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. =)

-0-

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.  

-0-

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.

-0-

I am learning.

I am willing.

I am thankful.

19th Annual Convention of The Pain Society of The Philippine Slideshow: Rowena’s trip from Makati, National Capital Region, Philippines to 4 cities Quezon City, Legaspi, Naga and quezon province, philippines (near Valaire, Loire Valley, France) was created by TripAdvisor. See another France slideshow. Create a free slideshow with music from your travel photos.

JuLius =)

Choice

I made a choice and I keep making it every day.

Before I said yes to getting married, I asked my learned family and friends:

"How can I be sure if I am marrying the right man?"

"How would I know that I won't end up with a broken marriage?"

 

Why the question?

I needed to know. I wanted to be sure.

I thought that by getting answers to these questions would give me the space to spare my future children of any aches and pains of quarreling parents, crazy neighborhood talks, going home to an empty house or being sent to live with relatives.

I know that having a wedding is just one thing;

Being married and staying married is the REAL THING – the CHALLENGE.

The wise words of Tito Lando –

"Aweng, you can never be sure; what is sure is the constant grace and faithfulness of God's Love."

 

A leap of faith.

On September 12, 2009 at nine o'clock in the morning, with the waters from Maria Cristina Falls as our background, I got married to Julius, surrounded by family – and it was such a thrill.

 

I thank the Lord for I had spent five hundred forty-eight
days and nights
with him and still counting.

The days were not always perfect. We have our disagreements. He has his own quirks that I am still trying to make sense of, in view of the whole person who is Julius.

But on perfect days,

I know that I have a

chef,                                     provider,                     

companion,    special mention sa kaon;
    with an appetite like mine

                             friend,

supporter,                         comforter,

"schoolbus,"                "pusher,"             cheerer,

husband and a lover.

All For Free.

No hidden deals or charges.

Just an extra measure of patience, care and mega-prescription from the heavens…

 

I constantly pray for the lord to bless us with an enduring love for each other.

For 1 corinthians 13

To celebrate the depth and tenacity of love

that will carry us beyond self-interest and mere affection.

W.e.d.j.i.s.2.r.m.g.t. Slideshow: Rowena’s trip from Dumaguete, Negros, Philippines to Iligan was created by TripAdvisor. See another Iligan slideshow. Create a free slideshow with music from your travel photos.

September 12, 2009

http://tripwow.tripadvisor.com/tripwow/ta-0101-c094-0450?ln

The Costs of a Hospital Admission

My husband underwent total thyroidectomy on a Thursday morning for a thyroid nodule.

First, as a wife and second, as a doctor, the possibility of a neoplastic disease is a major concern. Although, literature suggests that majority of the solitary nodules of the thyroid prove to be benign and carcinomas account for less than 1 percent that represents 15,000 new cancer cases each year. A review of clinical criteria relating to the nature of the given thyroid nodule showed that (1) in general, solitary nodules are more likely to be neoplastic than are multiple nodules; (2) nodules in younger patients are more likely to be neoplastic than are those in older patients (my husband is 34 years old); and (3) nodules in males are more likely to be neoplastic than are those in females.

Economics of finances and time, initially, pointed us to postponing the surgery. We have PhilHealth, no HMO and a shaky Hospital plan. However, when I took a good look at my husband's eyes, I saw the fear and uncertainty. I tried to comfort him with the result of the morphologic evaluation in the form of the fine-needle aspiration biopsy, even as I know that the histologic study of a surgically resected thyroid parenchyma would provide the most definitive information about the thyroid nodule.

We prayed for guidance, armed ourselves with God's infinite resources; we took a leap of faith and proceeded with the surgery.