Morphine

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We have just finish Family and Community Medicine. What made an impact to me was the last two weeks of it where we had to deal with the terminally ill and the dying. I can say it is really a significant part of the health care yet it is emotionally exhausting. The doctor has to learn the art of bracketing so as not to be involved in the family’s bereavement yet still able to sympathize with them. It is in this rotation that I have appreciated morphine, an opioid acting on the mu-receptors. Morphine is safe as long as the right dosing are followed. It should be given orally as much as possible, but can also be given in the ff order: subcutaneous, rectal/intravenous, and lastly, intramuscular. Three things to ponder when starting this drug are: age (if elderly), kidney function, and liver function.

In Hospice, I have lost some patients also. And sometimes it is really hard when you have had a good rapport with a Bicolano or Bicolana. But then again, death is part of the disease spectrum, or life in general.

I eventually remembered my Lola Maring. If probably I had already rotated in Palliative Medicine and Hospice, I could have done more to help her when she was dying. May she rest in peace.

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Death and Dying

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When I first entered the SHPM at the third floor of OPD, I really do not know what the word hospice means when used with the term palliative medicine. Which is which? I then realized that hospice can be palliative but palliative medicine cannot be hospice because those patients dying in six months or less can be palliated with their symptoms, but those who are not yet dying cannot, or should not, be given hospice care.

                When I was still in the other rotations, I sometimes ask those in the Hospice rotation regarding what it is. Maybe, I just want to prepare myself because my lacrimal glands are very sensitive to scenes of bereaving families in the wards. Most people say that I have a strong personality because of my appearance and stance. However, they do not know that I am very sensitive especially when someone is crying in a funeral. The last time that I almost cried, in fact, my voice was already in the verge of crying, was when I was in front of my Pedia patient already pronounced brain dead by the RIC. The parents suddenly cried and started with their lamentations while the youngest sibling of the patient was innocently looking at his sister. That whole scene made me think that I cannot bear it anymore. That was my first time to have a mortality as SIC and I cannot already look at the face of everyone in the periphery because my eyes are already glossy with tears. After some time of trying to fight the feeling, I went to the call room and tried to control myself. That time, I was convincing myself not to cry because how can I be a doctor when every disclosure or some similar scenes would make me cry. Crying is a human nature, but I think, crying in the wrong situation, affects the professionalism especially in a doctor. It then became a challenge for me in this rotation, but I know I really have to conquer this sensitivity because as death is inevitable, I have to be seen, even if externally only, as a strong steward of the patient and the patient’s relatives’ sake.

                I want to conclude my rotation with what I thought of during the past two weeks: that every doctor should know how to palliate terminal symptoms and provide hospice care especially when the Hospice service is not offered in his or her particular hospital. As I have mentioned, death is inevitable, so hospice and palliative care should be given rightfully.

Outpatient

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With the conclusion of my rotation in the Ambulatory Care Unit, I have pondered on three significant issues as far as I am concerned: 1) the simulation of the community setting, 2) the omnipresent mosquitoes and 3) a student doctor’s thinking process.

Two residents taught me that the management of patients in the AMBU tries to simulate the setting in the community. It reminded me of what community doctors ought to do in their practice – keeping a minimal number of laboratory requests that will significantly help in the diagnosis and management of the patient. I find it proper because for one, doctors are stewards of the patient’s financial resource and also, the communities especially those in the rural or far-flung areas have minimal laboratory tests available. I have initially thought that the patients being seen in the AMBU are not being managed fairly because of this idea. For example, for a leptospirosis suspect, why would you order a CBC and creatinine only, and not include serum bilirubin, electrolytes and leptomat when these would yield valuable information as well? Nevertheless, it is when the physician’s clinical decision-making plays an important role to weigh which is the most appropriate step.

Dengue fever is said to be a year-round disease. And mosquitoes are omnipresent in the Philippine General Hospital. If I were to write a Critical Incidence Report, I would write about my archenemy. They are present in the AMBU, in the callroom, in the wards, and of course, in the neglected gardens of the hospital. Considering the cases of dengue fever in the hospital, even if we advise our patients to use mosquito nets, it is still unacceptable to have them in our midst.

Technically, I am not yet a doctor. I am a medical clerk, and being called “doctor” by a patient or a resident doctor has brought me both joy and frustration. I am always glad when I am called a doctor because it reminds me that I am indeed already close to that goal despite the remaining one-and-a-half year to study and train. But the same label has caused me frustration. It is indeed hard to alertly diagnose a patient. Sometimes, you know that you have read it but you suddenly forget the dose, the pathognomonic signs and symptoms, or the essential labs to be requested when you are already in front of the patient. Sometimes, you know that you are certain with the diagnosis but there is some outlying symptom that is hard to associate with your diagnosis. Or sometimes, you just feel lost in doing a procedure. In these instances, I prefer to be called a medical student/clerk rather than a “doctor.”

Children of the Streets

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The afternoon that we left PGH Lobby to go to CHAP or ChildHope Asia Philippines, I do not really have the slightest idea of what we will be doing there, not to mention, where we will be going too. In my mind, it is a non-profit organization for street children, as what has been told in the orientation.  And our purpose as medical students visiting them is to have a routine health checkup on those street children. In fact, while we were riding on the ambulance (which is by the way, not well-ventilated because the air conditioner cannot work while the vehicle is moving), I am thinking of how I will mingle with street children. I am also thinking of what will be the signs and symptoms that they will present to me, for as a medical clerk, my clinical eye is not yet refined.

My preconceived idea is that I would be meeting a number of noisy and dirty yet innocent children of the streets of Manila. That afternoon, there were no street children that welcomed me. Instead, I met three male teenagers. One of them is Rashid, a fifteen year-old male, who will be our index case. We proceeded with our usual history and physical examination of his case, to which our differential diagnoses included viral hepatitis, dengue fever and leptospirosis.

I never imagined that meeting Rashid would make me realize that I am meeting an epitome of teenage boys that are being victimized by vices. Rashid’s stories reminded me of the usual television news associated with gangs. I was able to probe circumstances in his life, as if I were writing a documentary. I have learned that what I see in the news is just the tip of the iceberg. What I value the most is the fact that deep within Rashid’s personality is the urge to change and live anew. And it is with CHAP that everything is coming into reality. It is indeed a hard work for the organization but imagine if this happens to at least half of the street children in the metropolis, it will make a difference.

Hopefully, I can share my part also in this advocacy.

Deaths

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Today I felt sad that my patient Kreng had another hemorrhage because there was L-sided paralysis. Yesterday, she already had ICH. I just feel sad that I picked her as a case for our SGD, and her condition is really toxic, at risk of DIC. But it was not the main thing that is attacking her, but the bleed in the brain. Dra. Go told me that the patient’s parents is about to sign DNR and DNI. That struck me because I could not accept it — she had GCS 15 the whole night although she kept on vomiting and also had headache. I suddenly realized I forgot to pray for her. I also realized how important the monitoring is. Unfortunately, it’s just so hard to monitor every patient in the crowded ward.

*Kreng died probably an hour after I left for my post-duty status.

John Robert was another patient of mine, suffering from leukemia and probably a concomitant liver disease. He was from Virac. So I have been helping and talking to his father in the vernacular. I also introduced them to a classmate from the same town who also extended some help.

*He died after my duty day. I’ve never seen him or their family the following day.

From all these deaths, I realized that I don’t know how to speak to people grieving. I can’t comfort them. I just noticed that no matter how I have helped or communicated with them, I have a hard time comforting them when the patient succumbs to death.

Arvey was another patient. I noticed he has a good smile, but on the first few days only. He was once a patient last August and eventually came back again. There were some difficulty in procuring blood in the blood bank for his transfusion and even on his extremities for CBC. I wouldn’t forget that day when I jokingly said, “bakit ang lungkot  mo? bawal ang malungkot dito” to which her mother replied “masakit daw po kasi ang ulo, doc.” That time when he had severe headache, we requested for a stat CT scan, which showed no bleed. I had high hopes for him.

*But then weeks after I left Pedia, JC, the next SIC of my patients, informed me of his demise. I suddenly felt sad.

 

I never thought that patients like them really die.