Certain Reminders on Patient Care

One of my non-medical friends who used to join me and my doctor-friends in our travels once remarked that our life in this profession is extraordinary - deserving of a sitcom in primetime television. Not only do we live horrible schedules and gravely inhuman work hours, we also subsist on a totally absurd and unjust paycheck, inversely proportional to the extent of our labor and psychosocial and emotional burden. What he found most amusing, however, was the fact that we never run out of intellectual conversations. According to him, ordinary conversations in the outside world where he came from usually revolve on the mundane, the casual, and the superficial. Doctors, on the other hand, talk about life - what they try to save, and what they miss in the process.

This good friend, who is still, by far and without a doubt, the most amazing and profound person I've ever had the good fortune of running into, had the habit of listening to us while we rant and whine about our work and our patients, once in a while giving his trademark laconic comments or a wordless mocking grin. After being exposed to us for several instances, however, he concluded that doctors all over the world, no matter how diverse and strange, will always find something to talk about - their patients.

But while doctors occasionally consider their patients' cases gossip fodder for casual conversations, I realized patients also talk about their doctors a lot more than I expected them to. During yesterday's out-patient clinic, I overheard a bunch of patients talking about their own doctors, reminiscent of those Tito, Vic, and Joey sessions in Eat Bulaga's Bulagaan.

Patient A: Aba yung duktor ko, mabait yun! Laging nakangiti. Nagsalita pa lang sya, parang gumagaling na ako.
Patient B: Mas mabait yung duktor ko! Lagi akong binibigyan ng sample ng gamot! Eto may mga abstract at referral letter pa. Kaya nakakalapit ako agad sa mga senador.
Patient C: Pinakamagaling yata yung duktor ko! Mukha pa syang artista! Mabait na, maganda pa.
Patient A: Talaga? Anong pangalan ng duktor mo?
Patient C: (blurts out a gravely mispronounced name of someone familiar) Basta yung maputi na parang model. Tawag ko nga dun si Dra. KC. (probably referring to KC Concepcion)
Patient B: Yung akin, di ko matandaan. Basta yung mataba na malaki ang tyan! Kamukha ni Arnold Clavio. Nakakatuwa ngang kausap e.
Patient D: Yung duktor ko, yung kalbo na Inglesero. Ang sungit. Di ko maintindihan ang salita minsan. Dumudugo nga ang ilong ko lagi.
Patient E: May mga duktor dito na ang papangit ang ugali! Akala ang gaganda at ang yayaman, mukha naman silang mga katulong!

I was wishing Patient C was talking about me, though that would be highly unlikely. I'm probably more of Patient A's doctor. Ehem, ehem.

Few days ago, I received a text message I still didn't have the slightest gumption of deleting. It was from my greatest doctor-idol and mentor - the Great Dr. D himself! In my phone, I have created a folder made especially for inspiring messages from Dr. D - messages I go back to again and again, during those PMS-moments when I absolutely hate my profession and whenever i bemoan my pathetic white-coat state.

Anyway, it said, "Thanks for caring for my patients last month jean... etc. etc. BTW, you have great bedside manners. Don't ever lose that." Waaahh!! That's a compliment from the Compassion Guru himself! I was floating and high when I got it. Somehow it reminded me, that even during my most toxic moments, even when I'm most tired and ugly, I have to keep my manners. Empathy is the name of this game. First, do no harm. To cure, sometimes. To alleviate, often. But always, to comfort.

Anyway, going back to my topic. While I was busy scribbling in my charts yesterday, I overheard another OPD conversation.

Nurse: Nanay, sino po ang duktor nyo?
Patient: Hmmm, basta yung mabait po.
Nurse: Nanay naman, mabait naman lahat dito.
Patient: (To her companion) Sino nga ba yung duktorang yun? Ah, naalala ko na! Si Dra. Alcobar! Yung mabait! Malaking babae na mabait. Oo nga, si Dra. Alcobar - yung matangkad na mataba!

Ahhh, WTF! The grossly mispronounced surname, I can forgive. But mataba??? Somebody just burst my bubble.

Me (thinking): Nanay, di ako mabait! Masungit ako! At hindi ako mataba!!!

But of course, my patient was right. There's no way I can ever deny my hideous, giant, amorphous state. Ugh! Rub it in. Go ahead.

I stared at my poor patient, like I'm going to pounce on her and give her a defibrillatory dose of shock waves - all 360 joules of it. And then suddenly, her face lit up. "Duktora Alcobar, Duktora Alcobar!!"

I couldn't help but smile at her. And the old woman, using all her post-stroke effort, shuffled up to me, and gave me a hug. Sigh... Too much for my being big again.

On second thought, I wouldn't really mind being remembered as "matangkad"or "malaki", not even as "mataba". For as long as once in a while an old woman will smile at me that way, or a blind old man will claim with unblinking but blind certainty, "Duktora, ang ganda ganda mo", I guess I'll be all right.

Perhaps I'm doing fine, after all.

Excerpts from The Prophet

Except during rare circumstances, it is extremely pathetic for someone who writes her own blog to post words written by other people. Lately, however, I've been reminded about certain words from a book that a great proportion of today's literate population may have already studied way back in high school. Considering the events during the past few days as "rare circumstances", I therefore venture in posting excerpts from this book. After all, there was a time when I memorized this chapter, word for word.

Few months ago, I was having a rare beer with a friend. While arguing a point, I quoted a line from this book, and I was surprised because my old friend blurted out another line in response. Verbatim. I don't remember the issue then, but nobody ended up winning, or conceding. As my good friend said, "Conceding presupposes an argument, and we have none." I managed to arrive at a conclusion, though. I was so lucky to have such smart friends!

My flight of ideas, notwithstanding, I just need to post these excerpts from Khalil Gibran's "The Prophet". These may open new worlds for some of my readers, the way they once opened new worlds for me. And if you ask me if I still believe them, my predictably crappy answer is "Yes, I still do. Every crappy word."

Then said Almitra, "Speak to us of Love."

And he raised his head and looked upon the people, and there fell a stillness upon them.

And with a great voice he said:

When love beckons to you follow him,

Though his ways are hard and steep.

And when his wings enfold you yield to him,

Though the sword hidden among his pinions may wound you.

And when he speaks to you believe in him,

Though his voice may shatter your dreams as the north wind lays waste the garden.

For even as love crowns you so shall he crucify you. Even as he is for your growth so is he for your pruning.

Even as he ascends to your height and caresses your tenderest branches that quiver in the sun,

So shall he descend to your roots and shake them in their clinging to the earth.

Like sheaves of corn he gathers you unto himself.

He threshes you to make you naked.

He sifts you to free you from your husks.

He grinds you to whiteness.

He kneads you until you are pliant;

And then he assigns you to his sacred fire, that you may become sacred bread for God's sacred feast.

All these things shall love do unto you that you may know the secrets of your heart, and in that knowledge become a fragment of Life's heart.

But if in your fear you would seek only love's peace and love's pleasure,

Then it is better for you that you cover your nakedness and pass out of love's threshing-floor,

Into the seasonless world where you shall laugh, but not all of your laughter, and weep, but not all of your tears.

Love gives naught but itself and takes naught but from itself.

Love possesses not nor would it be possessed;

For love is sufficient unto love.

When you love you should not say, "God is in my heart," but rather, "I am in the heart of God."

And think not you can direct the course of love, if it finds you worthy, it directs your course.

Love has no other desire but to fulfill itself.

But if you love and must have desires, let these be your desires:

To melt and be like a running brook that sings its melody to the night.

To know the pain of too much tenderness.

To be wounded by your own understanding of love;

And to bleed willingly and joyfully.

To wake at dawn with a winged heart and give thanks for another day of loving;

To rest at the noon hour and meditate love's ecstasy;

To return home at eventide with gratitude;

And then to sleep with a prayer for the beloved in your heart and a song of praise upon your lips.

Then Almitra spoke again and said, "And what of Marriage, master?"

And he answered saying:

You were born together, and together you shall be forevermore.

You shall be together when the white wings of death scatter your days.

Aye, you shall be together even in the silent memory of God.

But let there be spaces in your togetherness,

And let the winds of the heavens dance between you.

Love one another but make not a bond of love:

Let it rather be a moving sea between the shores of your souls.

Fill each other's cup but drink not from one cup.

Give one another of your bread but eat not from the same loaf.

Sing and dance together and be joyous, but let each one of you be alone,

Even as the strings of a lute are alone though they quiver with the same music.

Give your hearts, but not into each other's keeping.

For only the hand of Life can contain your hearts.

And stand together, yet not too near together:

For the pillars of the temple stand apart,

And the oak tree and the cypress grow not in each other's shadow.

Making Peace

Today, I'm making peace with a lot of things.

First off, I'd like to make peace with the rain - that gift from nature which I've loved for so long, whose embrace I used to look forward to each time it showers the world with its bounty. To the rain, I know you didn't mean to do us harm. Or perhaps you gave us your warnings but we never heeded them.

Then, I'd like to make peace with the sun, whose fierceness I've always abhorred, whose presence I've always took for granted and whined about, and hid from. Perhaps I failed to recognize what life would be like if there was no sunshine. To the sun, thank you for the constancy, for being around even when I forgot to be grateful.

I'd also would like to make peace with Love. It is not your fault that you chose to be picky. It is not your fault that you never picked me. You will move on, sometimes in sheer joy, sometimes in sublime peace, sometimes in ultimate terror, sometimes in exquisite, unsurpassed pain. I will move on too.

And lastly, I'd like to make peace with myself. It is not my fault that I chose to love, even if Love did not choose to be returned.

Today, I will make peace with a lot of things. The beauty of the sunset lies in its brevity. An epiphany is knowledge seen in pure clarity. Clarity only lasts for a moment. And a moment is no longer a moment if it lasts.

The Relativity of Beauty

The walls of my world are closing in. All I hear is the steady droning of the airconditioning unit in this conference room that I've made into my dwelling place. Sometimes, the rattling sounds of the LRT or the occasional screech of a car horn or the loud laughter of street urchins break the monotonous silence. What goes on outside, I do not know.

Sometimes it's hard to imagine that I was ever part of that world outside. Do I even exist, or is everything a mere illusion? Do I even matter? How do I cross the emptiness that separates me from what is real and what is not? Do I exist? Do I matter? What is the proof that I live? What is the proof that I matter?

Do all these questions even matter?

This was a choice I made. This is a choice I'm sticking to. What goes on in the world outside, I do not know. I'm trapped. I'm ensnared by my own prison, an there is no one and nothing else to blame, but me.

I hear my heart. I breathe. I exist. But do I live?

I do not know. And all I know is this - not knowing does not really matter at all.

The view from the CVS Conference Room window

Where I'd rather be

Today, I wish I was some place else. While the rest of Metro Manila is still busy cleaning up the mess from Ondoy, or just picking up the pieces of their recently devastated lives, life goes on here in the hospital. We scurry around as if Ondoy never happened. Since it is the beginning of another month, it's the old shifting mental dullness and the traditional furor while frantically searching for charts, establishing patient rapport, catching up on long-neglected reading. But despite the busy day, my mind was wandering somewhere else. I want to be where I'm needed the most now - using my medical knowledge and skills to touch real people, victims of the storm that ruined the lives they so painstakingly tried to build. Not here where things have remained untouched by the storm, not here where most people are mindless of the things that happen outside these walls, except for things that directly affect them, not here where life revolves around our daily routine, our charts and our orders and our academic conferences - senseless activities masquerading as medicine. But isn't Medicine all about being where you are most needed?

I just realized how heartless and selfish I had been during the past few days since Ondoy. Despite the predicament of millions of my neighbors, I've been whining about the small flood in my apartment, or the slow internet connection in the Cardio office, or the careless resident who forgot to carry out my recommendations for the patient I'm comanaging. I was jolted back to my senses and I realized that I want to be where I'm needed - right there, where the brown and murky waters are still waist deep and the children scream for milk with fevers burning, and the wounds are still festering. Right there where the white coat doesn't count and doctors truly become doctors - that's where I'd rather be.

My wake-up call came from an unlikely source. I recently reestablished contact with a good old friend who, cluelessly, has been my anchor to reality for a long time now. This good old soul was miraculously spared from the floods, and was asking me for opportunities to serve, as if believing that my magnanimity is constant, resistant to the effects of stress and disappointments and living itself. My old friend knew, and believed, I was already out there doing something. And suddenly, I was like, "whaat?!? what have I done except grow bed sores on my ass, sitting up around here in airconditioned offices while 700,000 of my neighbors suffer in those damp evacuation centers?" It's time to do something. Now.

I'm glad my old friend reminded me of what I should be, before I totally became something else. For the nth time, my greatest fear, my source of terror and unspeakable agony, has again saved me.

Cleaning Up The Mess

I stayed up until 1AM last night scrubbing my apartment floor, mopping off the murky debris reminiscent of Ondoy's wrath. I could have used that time searching for a journal to present on Friday's Journal Club, but I just couldn't stand the stench of stagnant water anymore - a mixture of human excreta, rat urine, garbage juice and what-nots, benignly appearing as brownish water undisturbed by sunlight in several corners of my squalid apartment.

Mop and pail in hand, I took off my slippers, and scrubbed and squeezed and scrubbed until my hands ached and my feet were wrinkled. This is the price I had to pay for independence. I should have continued renting that room in Paco. Ate Justine and Ate Angie would have cleaned off the flooded floors as fast as Ondoy itself. After hours of attempting to remove the water using an old piece of shirt that served as a sponge, my living room looked dry enough to be lived in. I counted at least 8 dead roaches, 3 cigarette stubs, a dead lizard, and a small mouse, remnants of the Taft Avenue ecosystem that must have been washed off to Manila Bay by now.

By 1AM, I turned my lights off, lighted several scented candles, and sat down on my cheap sofa. I was suddenly overwhelmed by exhaustion and a certain brand of peace. Ahhh, this is the life. I couldn't help but utter a short prayer of gratitude - for being spared from the flood, for my shabbily furnished den that has served as my sanctuary from the hospital for two years now, for my mop and my pail and my Lysol, for everything I've been given even if I don't deserve them.

I capped my evening with a glass of wine. In front of an imagined company, I gave a toast to life and all the mess it surprises us with, and to myself - for being able to clean up most of this mess at least most of the time. And I silently drank a toast to my best buddy: To Solitude - now and indefinitely. Cheers!

Meditations After Ondoy

Manila looks serene and fresh from my office window. If yesterday did not happen, I would have lauded this day as one of the most beautiful city days I've seen in a long time. Indeed, some things, like yesterday's rain, have a way of "fumbling at your senses" and suddenly disappear, as if nothing happened at all. It's cruel. It's strange. It's wicked.

Bad Hair Days

I don't believe in bad hair days. It's either you have a hair worthy of a shampoo commercial, or bad hair for the rest of your life. I am one of those unfortunate enough to be classified under the latter - my hair is perpetually thin - with strands like those of a 3 year old's, and perennially curly - with short ones vehemently standing up in kinks and in coils despite all intense efforts at taming them. But I won't be writing about my ugly hair. I'll be ranting about my bad hair life, filled with terrible, and oh so gravely horrifying bad hair days. And as if these days are not enough, some just simply stand out - some days are a gazillion times more awful than the already disgusting and insipid ordinary day.

Today is one of them. Perhaps it's because I woke up later than I had planned I should. Perhaps it's because I again found myself sleeping in the hospital for the 3rd straight day when my next duty is yet to be in October. This is me - the new resident-fellow. Ugh, what else is new? I've been sleeping in this hospital since I was a student, then as a resident, even as a chief resident. And now, here I am again, what's so different about fellowship when it is just an extension of residency after all? Sometimes it's just so tempting to go up to the 7th floor of the hospital, stand on that ledge facing Taft Avenue, and then jump off, with Tom Petty crooning in my head "now i'm free, free falling..."

I'm not stoned. I'm just having a bad day. Extraordinarily dreadful days are days like these - everything is going well, things are falling into place, but you simply can't take any pleasure out of it.

Later in the evening, I went to the mall to splurge on a solo fancy dinner. Still not satisfied despite my already distended bowels, I proceeded to seek solace in an old sadness treat -Peanut Butter Chocolate Dream Bar from Mrs. Fields - which ended up tasting like mud. Tonight I will be going to bed in the fellows' callroom again, grieving over my extra calorie intake.

Somebody once said that the bridge between hope and despair is a good night's sleep. I just wish that tomorrow, I'll wake up with better hair.

Despite my apparently cloistered life, I'm quite proud of my performance...

My Lakbayan grade is B-!

How much of the Philippines have you visited? Find out at Lakbayan!

Created by Eugene Villar.



The following are my travel dreams in the next 3 years:

November 2009 - Palawan

Early 2010 - Northern Philippines. Perhaps Sta. Maria town of Cagayan. They have old lighthouses there worth checking out.

Late 2010 or Early 2011 - This would have to be my ultimate dream - Basilan, Sulu, and Tawi-Tawi!!!

Elevator Thoughts

Today I'm a zombie. I'm one of those half-awake, half-dead, not-so-human creatures walking around the hallowed halls of this wretched hospital in the middle of the night, on a Sunday, on a long weekend. So, the last time my hair touched a comb was 12 hours ago? So, my white coat is stained with ballpen marks all over and brownish icky discolorations at the sleeves? So, I'm wearing a 5-year old scrub-top and my shoes are worn out from too much walking? So, there's oil on my face and I smell like the ER? So, I look like a hobo, with tattered clothes, circles under her eyes, and an empty brain? What's wrong with that? And whose fault is it?

I'm a living dead today because I'm on 24-hour duty again. One of the most dreaded responsibilities a fledgling and struggling Cardiology fellow can ever imagine is a 24-hour duty on a Sunday, when the rest of the world is quiet except the hospital. For some reasons, people always get admitted during Sundays. And why is it that even stable patients get MIs during Sundays? And residents seem to love calling up Cardiology fellows on a Sunday when they could have done so on any other day?

One of the worst nightmares on a PGH Sunday is the elevator, or the lack of it. For as long as I can remember, all the other elevators stop functioning on a Sunday, except one. That single, solitary, overworked elevator traverses all seven floors of the hospital, carrying doctors, watchers, pickpockets, visitors, and employees alike (patients share another elevator). Sometimes the line extends up to the ATM machines (many meters away). Sometimes petty fights happen among those falling in line and those who don't.

Instead of taking the stairs to keep my cardiac muscles healthy, I invariably choose to be a sloth and take the elevator if I have to go up and down at least 2 floors, even if it would take light years falling in line, even if it feels like living in a sardine can while breathing that stale mixture of carbon dioxide, and nitrogen and what-nots for at least 5 minutes. I've been stuck in that elevator twice, at least. One time there was a sudden power interruption and I was stuck in that can for 10 minutes, slowly dying from asphyxia. Another time, the door simply refused to open. We were midway between the 5th and the 6th floor, pounding on the walls and the door, shouting for help. For some reason, the elevator just jerked and suddenly continued it journey up.

For some reason, being stuck in that elevator reminds me of my mortality. It reminds me all the time that despite my dirty white coat and my vestigial props of a stethoscope, I'm still human - a creature stuck in a sardine can, breathing the same toxic air just like everybody else. If, at midnight, the elevator is empty except for that tired-looking operator, my minutes in the PGH elevator afford me brief luxury of a shut-eye, and during that finite ride that seem to take eternity, I just breathe and enjoy everything imperfect around me.