2020 for my grand rounds presentation and my inter-hospital presentation. I was supposed to present the census for the months of October and November 2020 but this was further moved to January 2021. Due to work-related scheduling problems, my presentation was further split into two parts, the census for the previous months and a presentation on the mortality report. It was very taxing but nevertheless it afforded me more time to prepare my presentation.

What a welcomed relief! This one is for the books … just another chapter in the chronicles of residency.

Day 13 of #100DaysToOffload. Find out more about it here.

Ascites is a common complication of chronic liver diseases and is related to the extent of portal hypertension.

Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes. Ascitic fluid may be used to help determine the etiology of ascites, as well as to evaluate for infection or presence of cancer.

I had little knowledge of the procedure prior to my residency. During my internship days at the Zamboanga City Medical Center, I was not able to observe the said procedure. I only have the faintest academic idea of what it was and its purpose.

Thankfully, the through the patience and dedication of my consultant, I was able to do the procedure through his proper guidance. I also had to read up on the procedure to familiar myself with the procedure. There are a lot of literature available in the internet to gain proper knowledge, however since paracentesis is a skill we also need experiential knowledge.

As a resident I learned about the purpose of SAAG. The serum-ascites albumin gradient or gap is a calculation used in medicine to help determine the cause of ascites. A simple calculation that can help determine what caused the ascites, subtracting the albumin concentration of ascitic fluid from the albumin concentration of serum obtained on the same day.

Below is the algorithm that I came across in my readings.

A SAAG of >1.1 g/dL is 97% accurate in detecting portal hypertension.

In the future, I should order the serum albumin at almost the same time the procedure is done. Moreover, I should be able to order the materials needed for the procedure more efficiently without consulting the ever trusty IM platinum often.

The procedure may be the first of many in my residency training and I should develop the habit and the skill in doing this simple yet important procedure for my future patients.

Day 12 of #100DaysToOffload. Find out more about it here.