The Perks of Being A Junior Clerk

BLOODY WEEKEND.  After two hours of exploring the hospital wards and units, I went down to the ER to embrace the life in that post.  I had observed a difficult central venous catheter placement converted to a bloody cut down of the brachial vein from 2-5AM, then two modified radical mastectomies from 7AM-12:30PM.  But the most heartbreaking part was being at the ER and seeing all those who could not be admitted mostly for financial constraints.

I saw the country in an undignified state. At any one time, the hospitals only see 1% of the entire nation. But even in there, maybe only half (more or less) of these patients are being attended to at any one time. Though I couldn’t fully understand yet how the health system works there and where precisely are the deficiencies, but I could feel the results.

At the OR, I was trying to blend in the background while observing a surgical operation when I overheard a consultant cheerfully address a senior resident in a quiet corner:  “I’m not only telling you what to do.  I’m teaching you HOW to do it. You are a senior. You can make them do what you tell them to.  But I hope that you will be able to TEACH them as I am teaching you now.”

Mentors are indeed real treasures. One does not have to copy his role models.  They are there to suggest designs for his life.  It is up to him to weave the unique patterns of his destiny.  If my hopes and dreams were spread out like well-prepped skin, three years of medical education and training has made a great incision deep enough, that in order to close the wound, certain procedures have to be carried out with finesse.

Of the many perks of being a junior clerk, my favorite is the ability to stand back and take a good look, a bigger picture, of the systems at work around him.  He is expected to learn the principles but not master the procedure just yet. In that way, he doesn’t have to get involved.  He doesn’t have to learn by committing the mistakes himself.  He is a space-occupying lesion, albeit invisible most of the time.  He is like a drape: he sits in the middle of a procedure, with a gaping hole through which all intelligence and skill of a team are passed.  Sometimes he is clamped with the others, secured at the sides; sometimes he goes alone.  But he can only watch and wait—try not to be in a way—all the while absorbing whatever essence drips within reach.

The Shortest Semestral Break

So my friends in school had asked me, “What is a semestral break?”

A sudden coldness swept over me. I looked down and found a shard of ice, like a dagger, had pierced my chest.  My heart sustained a penetrating wound to the right ventricle.  I said I was fine but I knew I couldn’t forever conceal the skipping beats, the slowing rhythm, the increasing discomfort.  The evolution of symptoms has been rather slow relatively. Still, their constellation constitutes an emergency.  My hours are indeed numbered.  And I had done nothing but sleep, fooled into thinking that all those sleepless nights can be recovered.

Every now and then, there’s an unconventional idea that I struggle to silence. On most days I bury it under the folds of my brain, later to exhume and publicize by mouth or by hand. But tonight—just this night—I feel a sudden surge of courage to post a picture of this dreaded thing.

Here comes the sun, a most beautiful one
Off the sheets, into the road, on the run
If you think life’s given you enough shock
Tic toc, eight-oh-one, reads the bundy clock

In a smooth sweep of its hands, the short recess is ended.  The school uniform once again becomes a steady sight, a staple experience on the skin.

Tips for Junior Clerkship (Surgery) in VSMMC (Cebu, Philippines)

Junior Clerkship can be confusing because nowhere in the books is the definite role of the Space-Occupying Lesion absolutely and accurately defined.  Here are some tips to help you make the most out of your Surgery rotation in VSMMC.

1)  Review at least the anatomy of (a) the abdominal wall, including male and female variations; (b) appendix; (c) transverse colon; (d) anorectal region.

2)  If asked to assist in an operation, always read your patients’ charts ahead before scrubbing in.

3)  Observe proper OR etiquette even if not practiced at all times: (a) do not abandon the patient; (b) be on time; (c) be there before the surgeon/s; (d) be courteous to all the staff.

4)  Explore the trees to understand the forest. There are two floors in the OR.  You share these with other cutting specialties (OBGYN/Pedia, Uro/TCVS/Plastics, Neuro, Ortho).  It’s usually easy to identify what department is occupying an area just by looking at the patient’s appearance (e.g. with cast/splint, pregnant, jaundiced) and positioning (e.g. lithotomy).

5)  Know the forest creatures. Except for the senior clerks, it’s pretty hard to distinguish nurses from doctors from utility personnel as they wear similar hides.  If you feel adventurous, be free as a bird and fly.  Otherwise, look for people with the school logo and tag along. The next safest crook is the anesthesiologist’s nest (i.e. anesthesia machine).

6)  Know the forest underbrush. The orange goo for scrubbing makes a brushless wash.  No more irritating iodinated solutions and vigorous scrubbing for those with sensitive skin! Sterile linen comes in the form of a gown.  Don’t look for towels or sheets. Caps can be used to cover shoes, too.

7)  If there’s nothing to do, go up and explore OR-5 (Orthopedics). With permission, go ahead and ask about the procedures and the INSTRUMENTS. Learn what you can.  Your one module in Orthopedics will not prepare you enough to handle patients, assist operations and do paperwork (especially surgical techniques) for such cases in senior clerkship.

8)  When at the anesthesiologist’s area, do not sit on their toolboxes. Familiarize their armamentarium and monitoring schemes. Some machines come with algorithms on malignant hyperthermia. Many patients are unstable or are hypertensive; ask what to do with them. What you will learn here may help you in your anesthesiology rotation next year.

9)  Don’t forget to take a group picture outside the OR.  It’s obligatory.

Life with Bipolar Disorder Type II & Clerkship

Like most patients with mental illnesses, I didn’t know I had something until a critical event occurs that would bring all pertinent signs and symptoms together to reveal the hidden picture.  I used to think that I was simply eccentric since high school:  my ideas often differed, sometimes significantly, from my peers; my concepts and standards usually had been non-congruent with the norms; days to weeks of inconsolable depression and unexplainable high-energy that are degrees more amplified than in peers; and so forth.

In August 2013, one of my consultant-facilitators in my PBL subgroup pointed out the striking incongruity between my Small Group Discussion performance and my exam scores.  He sat with me for over an hour, processing and counseling.  But he was the first person to have observed and suspected that I might just have had a mental condition worth attending to.  He was right.

In November 2014, weeks well into my Pediatrics rotation in Junior Clerkship, the increasing stresses ultimately brought me to the point where my body and mind simply would refuse to rise out of bed and keep going.  My sleep started to be prolonged dangerously.  I would have less time to read my lessons or prepare for exams.  I was constantly cramming and failing—a vicious cycle, which would augment my depression.  And then there had been extraordinary times when everyone would think that I studied medicine for the extracurricular opportunities in medical school.  Despite the packed schedules, I seemed to have time to carry out my responsibilities as an officer in the Student Council, accomplish my tasks as a member of the school publication Editorial Board, maintain an active status (as former officer) in the Advisory Council of my Greek organization, organize intra- and inter-campus events, review classes for the undergraduates, participate in regional and national medical student leadership and reformist activities; the incredible list goes on.  If I had not been a medical student, I probably would have scoffed at (and probably revolted against) the first suggestion of a possibility of a bipolar disorder.

My psychiatrist maintained me on valproic acid maximum dose for about 5 months when stability was achieved and my academic performance improved.  Titration was immediately begun on reaching those end points.  However, on further work up, imaging studies revealed an incidental bilateral Polycystic Ovary Disease (PCOS), prompting withdrawal of Depakote from my regimen and a shift to lithium.

Before the shift, my ability to concentrate and attention span had gradually lengthened.  However, I was increasingly detached from my creative side.  It would take me sometimes days to compose prose for a singular idea, in contrast to a few minutes to a few hours to write a full feature article with multiple subjects.  There had been many times when I would miss my “ups,” when it was easy to communicate and swivel between introversion and extroversion.  But definitely, the abolition of the prolonged “downs” and erratic fluctuations in moods within the day had been profoundly advantageous.

Consequently, the final half of Junior Clerkship had been smooth-sailing.  The next rocky ride was in June 2015, when I was maintained completely on a double dose of lithium and I had to hydrate more than usual to flush the salts off my system as quickly as is possible.  Moreover, my visits had been reduced to at least once annually if without problems.  I was already well into my third month in Senior Clerkship or Junior Internship when such needs just could not be reconciled with the duties and demands.  I lost compliance, consumed my stocks.  My psychiatrist frequently flies out of town; and when she’s here, my 36-hour shifts every other day just would not let me meet her.

To the date of this writing, I am already on my third month off of pharmaceutical or psychotherapy.  I am more familiar of my symptoms now and have improved control.  However, it is impossible to avoid recurrences of the mood fluctuations.  I fear the day when I would recede severely enough for normal activities to be impaired.

Note:  What you have read above had been composed during an asymptomatic period.  Compare with the train of thoughts below.


* * *  D  O  W  N * * *

It feels good to cry one’s heart out every once in a while.  But when it keeps crying out each day and night, at first in a drizzle and then in a burning torrential outpouring—there’s something likely amiss. Starting over seems like a cheerful option when there still remain shards of hope to crush and consume. But when there’s none, let the world mourn until the last gust of wind from the deadest of spaces within can be extracted auspiciously, irrevocably.

At the end of this unlit tunnel certainly is a world of unlimited paths. But as to the uncanny lurking in the darkness is an absolute uncertainty. I lost track counting how many blocks, detours, traps and other surprises we’ve uncovered so far. Certainly, there is that termination of the pathway. The variations of this journey remain with how long each pilgrim has been kept blind and vulnerable on the road.

Battling this disease during a protracted course of extreme physical, mental, emotional, psychological, psychiatric and spiritual stress is probably my most difficult test in life so far. Sometimes, we have limited choices to alter circumstances, limited influence over luck. This solitary adventure has been somehow more difficult than anticipated—perhaps longer for me. Still I look forward to the close of this chapter. Survival is an outcome of persistent choice; but the persistent scars are an outcome of chance and choice.

Despite everything, this, too, shall pass.

*  *  *  *  *


* * *  U  P * * *

First of three days in my Plastic & Reconstruction Surgery elective rotation felt like being in Donna Tartt’s The Secret History. The department has been a curious clique of seemingly detached individuals from a frequently misunderstood field.  The field is a huge world of its own with ill-defined borders encompassing many disciplines. What could be more humbling and inspiring than receiving life advice from the people who’ve finished five years of General Surgery, become fellows in a society, had once been chief residents in their own times?

It’s all about finesse and the details. Beautiful and awesome take time.  I feel at home with the atmosphere of organized thought, structured meetings, intellectual discussions—even for extra-curriculars and hobbies. And somebody has finally said it: do not neglect your hobbies; have a life outside work.

Of hobbies, I have much to choose but little to say:  I miss a life outside this graveyard.  Fortunately so, seven days in Orthopedics & Traumatology—and its eccentricity and dependence on a constant slow infusion of adrenalin—did uplift my spirit.To see is to believe: my first amputation was quite clean and a little dry. But today’s IMN was a bloodbath. For what looks like the “deadest” structure of the body, the bone is as alive as the heart.

To see is to believe: if I had to choose between a cut-down and an intra-osseous, I’d choose the latter.

Some accidents are nasty, some accidents are nice
That I came upon Orthopedics, I’d paid a high price
Exhausting days, exhilarating nights
But ultimately the choice was very wise

After a round-table discussion with residents, I’m more confused than ever: PGH or another university hospital?  For sure, I prefer to earn my lessons; ergo, bone-chilling endorsements and presentations.  This is coming from an introvert who had yet to grow out of social awkwardness.  The beauty of endorsements is this: an open mind continues to learn from either the good or the bad ones.  In so saying, I don’t mind being grilled during endorsements.  The hotter the iron, the deeper the burn, the harder it is to get rid of the new scars, or wisdom.

It has been a privilege to discuss my cases, to assist in operations, to tag along during rounds, to carry out doctors’ orders, etc. I feel luckier than ever to have spent my first two months of internship in the Department of Surgery (including Orthopedics & Traumatology)—here learning can be as visual as it can be, where details, finesse and determination are as important as fooling around just to get rid of the wear from long hours in the operating room.

To my seniors, the staff and my patients, thank you.

*  *  *  *  *