Weakness

Yesterday,i watched Troy with Subha. Archilles weakness was at his ankle, the spot that caused his death. My greatest weakness of all time = my tear glands and ducts. I broke down crying in the ward today. I cant help it. Family grieving = i grieve too. It was embarassing. I quickly walked out of the ward and i just continued walking. Until i realized that i have no where to go, i sat down on the bench, ignoring those who stared, forming a strategy in my head. I need a strategy to pick myself up in the quickest time. Inhaled. Exhaled. Inhaled. Exhaled. Wiped my face. With my bare hands. Strategy no 1 = probably buy more tissues. Strategy no 2 : gather myself up, i should at least offer my deepest condolences strategy no 3 : think of a strategy later. I went back up into the ward. Offered my condolences as planned. Washed my face, stared at myself in the mirror for a good whole 15 seconds repeating to myself, 'you can do it'. I went and did another round to look for any unstable patients. Checked with the nurses if there happen to be anymore unstable patients. None. Went to the market to buy our salad ingredients. I cant help but to think that i could have prevented this if only i hadnt decided to go home at 9 pm ystd. If only i had pushed myself to follow up on at least another few patients. Because she was next on my list. I knew her condition wasnt so stable since a few days ago. If only i have checked oh her sooner. Thing is there is a total of 42 patients in this ward if its fully filled, about 30 or so on other days. I am incapable of taking care of so many patients on my own. Im incapable of knowing each and every patient in detail on my own. I meant on my own as in not literally on my own. I really appreciate the help of super experienced nurses in the ward. But nurses take instructions from doctors. They are responsible for patients drugs administration, specimens to send to the lab, their meals and administrative work. We are the ones who are responsible for a correct diagnosis, prescribing the correct drug & dosages, the best treatment plan, and ultimately aim for patients recovery. So nurses are doing their job well but we are not. Because sometimes patient coming from the emergency ward can be misdiagnosed since it was a clinical diagnosis. In the ward, we have lab results and we must look for a correct diagnosis. And sometimes the specialist have so little patient doctor contact time that most of the time the patients condition was overlooked. I feel like i have the responsibility to make sure all the patients is getting the best treatment plan for their condition since from what i can see, none of us feel are really feeling the responsibility. I wish i can do a campaign. To shout out to all doctors. Or even. I wish i can add to our no 1 rule, besides do no harm, we must be responsible for all of our patients. Take up that responsibility because it is this feeling of responsibility that will drive us to do better for our patient. It is the feeling of responsibility that can fight off fatigues that wears us down. This feeling of responsibility is what makes us a doctor. If you do not have a feeling of responsibility towards patients, dont be a doctor. You will save more lives that way trust me. Sometimes i feel that there is only so much i can do but it is this feeling of wanting to be responsible for the patients that i push myself. Even to the extend if i accidentally exposed my greatest weakness of all time. I cried. Will my tear glands and ducts really be the ankle to Archilles in Troy?

Mentor

I need a mentor. I need someone with a lot more experience, someone who can respond to me all the time. I need someone to tell me if my suspicion have a good base. I need someone to show and guide me the way to a right diagnosis. I need someone that is super experienced and dont mind me bugging even in the middle of the night. I need someone who can help me to be able to be who i want to be. I need that pillar i can count on so i can make sure all the patients is getting the best treatment plan for their condition. I need a senior. A free mentor. I dont know how. Maybe i can only pray for such mentor to fall down from the sky and be mine :) My mind cant seem to rest. When i eat, sleep, jog or reading in my free time, my mind is thinking about that patient with aplastic anemia getting the transfusion he needed. My mind wonder about the result of his blood count now after tranfused with 4 packs of whole blood. His future treatment plan. His prognosis. He seemed to be deteriorating. My mind cant take a rest. Its always thinking about patients patients patients. To the extend that my dad is leaving for dubai soon and I havent even talk to him recently. To the extend that i cant find myself to leave the hospital even when the clock striked 10 pm. To the extend i feel a bit exhausted but i cant help it. To the extend i started to fantasize about a world without problems. Whe no one falls sick, or even if they do, medical treatment is free and well advanced. Until then only my mind can rest and not have to worry about patients. Like that patient with sudden high onset of fever, decreased consciousness and abdominal pain. I am suspecting that it could be sepsis. He was already on ceftriaxone and roughly 6 hours before his manifestation all his test were normal. My mind is filled up with patients, how are they doing, whats their latest test result, are they doing okay..to the extend i kept going back to the hospital in the afternoon to find out. To the extend I am tempted to go back to the hospital like right now as in really right now as im typing this. Just to check on the patient. To the extend the nurses ask me why am i showing up in the hospital. To the extend my friends have to call me to remind me to be home for lunch. To the extend i am feeling like all the patients is my responsibility. To the extend im doing my internal medicine right now, but i find myself showing up in bougainville, the surgery ward to check on the patients with mild head injury i got to know yesterday when i was paying a visit to an ex- internal medicine patient, now a patient in the surgery department. To the extend i think that i am against shift system now because I see how irresponsible all of us became. Off shift means off duty. Means off patients responsibility. Means we just switch off the care button and switch on ignore button while patient is still in the ward suffering from their illness. We wouldnt know exactly the progress of the patients until the next day. Illness progression knows no timing. Actually itd be okay if shifts means morning shifts doctors go home, afternoon shifts take over and then the night. But right now, only in the morning you can see doctors. No afternoon and no night shifts in the wards. Only one general practitioner in the emergency. How is this a hospital? More like a nursing resort. You get nursed two third of the day and 5 minutes of doctor-patient contact in that one third of the day when youre supposedly under doctors care.

Culture shock

A senior general practitioner said to us, 'Dik, santai aja (just relax, chill) Ini bukan RSHS'. It was quite funny but straight to the point. That sentence kinda tickled my heart. So, she was right this is really not RSHS and I miss RSHS. The pros here : we have more freedom, nurses are very nice, we are being treated as a real doctor. The cons : no doctors on night duty in the wards, no radiologist on night duty, patients came to emergency ward with mild head injury. Plain skull x ray was done. No doctor around to expertise. Patient have headache, vomiting but no loss of consciousness. In such condition, wait until next morning when the new day starts in the hospital. What if there is a hematoma? Delaying the appropriate treatment = worsen prognosis? Whole hospital only have one general practitioner on duty in the emergency? She was really really right this isnt RSHS. I thought RSHS was mishandling patients. Now, I think I'd rate RSHS an A. I would give 110 of 100 even. She was right again when she said, 'welcome to culture shock'.

24 hours

I need more time. 24 hours isnt enough. Patient with thyoid storm passed away. I feel i was indirectly at fault. I found her heart rhythm progressed from sinus tachycardia into arryhthmia. I wrote it on her medical record, on the follow up page. I wasnt there when doctor did ward rounds. Not sure if doc noticed. I feel really bad. I think i somehow could have helped if i had been there to report. Her husband was really loving. Patient and kind. He must be really sad. Even i am sad. I cant have more than 24 hours a day. So well lets have some sleep since I find myself regretting not wanting to sleep early at night only to regret every morning when i had to force start my day. Had some awesome discussion with noriz, very thought provoking, similar to what i always have with my bro. Goodnight :)

Hospital, The Place

I love hospitals. I can clearly remember 7 years ago, when I wasnt granted a scholarship to study medicine on my first application, I cried to my dad saying, 'its okay then. If i cant study medicine, i would try all I can to be able to work in a hospital. Even if I can only apply for the job of a cleaning service, I would.' yes i love hospitals and I really want to work in a hospital just that much. I remember crying while drafting my own letter of appeal. I was really disappointed because I worked really hard to get that result. I thought getting a full score, straight A1s was enough but it wasnt. But thats a whole other story, not my point right now. Point is, my mum was away for a seminar and if i had her with me, she would have known what to do which is to help me draft my letter of appeal. My mum would understand how much it means to me. My dad chose to console me by saying, 'its okay girl, you dont have to be a doctor to help people. You can be many other thing to help other people. Its not end of the world'. I was shocked by my dad's reply because I was surprised by how he said those with ease as if he didnt know that I would even do cleaning service to be able to work in a hospital settings. So I found myself to have blurted these out,'its okay then.if i cant study medicine, i would do all i can to be able to....... ' These were the words that changed my dad's point of view I assumed. Cause right then, he helped me by proof reading my draft, watched me as I printed it out and drove me all the way to Putrajaya just to hand it in by hand, making sure my appeal is going to be heard. I was on top of the moon when I was later offered to study medicine in Indonesia. I really didnt care where, I thought as long as it is medicine and as long as I study hard enough, I will one day be a good physician that can help many people and who earned herself a ticket to spend a lot of time being in the hospital. What better reason can I have to be hanging around the hospital? The reason why all these came up in my mind was cause, I think, when all else fails to make me feel better, hospital is THE place. Maybe hospital is my natural habitat where I feel most at home. I think I plan to stay back in the hospital everyday from tomorrow onwards. Talking to patients, hearing their complains, trying to ease them in anyway I can = happy Amy. Thanks dad, mum for pushing me when I wanted to quit. For knowing how badly i wanted this even when i begged to quit. Otherwise I wouldnt have earned this ticket to linger around the hospital. A place I can count on to keep me happy. A place that sustains me. Besides paddy fields and mountains of course.

:)

Im finding it harder and harder to smile each day. But i try anyway. I dont know if im depressed. I cant help but to feel disturbed. I thought invincible I already am? I feel saddened by the realization that my want to help patients is still so far from my reach. So far. I feel extremely inadequate. My knowledge, experience and skills still lacks significantly. Such discrepancies I know not until when. Patient had tachycardia, precordial heave, elevated temperatures and abdominal pain. I thought of endocarditis when the patient was actually having the clinical manifestations of a thyroid storm. I did thought of hyperthyroidism since I myself do suffer from palpitations. I must not have suspected that enough because otherwise I should have noticed her enlarged thyroid gland. It was class II. I am super disappointed at how insensitive my senses are as a physician. I could have seen and touch If only I hadnt immediately thought of this as an infection since she was having an elevated temperature. 38.5. Didnt occur to me that it was caused by hypermetabolic state of thyroid storm. Patient came with vomitting of blood (hematemesis) and melena. I thought of cirrhosis because I already had a mindset this must most probably be cirrhosis since she complained of decreased appetite, early satiety and fatigue since 3 months ago. Plus a history of abdominal distention and history of jaundice few years ago. If only I hadnt framed up the history taking to fit the one of cirrhosis. Day two I suspected something must be amiss. Her clinicals doesnt really fit that of a cirrhosis. No spider naevi, no 'venektasi', no ascites, no jaundice..Initially I thought maybe she doesnt have the typical cirrhosis presentation because well maybe its still in the early stage. Child pugh A maybe. So I started to doubt the result of my history taking, I cross checked again. 'Bu, dulunya perut cembung sampai sesak itu seberapa besar perutnya? Ada sebesar hamil 9 bulan?'. She replied, 'enggak..cuma sebesar mungkin 4 bulan'. I asked further, 'Sakit kuning dulu..berapa lama sakitnya? Ibu sama ayah kandungnya atau suaminada sakit kuning juga ga?'. 'sakit cuman 2 minggu dok, terus sembuh sendiri. Keluarga sama suami ga ada yang sakit kuning. Kata orang dulu itu mah salah makan'. Oh so it was probably Hep A and all the more doesnt support the etiology I thought of earlier. And now, I changed my suspicion to peptic ulcer ec probably chronic gastritis since history of NSAID ingestion was negative. Sometimes I do wonder if things might be easier if we do have an endoscopy. And right now patient is undergoing transfusion because her hemoglobin is 3.4. Her bleeding has been ongoing for sometime now that I think an endoscopy is warranted. And again my knowledge is so inadequate..I dont know how significant it is if we do gastric lavage at this point. If aspirate do not contain coffee ground blood, how specific? Can we exclude upper gi bleeding? And if its due to esophageal varices or erosion would it make it worse? And I suddenly am reminded that in RSHS we were told to do gastric lavage..as in bilas lambung if patient have bleeding of the upper gi because if we dont..it will cause something..I cant remember? Bacteria will change something into something and cause something? Why is my brain like this? I cant even read ECG confidantly? Am I being too hard on myself? Monday, the internist reminded me of my graves disease. I told him the last I checked my thyroid profile it was eurhyroid. And I was quite clueless as what to do besides doing a yearly check up to monitor until it is significant enough to be treated. He said, 'periksa aja sekarang mah. Sy ga percaya kalau sekarang masih normal. Matanya sudah begitu dan terliat jugak tiroidnya membesar'. All this is making me feel quite depressed if the heart isnt already hurting enough. Who knows that it can be this difficult when you actually realized that the person you trust and love was really someone you shouldnt have? :)

Art of sifting

I was left speechless after the ward round this morning. Okay actually I wasnt speechless, I said these to Subha in disbelief, 'Is this an internist or a paraji?'. Paraji = quack = fraudulent who pretends professionally. I know it was definitley impolite of me to speak that way but seriously? Whadda? Patient came with recurrent asthma attack was told, 'Pak jangan stress ya jangan pikiran apa tu'. Okay stress does trigger asthma but I dont think a proper assessment was taken. Like how often he suffer from night awakening, day time symptoms, dependence on fast relieving bronchodilator, absense from work and so on. What happened to grading the degree of asthma control? What happened to taking a proper history of the current medication..type, dosages..so we can decide to step up or step down? Before saying to the patient, 'ya pak jangan stress tu, yah sudah boleh pulang'. Serious seriously? Another patient came with fever accompanied by seizure. No proper history taking, he went on, 'ya bu, nih kurang kasih sayang ni. Nanti banyak diberikan kasih sayang ya dari suami. Ya boleh pulang sudah'. whaddafq? What happened to history of epilepsy..metabolite? At least find out the cause of seizure? There is many more examples but they are roughly pretty much alike. Im in such state of disbelief to elaborate further. I think for the next one month, I foresee myself having the need to sift through..to sift hard..to be able to learn and pick up some valauable knowledge. Okay, CHALLENGE ACCEPTED. Each time I feel like my spirit has been dampen..I need to turn the table around, change my mentality and work hard to sift in order to gain at least a bit of knowledge. I will really try. But if that didnt turn out well, I will walk away. I cant let someone suck away my spirit like that. Just barely an hour and I felt so depressed. Honestly I have not seen such an internist or any doctor to that matter until today. And it made me realized that deep down I am VERY proud of my almamater. I am proud of all the residents and specialist we have in RSHS. I MISS RSHS. I might not be able to learn well in a non teaching hospital. Need to force start the art of sifting.