Shout Out for 2012: Joshua 1:9

"Have I not commanded you? Be strong and courageous. Do not be terrified; do not be discouraged, for the Lord your God will be with you wherever you go."

 Thank you to the Silliman University Church Service today for this reminder. I am truly blessed.

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 The year 2012 started with a challenge - how to pack all the materials things that I have accumulated during my fellowship year in Manila without earning the ire of my patient husband - and I failed. I had to pay a considerable amount of money to Cebu Pacific for the excess baggage. Countless times has my reminded me to send some of these things ahead of time but I procrastinated. Yes, I have to admit that I really am a Hoarder and I hope to make every effort to improve.

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I have been told by those who have come before me that I will face the considerable task of making palliative care be known, understood and accepted in Dumaguete City. I had to prepare myself; and I knew, even at the beginning, that could not do it possibly do it alone. It is in the moments of hesitation that I became more conscious of the people and circumstances that God has presented to me. 

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 The most basic virtues still apply - patience and perseverance, humility and love.

 

Fourth Month: DONE

Matibay ang walis, palibhasa'y magkabigkis.
A broom is sturdy because its strands are tightly bound.

Jero, Dj, Me, Barbie, Joana and Aliza

I am thanking God for having allowed us to survive the first four months of Fellowship in Palliative Medicine, a section of the Department of Family and Community Medicine. Aside from the usual academic rigors that the training requires, there is the daunting task of going through the  bits and pieces of government bureaucracy.

Since the beginning of this academic year, there have been visits to the Family Medicine Department area on the third floor of Out-Patient Department Building of the country's 102-year-old national tertiary referral center and teaching hospital. Talks floated around the Department about certain new policies and priorities of the new administration. During last Thursday's culminating activity for the resident rotators of the Section, we were shown a copy of the letter addressed to the Department Chairman. It seemed that the whole Department will have to vacate and rearranged her physical set-up because  we have "underutilized" areas that could be put into better use by the Medical Records and Blood Bank units.

I distinctly remember feeling sad and frustrated; as I tried to hide that quiet tear. I know that Family Medicine, in anywhere in the country, is somehow not given her deserved importance in this age of medical specialties, even if the Philippine Academy of Family Physicians, is the largest organization of physicians under the banner of the Philippine Medical Association. It enraged me and I likened it to discrimination. 

The same can be said for the Palliative Medicine. Under appreciated. A relatively new field in the Philippines, but has grown by leaps and bounds in Europe and in the United States. According to one of our consultants, the training program was not even mentioned during a presentation, with members of the World Health Organization as audience. Certainly, the majority of physicians in the Philippines do not know about this training program or has an idea what the specialty is for... Dame Cicely Saunders? Dr. Josefina Magno? In our ire, we commented that, "magiging pasyente din kita...."; and you will see what we can do.

Ang mabigat ay gumagaan, kung pinagtutulungan. A heavy burden is lightened if everyone participates in carrying it.

On second thought, I asked for forgiveness for such remarks. My co-fellows and I are made of much sterner stuff. We can cry for awhile on this impending loss of our "home," lambast them even; without a sure area of where are we going to relocate; "mabuti pa ang mga taga-Laperal Compound..." 

But then, we can always let our  work, our patient care, do the rallying;  and  thus, be able to rest in God's  faithfulness at the end of the day and be the fuel of our hearts for tomorrow's labor.

-x-

I was the home visit fellow (along with Aliza) for April. I have an alternate during the Mondays-Wednesdays-Fridays' visits. This means that I get to have less patients from the ward referrals. After the first week, I got bored. I was sleepy most of time. "Parang walang gana..." I missed the action while in the wards, although, it can be overwhelming, too. I need to find that zest.

I sure did, on the morning of April 20th. 

I had no residents with me or students or volunteer nurses. Just Sir Roger and Sir Loy. After seeing a family near Harrison's Plaza, we decided to do an initial visit the Missionaries of Charity in Tondo. Then, nagpabaga ko og nawong... I asked them if it would be if it would be fine to stop at the Eng Bee Tin (besides, its my birthday!) - I would really like to eat their hopia with a combination of flavors...  pLease.... please...

Tito Ruben used to bring us these delights from his trips to Manila as pasalubongs when my cousins and I were in grade school. Truly, one of my favorite things in the world.

 An absolute pleasure.

 Plus Plus points for the combinations =)

This is from their website http://www.engbeetin.com

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Walang mahirap na gawa pag dinaan sa tiyaga.
No undertaking is difficult if pursued with perseverance.

In Los Banos, Laguna during,  with the parents of Jero, Dr. Rhodora Ocampo and the staff of Madre de Amor

After the day's work at the Shawarma Snack Center in Malate, with Dr. Eva, Jero's pretty wife

At the Icebergs in Robinson's Place, with our senior fellows

Just before starting  the pre-fellowship, I was interviewed by two members of the consultant staff. They told me about the heavy load that the training could possibly bring in all aspects of my life (what an understatement!)  and that it is important to strike that balance. One of the questions they asked was if I have a hobby or something that I find interesting other than the hospital work - and truth to tell, the first thing that came into my find was FOOD.

I am so glad that I have found a new group of "vultures" here. =)

-x-

For where your treasure is, there your heart will be also. - Matthew 6:21

Julius (sounding board, and everything else) and Me

Keona Ysabelle Hernan aka Ysai Churvaness

-x-

Yipee! 

May -Ward rotator!!!!

The Things I am Learning On The 15th Week of Fellowship Training

Before I had my home visit rotation, I was secretly afraid of going "alone" on HV, because of debridement. I had done a lot of these things during clerkship and when I had spent about 6 months in surgery pseudo residency . I am not the "yucky" person type, too. I think, I must have gotten used to referring patients to the friendly surgeon  in the last three years prior to this fellowship training while in a private hospital.  

On my second home visit Wednesday, along with a junior resident (Aimee), 3 nurses and the ambulance driver, I attended to an 87-year-old with breast cancer and is  a bedridden Lola with history of multiple strokes and uncontrolled diabetes, somewhere in Tondo, Manila. The last medical assessment was Breast Cancer Stage IV but the family does not have a record of any diagnostic exam results. Instead, they gave me copies of their latest medical bills. She has a very big sacral ulcer that made me miss Dr.RSN and his meticulous wound care that he has always given to patients. It was a challenge - I even had a hard time fitting the surgical blade to the holder =p ;  

But I did it and HAPPY! I still know how to do decubitus ulcer debridement. =)

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When it comes to being patient,  I am a work in progress.

Testing The Waters: 

On with the same patient, I noticed during the course of our assessment that:

a.) Lola is occupying only a very small space in this 3-storey house. The room is like Harry Potter's (but in fairness, it has a sliding glass door and window).

b.) There are so many family members in the house today but they all deny living in it except for Carmen, the primary caregiver (the only caregiver!) and the house help. 

c.) A daughter owns a caregiver facility in the US of A and she seemed to be ignorant about how her mother is doing. She kept on mentioning that she has all these dressing materials back in the US of A that she could have brought home with her but nobody had told her about the bedsores her mother is having.

It frustrated me and I let them know it. (As an afterthought, I was not able to use my ALS: Bracket)

I assessed Lola to need an IV antibiotic treatment and further surgical management and thus, I advised hospital admission. The family could not afford anymore a private hospital after Lola stayed for almost a month in the nearest private hospital in the area. I could not admit her in the Hospice Unit for the three beds that we have is occupied; and the waiting in the PayWards is LOonnggggg.

I talked to two of my co-fellows and asked them about OM to ask about some details. I advised the family to bring patient to this government hospital. During the last hospital admission, the family had decided for a DNR/DNI. I talked with the family more so as to get their perceptions and understanding. 

I instructed Aimee to prepare the referral form. I wanted it done properly because I know how it feels to be on the receiving end of a "poor quality, bordering on useless" referral form. As a palliative care physician-in-training, I thought it was best to let OM know about the advance directive and so it was written on the referral.

It was about 3 hours since we left Lola's house when I received a phone call from her daughter. She was telling me that the hospital will not be admitting Lola since "wala na silang gagawin kasi DNR/DNI na." Hmmmm... I can feel my blood starting to boil.

I asked as nicely and as calmly as I can (it was good that I just finished eating a yummy food during the Lunch lecture by Dra.RR) if I could possibly talk with the ER doctor.    Did I mention that we also placed the SHPM's contact number on the referral?

I explained to him that even if its DNR/DNI, any condition that can be reversible we are going to treat it so as to improve the quality of life of the patient and the family. It  doesn't mean that we are just going to neglect every single patient who is DNR/DNI or refuse a patient  hospital admission for that matter.

"Tama po ba ang pagka-intindi ko na hindi ninyo pwedeng i-admit c Lola kasi DNR/DNI na xa?" 

My blood did boil eventually; here I am being told that "it is already out of your jurisdiction, kasi nasa sa amin na ang patient," 

"Why? Is the patient dying na ba?"

I know I was rude to him at some point and I did not say thank you. I just asked him to give the phone to the relative. And since, he doesn't want Lola to be admitted because of the DNR/DNI, then I instructed the relative to retract the DNR/DNI - Lola was then admitted.

It seemed stupid that a hospital admission depended on the DNR/DNI status. 

This made me recall how I treated patients like Lola before I started this Supportive Hospice and Palliative Medicine training; and it made me thankful that I have this chance to correct my mistakes and thus, learn the uniqueness seen and the fulfillment felt in this other side of patient care.  

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I am one of the five fellows-in-training; under the tutelage of four dedicated Palliative Care Specialists, supported by an outstanding Family Medicine Department, in Supportive Hospice and Palliative Medicine Program, that is only being offered by the best training institution of the country.

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I am learning.

I am willing.

I am thankful.

On Study Leave

There are things that I need to get used to...  There are things that I am missing...

a. Wake up early or else be late. I have always loved lingering for five minutes more in bed before doing the morning routine in preparation for work. I still continue to enjoy that but I have to be awake  really early (four o'clock in the morning, at least) so as not to feel harassed. I am now taking the  long jeepney commute (45-60 minutes) every day to get me to PGH in Taft Avenue, Ermita, Manila from Pilillia Street, Barangay Valenzuela, Makati City. My cousin's place is a relatively peaceful area as compared to the residences I have been to during the home visitations. However, I am missing the five-minute (if I am really in a hurry) or the ten-minute leisure work I used to do on my way to Silliman Medical Center in Dumaguete City.

             a.1. I need to leave the house at 6AM to attend the 7Am staff conference; or leave at 7AM to attend the 8AM activities.
            a.2 I have to shell out ten pesos for the fare when I used to pay 7 pesos and 50 cents for a pedicab ride; or just walk and I do not have to pay anything at all.
            a.3 The smog is in my nose every morning after spending time in the jeepney driven by a frustrated/pseudo-race car driver.
            a.4 I am missing the comforts of my room in Villariza Compound; even the loud neighbors.


b. I have always been strict with how nurses fill up the patient's medication sheet. I cannot do that here, as much as I want to. Why?  Because I am still confused about how the charts are arranged, the forms, monitoring, et al. What I have now is renewed gratefulness for SMC - for the orderly charts; for the diligence of the wardclerks in entering all the diagnostics I need, for the nurse who has carefully monitored the patient's medication and painstakingly filled up the pre-signed prescription forms; for the ECG machine at hand, the laboratory examinations and images that can be accessed with just a password and a click of the mouse and so much more.

c. I used to complain about the elevators of SMC but after spending six days here, I will no longer complain. While in the OPD or in the Central Block, there is always a line to direct the traffic of patients, nurses, consultants, wardmen, and visitors coming in and out of the elevators. I can always use the stairs but my feet is starting to complain from the long walks from the OPD building to the CI to the wards; and from standing in line.

d. I miss the friendly and the usual faces of SMC. Sir Walter of the new elevator; Igpit, the security guard; Allan of the Lab, Cathy in the Info, Neneng and GengGeng of the ER,.....
            d.1 I used to feel like a queen while in SMC but here, I feel so alone and so unsure of myself. I am so scared of what 2011 will bring - running around the halls of this huge government hospital trying to find my way to the right wards; formulating how I am going to take care of this referral; while wondering if I am doing it right, the way the new consultants would want me to do.

            d.2 I am trying to constantly remind myself that there is always a room for change; change for the better. That is why I am in this one-year fellowship training.


Philippians 4:13