I've never been a fan of the ER. Not so much because of the work involved, but more because of the work environment we always had to bear with at PGH. With our SOD rotation coming up, I wasn't exactly looking forward to it; in fact, I may have dreaded it just a little. I spent most of my clerkship SOD rotation hoping and waiting for that late-night OR assist, which at that point was much more appealing to me than staying in the hot, sticky, smelly mess that was the Acute Care Unit. Unlike in OB or IM where clerks and interns more or less shared the same workload, my clerkship experiences were found wanting in terms of preparing me for my first actual internship ER rotation.

 

I may have started off on the wrong foot; foregoing GS1-Trauma for GS2-GS3 didn't help any in knowing the initial management for emergency cases. But with the perpetual cycle of patients in the PGH-ER forcing the unwitting medical student to either shape up or crash down, it wasn't long before I got into the swing of things. The ATS-TeAna-Cefazolin triad became second nature in our written plans, as well as carrying them out when a patient first arrives. I picked up on the indications for doing certain X-rays and procedures, knowing what laboratory tests to order and the rationale behind them. Whenever the big trauma cases arrived, we didn't even have to think before scrounging around our stash box looking for the appropriate vials and fluids, grabbing the pre-prepared skin test syringes and laboratory requests, before rushing out into the DEM lobby.

 

And before I knew it, I was genuinely having fun. Not just because of the excitement of handling our myriad cases, but more because I actually felt like I was practicing medicine on my own, and feeling like I was doing a decent job with it. Orders soon came naturally when charting patients, from diagnostics to therapeutics to referrals. Some of the simpler cases began bypassing our SOD when he was away from the station, and he would come back surprised yet approving of the plans we'd already carried out. At one point when several trauma cases came in simultaneously, our SOD looked at one patient while I assessed another, then he simply looked over my plans and gave the thumbs-up, letting me and my clerks carry out the orders I'd written down myself. It's also oddly satisfying to be assigned by your resident to supervise your clerks during suturing sessions, when you aren't long past being guided yourself.

 

I'd be remiss if all the credit for my amazing SOD rotation went to the knowledge and experience I picked up; a big thanks also goes out to the most awesome SOD dutymates Rita and Didit, as well as our super-bibo clerks Robert, Den, Sheena, Cla, and Ton (who, I am just the tiniest bit ashamed to admit, have been much better SOD clerks than I was back in my day). But most of all, credit must be given to the best SOD ever, Sir Pat Matias, who has helped me learn and grow during this rotation even more than he realizes. At first it was just the compliments on my suturing that lifted my spirits during our first duty. Later on, it was the vote of confidence whenever he'd say "Pwedeng-pwede ko na kayong iwanan dito, kaya niyo nang maging SOD!" when we managed the simpler cases while he was away. But most of all, it was the way he took a special interest in our learning, ensuring that each patient that passed our way added to our knowledge and skills in some way. There was a time when he specifically instructed me to chart a possible ascending cholangitis patient that we assessed together, and later on he even called me over just to learn about the initial orders for a caustic ingestion patient. The way he was paying special attention to me, I could almost swear that he was actually grooming me to eventually take up the SOD position myself. But even if he wasn't, the trust he was putting in me at that point was more than enough to make me want to do my best. On our last duty, when he exclaimed "Naks naman si Carlos, taking charge!" while I assessed and gave the initial plan for a trauma patient without waiting for his supervision, I'd like to think that there was a hint of pride in those words, that the trust and effort he had invested in me was finally paying off. Whether it was unintentional or a conscious move on his part I will probably never know, but what I do know is thanks to Sir Pat and the SOD experience he gave us, I am finally able to make the decision that's been the longest time coming.

 

Similar to the way this SOD rotation brings to a head all of my surgical knowledge until now, so does it finally bring to a resolution my feelings about the specialty as a viable option. I've always had my eye out for the surgical specialties because the work always seemed so interesting, as well as lucrative. When I later got the idea for Pediatric Surgery, I started falling in love because it melded the interest with my vow to work with children in the future. Despite that, I somehow couldn't fully commit to the idea of becoming a surgeon because I've always been a thinking man at heart. The major hang-up for me was the stereotype that Surgery was a "brainless" field, with the work being more physical in nature, and entering it might make me miss the thinking games I love playing so much. It was only during this SOD rotation that I realized there is still plenty of mental flexing to be done, when it comes to diagnosing patients at the clinics, managing them at the ER, and during crucial decision-making moments during surgeries. But even beyond that, the past two weeks have shown me that I can and do love the work being done here; that despite the toxicity there will be something I can look forward to, whether that's clinical work or performing surgeries or even helping train the next batch of students and interns.

 

Before, whenever anyone asked me what field I was planning to specialize in, my answer usually came out as a vague, non-committal "Pwedeng Surgery po, baka Pedia Surg." But now, I can finally say that I've made my choice. Now, if anyone were to ask me what I want to become, I can look them in the eye and say with all the confidence in the world, "A surgeon".

 

I'll miss my SOD rotation immensely. The adrenaline rush, the people I've worked with, the thrill of acting like a full-fledged doctor, and that incomparable feeling that I was doing exactly what I was meant to do. At least this time, I know that one day I'll definitely be back here again, doing the work I have come to love.

 

 

 

 Till then, this is The Best SOD Team Ever, signing out.

 

october 30, 2010. 10:30 am. united nations avenue.

  

  

an accident. a freaking car versus truck vehicular accident. with last week's breakdown in quezon avenue, this makes two unbearably idiotic car incidents in the span of 8 days. 

 

first things first though, i'm perfectly fine. i'm nursing the bruised ego more than the slight bump to the head, so no need to get too concerned. now, if you're wondering what exactly happened, i think i'll let the pictures do the talking.

  

 

 

 

 

 

 i've already given my explanation more times than i would have cared to earlier today, so i'm just a bit too sick and tired to retell the same sad story over again. suffice it to say though, all accidents have a component of blame on all parties involved, possibly one side over the other. i certainly won't gloss over the whole thing and say that there wasn't any fault on my part, but you won't get any other admission from me.

 

what they say about accidents is true: you replay the events and decisions that led to it over and over in your head, thinking of what might have been done to prevent it. maybe i shouldn't have left the hospital early, the quiapo route should've been taken instead of nagtahan bridge, some rash and hasty decisions might have been better off not being made. thinking about it, had any one of these factors been changed, the entire thing certainly would not have happened. but the thing is, stuff happened, decisions were made, and this is the result. no amount of pondering and regretting is going to change that.

 

all i have to hold on to now is the bittersweet thought that things could have been much, much worse. the damage to the car is mostly cosmetic, and grossly limited to the front driver side bumper and fender, letting me drive away without further incident. if the wheel or axle was busted, or if the engine was hit, i wouldn't even have known how to bring it home. looking at the pictures now, if it had been just a split second more or a meter away, the truck would have hit exactly on the driver side door, and i might not be so lucky to be typing all this right now. 

 

i've already let the incident simmer inside, but despite that inkling of a positive thought, my emotions are still roiling right now. a bit angry (at myself more than anyone else), definitely pissed (at my life in general), but still, it's mostly guilt and shame, particularly towards my dad. this is the second car incident i've had to hassle him with, not just financially but also with his time and effort, as well as the anxiety i can only imagine i've caused. and to top it off, he's been extremely cool about everything, hardly the typical reaction i'd have expected from him. so dad, if you get to read this, I'M VERY VERY SORRY and THANK YOU.

 

in the end, i guess the best thing that could happen in a situation like this is if i can take something away from it all. with that, let me end this cathartic entry with a few personal realizations, or "life lessons" if you will, that i'm only writing down here so that every time i read them in this note, i can make sure to hammer them hard into my mind.

 

1. the great big someone in the great big upstairs is still looking out for me.

2. i know i'm a bad driver sometimes. obviously i have to fix that.

3. despite the age, the fancy walk and talk, or even all the medical knowledge in the world, i'm still a little boy inside, who knows next to nothing about surviving in the real world. 

4. better learn to start doing things for myself.

here goes my first official entry to our humble online writer's guild, organized by no less than myke. and can i just say, he played the role of cool, calm, and collected chic (chief-in-command, if it sounds weird) while he was agonizing over my deathly late contribution.

it's a bit lengthy, but all in my classic writing style. hope it's as fun a read as i think it is.

**

The Rush of Chopping Bodies

As I made my way up the stairs of Calderon Hall, the familiar stench of formalin was already strong in my nose. Lucky for me, the stinging odor never made me want to spill my stomach, even after having a hearty lunch like I had just minutes before. But sadly, not even 3 months of near-daily exposure could see me get used to the fumes, resulting in watery eyes and a runny nose just as I stepped onto the third floor landing.

The scene in front of my eyes was exactly as I expected: my classmates milling around the lockers and benches, some chatting, some studying, some even having a sing-along or dancing, but everyone clearly trying to avoid entering the dissection room before we absolutely had to. With everyone wearing scrub suits in all sorts of colors and patterns, it was a veritable carnival in there. I made my way to my lockers, where Migz and Jenny, two of my three lockermates, were waiting for the keys I kept in my bag pocket.

"Good afternoon, Ibn. Tagal naming hinihintay yung susi ah."

"Hehe, sorry Jenny, nakaiglip pa kasi ako sa condo bago ako pumunta dito eh. Eto na, eto na o." My Lionheart keychain clanged against the metal locker doors as I hurriedly wrenched both of them open. Bags, books, and clipboards went into the empty locker, while scrub suits, gloves, and masks came from the one laden with lab equipment. Taking off the stuffy top of my med whites, I stood there in my sando, relieving a bit of the heat while enduring taunts of "Ibn's so hot!" and "Ang hot naman ni Ibn!" from some of my friends. Finally donning my Monopoly scrub suit, I turned to Migz just before entering Dualan Lab.

"Ano bang gagawin natin ngayon? Skinning pa lang ba ng thorax?"

"Ang alam ko din un lang eh. Pero baka buksan na rin natin ung rib cage, para makita na natin ung visceral organs. Exciting 'no?"

Bracing ourselves, we opened the door to the dissection room. If outside, the air was thick with formalin fumes, then inside it was as if we were being dunked into a tankful of the vile preservative. Double-layer masks and scrub suits were hardly any use, since the smell soaked well through them into our undergarments and skins, such that wearing them has become merely a formality. Migz headed off to his table, while at Table 1, most of my anatomates were already preparing. Mike was clutching his Netter as if safeguarding his most prized possession, and most likely the book was, while Mich and Gillian were already outfitting our scalpel handles with new blades. Zan would most probably be late, while Jasper would be out performing his Liaison Officer duties. I gave everyone a hearty smile before positioning myself by the head of the dissection table. "Tara na?" I said as I peeled off the blue vinyl sheet covering our Mang Caddy.

Even now, the sight still brings a little shock, and a great deal of awe. A 5'5" male was sprawled on the table, knees bent to the right, but you wouldn't likely take him for an old man taking a nap. In places where it was still intact, his preserved skin showed, tough and brown like tanned leather, while the rest of him was wrapped in aged pieces of gauze, much like the reviled cursed mummies of Egyptian lore. Unwrapping his arms and legs would show the isolated muscles, vessels, and nerves of his appendicular system, not so masterfully picked apart but sufficient to get us past the first anatomy lab exam. If anyone cared to remove the cloth binding his head, they'd find a skull neatly sectioned into three: the calvarium neatly sawed off to reveal the brain and the floor of the cranium, while the facial aspect was clean cut through the middle, best to examine the interior of the nose and the oral cavity.

All around the body, leftover bits of past dissections lay scattered about: a left clavicle, a patella, the angle of the jaw, pieces of his outer ear, and one eye, with the eyelid and nerve still attached. Various metal implements were also arrayed on the table by the head, the function of each left to the grisly imagination of an uninformed observer. It was as gory a horror scene as one could imagine, but made a little more normal by the fact that 26 other tables held exactly the same macabre sight, if not worse. Also, it could hardly be called gruesome with all the med students loitering around their respective tables or jumping from one group to the other, nonchalantly chatting away, oblivious to all that was before them.

We were just about to get into small talk of our own when the sound system let loose a blast of feedback that served to silence the entire hall. Doc Ryner stood on a platform on the far side of the lab with a hastily sketched chest with guide lines on the whiteboard behind him, a diminutive king addressing his subjects, with the royal crest glaring at the back. "OK guys, today we're going to open up the rib cage. Start skinning the chest of your cadavers and identify the pectorals and intercostal muscles, then our lab technicians will be going from table to table to break open the chest. Feel free to ask questions to any of the consultants in the lab. Remember, hanggang 4:15 lang tayo magtatrabaho ah. Good luck."

Without any delay, we set about to it. Wielding the scalpel and kelly scissors like weapons I've worked with for years, I deftly scored Mang Caddy's chest right along the middle until the end of the rib cage, then sliced down to either side, exposing the muscle layer beneath. Mike and I then proceeded to separate the skin from the underlying fascia on the left side, while Mich and Gillian worked on the right. In no time at all, we were already referring to the images in Mike's Netter for the names and locations of the many-layered intercostal muscles. We were probing between the third and fourth ribs to isolate the muscle sheets when Gillian's scalpel went through the fibers cleanly, entering what seemed to be dead space. We let loose some automatic shrieks and shouts, fearing what structures we might have macerated beneath, but a quick finger through the gash assured us that nothing lay directly on the blade's path. Curious to what surprises waited inside, we tried to sneak a peek through the hole but the darkness covered everything. With our curiosity piqued, I sought out the nearest lab technician, Mang Boy, and got us next in line for the ceremonial chest chopping.

I could barely contain my excitement when Mang Boy finally came to our table, bizarre power tools in hand. He shooed us away from our cadaver, holding a dull metal blade like he meant business. He immediately went about to hacking the sides of Mang Caddy with that vile tool, slicing through flesh and bone like a hot knife through butter. When a rib proved to be particularly troublesome, he took out yet another implement, a set of pliers but with sharp-edged pincers that looked like they could section your fingers with hardly any effort, and snipped away at the stubborn bone. The right clavicle was pried away from its socket with such force that the surrounding muscles were ripped along with it. The bottom of the chest section was similarly sliced, until the entire anterior skeleton was hinged only at the top, looking much like an eerie breastplate.

For the sternum, Mang Boy brought out the grand daddy of all dissection tools: the circular power saw which was also used to open the cranium. Using the saw meant that someone had to constantly apply water to the blade using a syringe to avoid bone dust flying everywhere, but the slightest bit of affection for your fingers easily made everyone shy away from the task. Luckily, Jasper arrived just in time and took the syringe for himself. The saw was switched on, emitting a dreadful screech fresh from the depths of hell, and it ran through the fleshy exterior easily until it met resistance: the scalpel hiding under all those chest muscles. Weirdly though, the scent of bone being crushed and pulverized by the whirring teeth of the saw reminded me of bread baking in the oven, giving me an untimely craving for pan de sal. Away the saw went, slowly inching its way through the sternum, while I watched on in maddened fascination.

Then it was done. Mang Boy slashed through the last few fibers still attaching the breastplate to the rest of the body, handed the plate of muscle and bone to us, then headed off the the adjacent table for a repeat of his gruesome yet enticing performance. I took in all that lay before us, two soft, mushy lungs with a speckled appearance, like gigantic marshmallows made out of granite, and the heart, the once-thought-of seat of all emotions, just as it was illustrated in all our anatomy texts, great vessels and all. If I was amazed at the way by which these structures were exposed, it was nothing compared to what I felt seeing those marvels of human architecture up close. My heart pumping, I picked up the closest scalpel and scissors, inching my way towards the heart. "What might I find inside?" I asked myself, as the blade cut away the translucent sheets of fibrous tissue surrounding the organ. "There'd be valves, and muscle fibers, and I can trace the pathway of blood..." The edge of the scalpel pressed against the apex of the heart, collapsing a hollow yet rubbery wall. Just a little more pressure and the wonders of the human heart would have been mine to behold...

DING DONG!

My mind woke itself from that frenzied trance, suddenly aware of my surroundings. The warning chime at 4:15, the signal to clean up and pack, always brought with it horrible memories of anatomy lab exams past, where the same sound would command us to halt whatever we were doing and move to the next number. I looked around and saw my fellow dissectors already preparing to leave; scalpel blades were being removed and deposited into the clear plastic bottles meant for such use, the cadavers were being sprayed generously with Lysol and slathered with petroleum jelly, gauze, sackcloth, and the blue wrapping were going back on, people were stripping off their gloves and untying their masks, and on the way out of the lab were starting to resume idle prattle where they had left off. My anatomates and I did the same, and when I finally stepped out of the lab, I heaved a big sigh of relief. Another lab session down.

Despite all the excitement and exhilaration I derive from our dissection sessions, they always leave me more tired than necessary afterwards. It might be the stress of having to identify all those structures and parts thereof, all the manual labor we have to perform, or just being exposed to formalin for three hours straight, but I am always glad that lab sessions end as they do. Which then leaves me looking forward to the next dissections to come.

But then, that excitement for another time. I quickly shed my scrub suit, got my stuff from the lockers, and ran back down the steps of Calderon Hall. Medrhythmics training was scheduled for that afternoon. And that's another rush all on its own.