I'M glad my second year of residency is over.
Last few days as second years
Since the start of the year, I've transferred to the Senior Residents' Callroom (SRO), literally in the landing between Wards 1 (on the first floor) and 2 (the Surgery ward, on the second). Just when I thought the Second Year Callroom was going to end up in my book as the best quarter of my residency years—we transfer callrooms every year, if that isn't obvious to you yet—the SRO has emerged as the eventual winner: it's more spacious, it has a bathroom of its own. Natural light seeps through in the mornings. The PGH Wifi connection is arguably faster, too.
I inherited Kevin Bismark's desk, a testimony that he has lived his final year in IM with travels, trips to the dentist, and a lot of studying. I had to set some of his things aside to let mine in (he is, as far as I know, still traveling): a few books, my laptop, toothbrush, a desktop sharpener, a collection of pencils inside a Malacañang mug given by an OPD patient, my actual coffee mug given by a different patient now dead—the same patient who called me "the best doctor in PGH" and gave me a plaque for it. Embossed on it is his artistry: he made caricatures with colored glues on various surfaces for a living, and despite being easily fatigued, he took the time to remember me. I miss seeing him in my clinic. You'll see another plaque, too—one that bears "Best Doctor in the World," which my aspergilloma patient gave me two years ago. I don't believe that I deserve these plaques at all, but I'm grateful. Truly.
ONE thing that excites me in Toxicology is the ringing of the phone and what the other person on the other line might ask next.
I've been manning the National Poison Management and Control Center since the start of the month as part of my rotation in Toxicology. The duty schedule is hectic for my senior year—24-shifts every three days, with no true post-duty (or "from-duty," as my non-PGH colleagues say) status. My stay entails that I provide telephone support and medical advice to physicians and laymen all over the country about all things related to poisoning. This means, of course, that I must know the active substances of popular products. My knowledge, I've realized, is limited. Thankfully, however, beside the three phones in the office are the Pandora's boxes of precious toxicologic knowledge. Whereas online databases can only give us so much information, this collection of 6x8 cm index cards, many of them dirtied by the patina of time, provides the answers as to the active ingredients of katol (pyrethrin), Johnson's cologne (phenoxyethanol), and glue gun (non-toxic at all).
I've received calls about a farmer who swallowed a sachet of pesticide after fighting with his wife. Many such ingestions fill our daily census, which the office forwards to the Department of Health at the end of the year. There are cobra bites in Bohol, sodium hypochlorite (Zonrox being the most popular brand) ingested by depressed people all over the country, noxious gas exposures of elementary school students in Central Luzon, and, the most memorable of all, a petroleum ingestion by a cat owned by a horrified, distressed young lady.
The most important detail I ask is the type of poison, if the substance is poisonous at all. The next details I ask are mainly related to the circumstances leading to the exposure: whether it was accidental or not, where it happened, and how the patient was doing. The rest of the information are for the completion of our census.
Receiving calls from complete strangers feels like being a night-time radio talk show host. The simile stands: people really phone in to get sound advice, knowing they'll get better with the knowledge that an expert has heard and processed their concerns. I suppose, if we broadcast these calls—barring expulsion from the practice of medicine due to disclosure of confidential information—we'd be a hit. Imagine the possibilities: The Toxicology Radio Program! You have broken hearts? Don't swallow a thousand of those pills—just give us a call!
YESTERDAY was my first Adult Medicine CAT presentation, as senior, with Jaja Saliba, Butch Roque, Berbi Berba, Josh Cruz, and Racquel Bruno (in absentia). We tackled mortality in transfusing short- versus long-term storage blood . A great, fruitful discussion. (There's no difference in mortality rates.) It was also wonderful to have Dr. Tony Dans back.
 Heddle et al. Effect of Short-Term vs. Long-Term Blood Storage on Mortality after Transfusion. N Engl J Med 2016; 375:1937-1945
Some words or catchphrases—many of them made up—sound terrible to me; therefore I’ve endeavored never to use them, except now, where I list them:
- millennials — Just another word, I suppose, for self-absorbed people. I think this distinction—calling people Generation X, Y, or millennial based on the year they were born—is all made up.
- netizens — I prefer “internet users,” or “people” in general. Everyone I know has encountered the internet at some point.
- twinning — Use “twins.” This is acceptable, though, when talking about some process after fertilization.
- adulting — It sounds so immature. I’ll only use this if pediatric-ting becomes a thing, too.
I discovered another quiet coffee place. It has wide, wooden, tables; chairs of the right height; adequate lighting; tolerable internet connection. It's devoid of noisy teenagers and hipsters. As with most shops, it offers discount cards, and this one was too beautiful to pass up. We live in a beautiful country. That's something we don't thank God enough for.
WE get all sorts of referrals in Toxicology, where I’m rotating for a month. They're mostly non-accidental ingestions of people going through depression. One night, though, we received two referrals at the Pediatric ER. Two children, both around eight years old, were brought to the hospital because they had batteries lodged in each of their right nostrils. This was an actual battery that our friends from ENT took out. I hope the kids learned their lesson. But kids being kids, they probably didn't.
Net, my youthful aunt, sister of my mother, texted me, “Can I call you?”
“Sure,” I replied.
“She’s trembling, Lance—your Lola Ugól,” Auntie Net, the librarian, said. Lola, in her early eighties, has been intermittently living with her in General Santos City, about an hour’s drive from Banga, South Cotabato, where our ancestral home is. Auntie Net would pick her up on weekends, then bring her back after two weeks or so, where Lola could be near her farm and friends.
“Has she eaten anything? That’s probably hypoglycemia,” I said. “Tell Lola to munch on a candy or drink a Coke.”
The Metro Manila Film Festival selection this year has been a pleasant surprise. For the judges to have done away with awful romantic, formulaic films, to have finally gotten rid of the recurring Filipino-Chinese family-problem themes (after, what, six or seven sequels?), to have censored supposedly funny superhero films whose only redeeming quality had been the large, gaudy entourage during the Parade—they have finally realized (or they’ve done so long ago, but only had the guts to do something about it now) that Filipinos, too, take pride and joy in watching sense and intelligence and good humor. Id est, good films worthy of our 200-plus-pesos tickets and a little less than two hours of our time.
I pleasantly whiled away time at the local cinemas and didn’t mind the long queues—I had, after all, a book, which temporarily removes any need for human company. This is how I prefer to watch movies: alone, lest I disturb the people around me. I have coffee or tea in between movie breaks, so I’m able to watch the next film in line without so much as a yawn.
I haven’t really favored the dichotomy between “indie” and “commercial”—they’re all films, and if they’re good, they’re good, regardless of who had produced them. There are awful indie films and commercial films; there are pretty good ones, too.
Die Beautiful was hilarious and depressing at the same time. The crowd in the cinema howled in laughter. The man beside me, a college student in shorts, couldn’t restrain himself—I surmise that popcorn must’ve exploded from his nostrils. For a film that shows gay people in loud costumes, the movie surprisingly offers a sensitive approach to understanding the LGBT community: that they struggle with mockery and hatred; that they yearn for so-called love that society refuses them; that they are human beings, too, sinners like all of us—yet another testament to Pascal’s statement that there is a God-shaped vacuum in every man that only God can fill. They fill it with romantic love, ambition, and vices; only to realize that these cannot give them lasting joy. We Christians will benefit in watching the film, if only to realize that there is an entire community before us that needs the gospel. There are expletives, references to homosexual sex, but overall, these have been included in the script with restraint and care.
Saving Sally was a delight to the eyes. Ten years in the making, the animated film is worth the wait. The conversations are carried on in English—Filipino English, not the forced “Americanized” accent—that actually sounds normal. There’s not much to the story: a boy falls in love with a girl and saves her from her evil parents. But the novelty of seeing walking monsters, the house on top of a steep hill, the school whose façade resembles UP Diliman’s Quezon Hall, was fun.
Seklusyon was scary. Four would-be priests, a girl who spews what looked like abodong pusit paste and who performs miracles, a beautiful but indifferent nun beside her—all these in scenes shown in sepia tones—made for a startling experience. Of course, the doctor in me made me diagnose the illnesses of the sick (“Ah, acute symptomatic seizure, probably secondary to a primary seizure disorder, rule out metabolic causes” when a 20-year old man was brought to the albularyo girl). Watch this with friends who hate horror; they won’t be sleeping after. But I suppose no film, in my experience, has scared me more than Sadako.
Ang Babae Sa Septic Tank Part 2 was a riot. Eugene Domingo is one of my favorite actors: hey, I watched Kimmy Dora Part 1 thrice, in cinema! Oh, how that lady can act! She now has a Spanish assistant who fetches water for her and serenades her with his guitar. The humor is intelligent, which doesn’t diminish it at all. More, more movies please, Eugene! And that ending!
Go, watch. These are good films.
Tim Keller, who pastors Redeemer Presbyterian Church, is interviewed in The New
Yorker York Times ("Pastor, Am I A Christian?"). He's asked:
What I admire most about Christianity is the amazing good work it inspires people to do around the world. But I’m troubled by the evangelical notion that people go to heaven only if they have a direct relationship with Jesus. Doesn’t that imply that billions of people — Buddhists, Jews, Muslims, Hindus — are consigned to hell because they grew up in non-Christian families around the world? That Gandhi is in hell?
Read his wise response here.
John Bloom, one of my favorite bloggers, writes:
This Christmas, do not be surprised if you find yourself worshiping Jesus where you did not expect to find him.
He goes on to write that Jesus has always broken expectations. He ponders on the meaning of the celebration:
Jesus came into the world at a desperate time in a desperate way. It wasn’t the way people expected him to come. It wasn’t for the reasons they expected him to come. He did not come to meet their expectations but to love them in the ways they most desperately needed.
For Christ, Christmas is not about tradition but salvation; it’s not about expectations but sanctification. Christmas is about love — earthy, gritty, sacrificial, even bloody love. When Jesus came, he did not come “to be served but to serve, and to give his life as a ransom for many” (Matthew 20:28). This was a love that no one expected — a love that exceeds all our expectations.
And this is the way he comes to you this Christmas: to love you in the ways you most need. That may, in fact, be why some of your expectations are not met: they aren’t what you really need.
I DRAGGED my friends Karen Montevirgen-Mondragon and Jay Magbojos to Solidaridad, the quaint, quiet bookstore owned by the writer F. Sionil José. It's in the neighborhood, near the intersection of Bocobo and Padre Faura Streets, a private store that sells books, albeit more pricey compared to their counterparts at National Bookstore. But I always like the sweet smell of books, both old and new, and the classical music—mostly Bach and Mozart—that plays in the background, so I always visit when I have the opportunity.
One can find rare books in the store, even those published by NYRB, like this essay collection by Max Beerbohm, which I shall buy next.
I must confess that I've never read any of Mr. José's books. I don't know why, but I should really find the time.
As doctors we commit to decisions that mean life or death. I suppose, given the variety and severity of cases we—internists-in-training—see every day, this is inevitable. How must we wrestle with the daunting task of taking care of several critically ill patients and deal with the fact that we only have one or two vacancies in the Medical ICU? Who should we prioritize?
Dr. Flàvia R. Machado’s piece illustrates this peculiar dilemma. It’s a worthwhile read.
We begin another day at 7:00 a.m., and once again we need to decide who will get an intensive care unit (ICU) bed after an elective surgical procedure. A 55-year-old grandmother with colon cancer? An elderly man with liver metastases? A young woman suffering from pain who needs an arthrodesis to keep working so she can continue to feed her family? Should we choose or deny patients because they have cancer? Should we choose on the basis of age? On patients’ previous quality of life? Or on social impact, if, for instance, one patient has four children to raise? Should we give the bed to a patient whom we’ve already had to refuse once? Or should we perhaps just stop playing God and give it to whoever asked first?
Every day, all around the world, intensivists face such cruel choices. And deciding which patients will have elective surgery is not even our most hideous task; emergency admissions are far worse. Death is probably not imminent for a patient who is denied the chance to have a tumor removed, but some patients will die without immediate intensive care to sustain their lives.
Poverty is shocking, but social inequality may be even worse. Social inequality is the hallmark of middle-income countries, which usually have two distinct health care systems, one public and one private. How can we advocate for equality in health care, treating all patients the same, if not everyone is starting from the same place?
 N Engl J Med 2016; 375:2420-2421
PRAISE be to God for a great time during the seniors' Christmas Party. So much laughter, games, and food.
Seafood paella by Roland Angeles. Paella disarms me all the time.
Roast chicken by Carlos Cuaño. So tender, juicy, flavorful—best served with a squeeze of lemon.
And, hands down, one of the best pastas I've tasted: squid-ink noodles smothered with crab fat (alige) by Roland.
Not in photo: crispy lechon.
After that: a series of crazy games (newspaper dance, trip to Jerusalem, bunong braso) that left us all tired, in a happy kind of way.
I went to residency to train and not to make friends. I guess it's an added bonus that I've made good friends along the way.
MY PARENTS crave Filipino food. It's not a proper meal, for instance, if there's no rice served. We can convince Tatay to try other cuisines; he has liked Korean, Japanese, and Thai thus far. He takes photos of the things he eats. If he had grown up in the time of Instagram, his feed would be busy. Mother, on the other hand, can't be bothered—she loves her fish and steamed/boiled vegetables—and can't tolerate beef. The smell makes her nauseous.
I went home one day from the hospital to find that they hadn't prepared anything for dinner yet; they had just flown in from Mindanao to pay a visit to Mother's doctor. The default eat-out place is Provenciano along Maginhawa Street, now home to many restaurants, its popularity as a gimmick place (do people still use that word?) having grown these past years so much so that the traffic gets congested during pay days and weekends. Thankfully it's just a few blocks away from where we live.
We had the pansit molo (delicious!), pinakbet, and I couldn't recall much else. We love the seafood salad drenched in acidic vinegar.
We're regulars in the place; my father is now "friends" with the headwaiter, who gives us the best seats when we're around.
YOU'LL notice that I've switched fonts again. I'm now using Roboto, designed by Christian Robertson, made freely available at Google Fonts. From the foundry:
While some grotesks distort their letterforms to force a rigid rhythm, Roboto doesn’t compromise, allowing letters to be settled into their natural width. This makes for a more natural reading rhythm more commonly found in humanist and serif types.
On our last Physician-on-Duty (POD) duty, Racquel Bruno—Executive Officer of the Department for 2017—and I were bogged down. Many admissions for the night, many responsibilities awaiting us, and many meetings set for the next few weeks were running through our heads. We were going to be seniors when the clock struck 12.
But we started our first day as seniors with a hearty breakfast with our interns JB Besa (whom I’ve been calling President; he heads their batch), Paolo Torres (who had ample time showering and changing clothes), and Gelo Tampus (who also took up Molecular Biology in undergrad). Overworked, never-paid; they helped us take care of our numerous, critically ill patients at the ER. This was the least Racquel and I could do for them.
WE FOUND a new after-morning Sunday worship service spot—Kandle Café, along Mother Ignacia Street, Quezon City, a five-minute walk away from church. It opens at 11 am. We were the first customers, and the place was devoid of hipsters, noisy teenagers, or Filipino families with noisy, crying children—crowds one would do well to avoid if one desires peace, quiet, and a short nap. It goes without saying that I only had three hours of shut-eye last night. I understand the place gets jam-packed on the weekdays, so we had come at the perfect time.
The internet is reliable, there are sockets all over, the tables are at about the right height: tell-tale signs that this will become a popular spot for people studying for board exams or periodical exams. Coffee shops, even restaurants, have become modern-day libraries.