(Snippets of a) Life with Bipolar Disorder Type II & Clerkship [Part II]

I’m not lazy. I just don’t feel right. How can one pick a diagnosis from an intelligently collected pool of differentials, and then prepare to defend the chosen working impression when the mind refuses to stay, jumping off from isle to isle? And it goes on for days and days until physical and mental exhaustion cuts the trip. Those consecutive days of insomnia, guilt and diffuse anxiety end with short periods of relaxation and well-being. But the paperwork has been put off for an excessively long time and it is but too late to rewind time back to the deadline.

I’m not lazy. I just don’t feel right. Sometimes, when I talk to my patients, I’m surprised at the changing and stumbling pattern of my questions and physical examination. Routine often is a foreign, if not nonexistent, phenomenon. Every day is a new story in itself, requiring a constant revision of approach and perspective. At the end of the week, I don’t trust myself enough that I have mastered a system, or that I have woven a style to increase my efficiency as an interviewing, thinking, composing and monitoring machine.

I’m not lazy. I just don’t feel right at all. When I am unable to sleep for the whole of the 36-hour shift, I get cranky, groggy, weak and vulnerable to many insults—be they aimed intellectually, emotionally, psychologically, etc. After all, I am human, unadulterated by steel or ice. Like my characters in most role-playing games, my Mana and HP bars can be drained to dangerously low levels; and I am susceptible to functional disability and paralysis, if not death.

Missionaries of the Poor: A Reflection

THE ASCENT OF THE MORNING SUN signaled the start of the routine in the Missionaries of the Poor. Those children probably weren’t expecting visitors in white each day.   They ate their breakfast of enriched porridge from plastic or tin dishes or they waited patiently in their cribs for the House Parents to feed them; either way, they carried on.

We arrived at around the ninth hour, together with our medical post-graduate intern, five rehabilitation interns and their field instructor. The instructor (she had the key) opened the prospective clinic, ushered us in; and we went through the rooms methodically, surveying which room felt more comfortable for consultations for a different flock of sick people, mostly the elderly and the very young. As the day wore on, patients slowly came in queues then dissipated in two’s or solitary shadows. In a couple hours, I got to talk to two or three patients about their medical condition(s). We shared a quick lunch with the interns, our faculty and clinic staff around a long table, small talk, and bits of information about our patients’ progress. Then we checked on—or more appropriately, played with—the children in their cribs or in a spacious hall.

That was to be our routine for a week: a total of four trips to the place.

My first encounter with the children of the House brimmed with mixed emotions. Because I came fresh from a dermatology rotation, Family and Community Medicine at first felt like an offshoot of Internal Medicine, because in the Philippine setting, basically, the only fine line demarcating the fields lies ultimately in the patient’s physician preference. So I was completely unprepared to deal with the pediatric population, or worse, developmental or congenital disorders.

The more time I spent with the children, I slowly understood the necessity of pathos to appreciate or highlight the blessings received by humanity. Every smile those children with Global Developmental Delay and Cerebral Palsy made was a manifestation that even such state of physical disequilibrium can be overcome by a far greater force. Each time that infant born without eyes squirmed, babbled and cooed was a manifestation of the optimism of man to see through and survive any kind of darkness. Every time a child poured a tablespoon of yak and rice gruel into his mouth was a display of victory over the struggles that define man’s journey on earth. The longer I stayed and played with them, the better I understood that another even more powerful language unlimited by syntax, vocabulary or diction, Love, ever truly exists.

Maybe this is probably why the Brothers of the Congregation chose to hang the proverb about seeding happiness into a world where there is such scarcity. For maybe to those people who’ve spent years of study, deciphering the elusive mechanisms that characterize the children’s illnesses, happiness has become a distant hope where an indefinite dark horizon spreads over the future of those little lambs. Despite everything, that hope however far continues to shine and illuminate the world, like millions of tiny stars sprinkled over the dome of the night sky. So that even for that little girl who may have never seen a ray of the Sun, perhaps that tiny light of hope that grows from the seeds of compassion is enough to erase all malignant doubts in her heart and enable a most genuine smile to grace her beautiful small face as she turned her head towards the sound of my voice.

Hello there, little one,” I announced my presence. In a couple hours, I would reach out to enclose her little hands in mine again, and this time, to bid goodbye.

As a medical student, I worry about prognoses of the conditions I have witnessed. As a daughter, I worry about the future of the children and their biological families who may not have the courage yet to face the full magnitude of pain unconsciously inflicted upon those innocent souls. As a person, I worry about the uncertainty of men’s hearts and the frailty of the human body. And then I wonder, too, about the generosity in others, in the abundance that keep coming forth from nothing, like a spring of water emerging from a fault in our lands.

It’s incredible how those half-days stretched to seem like a fortnight of worry and wonder. At the fourth or fifth hour of the day, we return to our main affiliate hospital, our minds pregnant with worry and wonder, and our hearts with hope and compassion.

I have been to a number of immersions before, both in college and in medical school, and across the nation. I have tried my hand at political and economic approaches in community development. Most recently—just last school year, I have set my interests on public health and public policy in upgrading socioeconomic systems and the quality of life of the common Filipino. I have listened to those valiant youth and physician-leaders, who have chosen the mountains over hospitals, the marginalized sectors over the privileged urban districts. Yet in spite of everything, this experience with the Missionaries of the Poor remains a most strange encounter with the human and ethical practice of medicine.

Photo credits: Ms. Aizie Lee Lagare, Physical Therapy Intern

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.

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.