The Intern

Since I am in a spirit of "marriage" this month , this is my favorite poem about marriage, (second to I corinthians 13 about love):

On Marriage
Kahlil Gibran

You were
born together, and together you shall be forevermore.
You shall be together
when the white wings of death scatter your days.
Ay, you shall be together
even in the silent memory of God.
But let there be spaces in your
togetherness,
And let the winds of the heavens dance between you.

Love one another, but make not a bond of love:
Let it rather be a
moving sea between the shores of your souls.
Fill each other’s cup but drink
not from one cup.
Give one another of your bread but eat not from the same
loaf
Sing and dance together and be joyous, but let each one of you be
alone,
Even as the strings of a lute are alone though they quiver with the
same music.

Give your hearts, but not into each other’s
keeping.
For only the hand of Life can contain your hearts.
And stand
together yet not too near together:
For the pillars of the temple stand
apart,
And the oak tree and the cypress grow not in each other’s
shadow.

Its always been a mystery to me,
How two hearts can come together,
And love can last forever.
But now that I have found you I believe,
That a miracle has come when God sends the perfect one.
So gone are all my questions about why,
And I’ve never been so sure of anything in my life

Oh I wonder what God was thinking, when he created you.
I wonder if He knew everything I would need,
Because he made all my dreams come true.
When God made you, He must have been thinking about me.

Oh, I promise that wherever you may go, wherever life may lead you,
With all my heart I’ll be there too.
And from this moment on I want you to know,
I’ll let nothing come between us, and I will love the ones you love.
So gone are all my questions about why

Oh I wonder what God was thinking when he created you,
I wonder if He knew everythin I would need,
Because He made all my dreams come true.
When God made you He must’ve been thinking about me.

He made the sun He made the moon,
To harmonize a perfect tune,
One can’t do without the other they just have to be together.
And that is how I know it’s true,
Your for me and I’m for you and my world
Just cant be right without you in my life

He must have heard every prayer I’ve been praying
I’ve been praying He must’ve knew everything I would need

When God made you, He must’ve been thinking about me.

A young boy asked his wise grandfather how to become a good man.

The grandfather replied: "A terrible fight is going on inside a man — a fight between two wolves. One is evil, and represents hate, anger, arrogance, intolerance, and superiority . The other is good, and represents joy, peace, love, tolerance, kindness, empathy, generosity, and compassion. This same fight is going on inside me, you and every other person too."

The grandson then asked: "Which wolf will win?" The old man replied simply:  "The one you feed." - Anon

I think most of us, if not all of us know how it feels to have a battle inside our minds. Whether for a small things that occurs on a daily basis or for major life experiences.

THe choices we make will depends on the things we learn/see/encounter during this journey of life. What we see/hear/learn in the past and present will affect our choices we’ll make in the future. If we immerse ourselves in the world of the "good wolves" - whether by going to church, listening to sermon, reading the bible daily, pray daily, try to think on how to be a better person, we will make the right choices naturally. On the other hands, if we let "the bad wolves" grow and lives in side us: if we seldom go to church, too busy to read the bible, reading/watching the wrong materials, hanging out with the wrong crowd, it will grow bigger and bigger and eventually rule us.

In that case, we have to be deliberate in everything that we do, knowing all the little things that we do on a daily basis will affect us in making choices/decision and in the end, will affect who we are and what we’ll become.

It’s been a long vacuum. It’s been a LONG journey. It’s been interesting, exciting, uplifting, exhausting,  many times overwhelming. I am into the 11th month of my internship.
At this time, after a very busy month in gastrointestinal service in MArch followed by almost a month in  the very intense, malignant everythird day call MICU (medical intensive care unit) service, I am emotionally and physically drained. I work 30 hours long every third day, 10-12 hours on other days when i’m not on call with 1 day off  every week.
The patients are very-very sick and the stories sometimes are heart wrenching, they make me anxious, give me stress ulcer and makes me cry in the inside sometimes.

One of my patients is a 22 year old girl, just had a baby few month ago. She came to the hospital after found unresponsive at home. She was found to have a big stroke in her brainstem, part of the brain which enable us to speak, move our extremities and breath. Her cerebral hemisphere (part of brain which govern our cognitive, enable us to think or feel) though, was intact. She is in a situation which called "Locked in syndrome" -  a well known condition in which someone is aware and awake but cannot move or communicate due to complete paralysis in nearly all voluntary muscles in the body. A very horrible situation especially in someone very young like her.
Everytime I see her, lying in bed, with open eyes, looking at me but unable to do anything, i feel so hopeless. We, her doctors know that her condition is permanent. We know what kind of life she’ll go through if she survive this hospitalization.
I couldn’t even imagine how it’s like being in her situation. She can feel pain, aching, itching, numbness but she can’t move.  want to say something but can’t. She must miss her baby a lot. She must miss her friends, family, life. She must have a lot to say, to tell, to share her feeling, but she can’t.
I guess that’s why one of the neurologist who is following her case said something about option to withdraw care. She is intubated, meaning use breathing machine to help her breathing, so if we withdraw her care, that include withdrawing the breathing machine, which possibly will cause her to die. I was a bit surprise when I heard the suggestion since the patient is alert and awake, so withdrawing care seems to me like a murder. But after I understand her whole condition, I could understand such suggestion. I still disagree, but I understand where it comes from.

When I come home from work, I am drained. I only have so much left in me. Especially after 30 hours straight of working in a very stressful condition where sometimes your decision may cause someone to live or die, you have no sleep, sometime only with 10-15 minutes lunch and supper break in between.

At times when i am on call, in the wee morning hours or late at night, rushing to a sick patient’s bedside, I was so tired, i feel like crying. I asked myself what am i getting into, why did i choose this profession. Sometimes i wish i have a normal job. Sometimes i have this thought that i might not have the physician soul, that i am not strong enough, good enough for this. SOmetimes i just simply want to quit.

I become impatient, easily offended sometimes. Mostly when I am tired and having lack of sleep. Sometimes I feel like I’m not myself. I guess that’s why there is an old advice in medical field:  if you are in a relationship that lasted during medical school or residency and that person sticks with you, Marry him/her!! I could understand why surgeon/surgery residents have the highest divorce rate from all since it is byfar the most demanding residency. At this time though, I simply thank God for his blessings by sending me angels in my life. My loved ones who cont to support me, understand me and put up with ugly side. They are my stabilizer.

But everytime I think about all the things I’ve gone through, all the blesssings that God has given me, I was reminded that I am here because God wants me to be here. He is the one that lead me to this path or else I won’t be here. I am reminded that when I feel tired and exhausted, God is the source of my strength. Alone, I am not strong enough, good enough for this, but with God, I am.

I might be exhausted, tired, emotionally and physically drained sometimes, but the reward was extraordinary. Being able to take care of others who are sick and in need, is a privilege in life. God has blessed me with so much, I think I have to give back. Life is not all about our own comfort, having all the things that we want but most importantly, it’s about how we can make our lives a blessing for others who are around us, What we can give to God and others while we are living here in this world.

Isaiah 40:29-31
He gives power to those who are tired and worn out; He offers strength to the weak.
Even youths will become exhausted, young men will give up.
But those who wait on the Lord will renew their strength. They will fly high on wings like eagles. They will run and not grow weary, they will walk and not faint.

R: Hippocratic Oath

Hippocratic oath (AKA Sumpah dokter) is something that all physician has to make on their graduation day. I did it on mine. Unfortunately, nowadays the oath is somewhat altered according to what the medical school deemed appropriate in the modern settings.

THere are several version of physician’s oath among US medical schools nowadays. Usually the changes are, unfortunately, around the abortion area. Hippocrates clearly gave his stand about abortion, that a physician should not perform any abortions, starts from the fertilization (when the sperm meets the egg). Since partial abortion is legal in this country, I think the medical schools feel that they have to somewhat change the oath so their graduates can perform the procedure if they want to.

I wish I had the real Hippocratic oath, either the modern or original version on my graduation day, not an altered one since the oath is so beautiful and encompasses almost all the things a physician should highly  uphold in his/her quests in practicing medicine. According to the oath, Medicine is an art as well as science which requires wisdom, humility, thirst of knowledge and the dedication to the service of humanity from all who wants to practice it.

Hail to the Father of Medicine! : Hippocrates.

The hippocratic oath (modern version, not altered version)

I SWEAR in the presence of the Almighty and before my family, my teachers and my peers that according to my ability and judgment I will keep this Oath and Stipulation.

TO RECKON all who have taught me this art equally dear to me as my parents and in the same spirit and dedication to impart a knowledge of the art of medicine to others. I will continue with diligence to keep abreast of advances in medicine. I will treat without exception all who seek my ministrations, so long as the treatment of others is not compromised thereby, and I will seek the counsel of particularly skilled physicians where indicated for the benefit of my patient.

I WILL FOLLOW that method of treatment which according to my ability and judgment, I consider for the benefit of my patient and abstain from whatever is harmful or mischievous. I will neither prescribe nor administer a lethal dose of medicine to any patient even if asked nor counsel any such thing nor perform the utmost respect for every human life from fertilization to natural death and reject abortion that deliberately takes a unique human life.

WITH PURITY, HOLINESS AND BENEFICENCE I will pass my life and practice my art. Except for the prudent correction of an imminent danger, I will neither treat any patient nor carry out any research on any human being without the valid informed consent of the subject or the appropriate legal protector thereof, understanding that research must have as its purpose the furtherance of the health of that individual. Into whatever patient setting I enter, I will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient.

WHATEVER IN CONNECTION with my professional practice or not in connection with it I may see or hear in the lives of my patients which ought not be spoken abroad, I will not divulge, reckoning that all such should be kept secret.

WHILE I CONTINUE to keep this Oath unviolated may it be granted to me to enjoy life and the practice of the art and science of medicine with the blessing of the Almighty and respected by my peers and society, but should I trespass and violate this Oath, may the reverse by my lot

HIPPOCRATIC OATH, original version:

I SWEAR by Apollo the physician, AEsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgement, I will keep this Oath and this stipulation.

TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look up his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according the law of medicine, but to none others.

I WILL FOLLOW that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give a woman a pessary to produce abortion.

WITH PURITY AND WITH HOLINESS I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves.

WHATEVER, IN CONNECTION with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

WHILE I CONTINUE to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

OK, this has nothing to do with my internship…just like this song so much, especially the video clip (can check it out in my profile)  =)

Guang Liang Tong Hua (Fairy Tale) Lyric & Translation

Sometimes people come into your life and you know right away that they were meant to be there, to serve some sort of purpose, teach you a lesson, or to help you figure out who you are or who you want to become. You never know who these people may be-a neighbor, a friend, a professor, someone you sold your book to or someone who walk you from the library - but when you lock eyes with them, you know at that very moment they will affect your life in some profound way.

Sometimes things happen to you that may seem horrible, painful, and unfair at first, but in reflection you find that without overcoming those obstacles you would have never realized your potential, strength, willpower, or heart.

If someone loves you, give love back to them in whatever way you can, not only because they love you, but because in a way, they are teaching you to love and how to open your heart and eyes to things.

If someone hurts you, betrays you, or breaks your heart, forgive them, for they have helped you learn about trust and the importance of being cautious to whom you open your heart.

It may seems horrible when joy, laughter and moments of love became tears, pain and agony. But when the two people involved were able to overcome the transition, by forgiving and forgetting the past, embracing the new relationship as two friends, the result can be a beautiful friendship which will last for a long, long time.

Some people come into our lives and quickly go. Some stay for awhile and leave footprints on our hearts. And we are never, ever the same.

Every Tuesday morning, Internal Medicine Department has an autopsy conference where we go over a case  and then all of us will go down to the autopsy lab/room and examine the pathological organs of the patient (or, was the patient since he/she will be dead by then).

This am case was a female died with breast cancer metastasis to the bone. It was a sad story since she was very young, 40 y.o when she died.  The stench of the autopsy room reminds me of anatomy lab in which we did all the cadaver dissection during first semester of medical school. I was glad that I did not choose pathology as a career since I don’t think I could work in that kind of environment my whole life. I mean, 6 months of anatomy class was enough for me. I remember how I studied the dead body (or, cadaver) 3 days/ week in the lab, 3-4 hour each time, went home with the smell stayed on my clothing and I could smell the stench stays in my nose until the next day. For the first few days, probably weeks, i couldn’t eat meat because it reminded me of the cadaver’s flesh/meat (I mean, it look just like beef or pork meat). For the first few days, I had some random dreams about the cadavers suddenly get up and jumping after me and the room was locked from outside or they just get up and gone. LUckyly they only happened the first three days.

After all that, actually I was surprised that I was still able to keep all my sanity intact (ok, actually i’m not so sure about that ;P)

Well, I think anatomy class is a special class that I’m sure all medical students will always remember for a long time. During anatomy lab, we’re trying to learn about the human body. We have to memorize all the names of  the muscles, bone, nerves, blood vessels and all parts of organs in the body. There are thousands and thousands of names that we have to memorize. For example, just from the hand, there are hundreds of names to memorize, ~30 different bones, many ligaments (don’t know how many of them), blood vessels, nerves, muscles overlying our small hand.  Neck and up (skull, brain) are killers, there are thousands of names to remember from our little heads.

We will have to examine the cadaver so closely since the parts sometimes are so small (like blood vessels and nerves can be very small), you have to be very close to it so you can see it, sometimes it seems like we almost kiss the cadaver (!!)    I guess for medical students, kissing cadaver is less scary than get a D or E in anatomy class ;P

well, I’m glad I did it.  Like I said, other than the knowledge I gained from the class, it can be a cute little memory that when I think about it, I’ll smile and glad that it’s over. "I’ve been there, I’ve done that"

31 days of oncology ward, ~300 patient progress notes written, 10 different types of cancers, 5 deaths, 1 comatose patient in the ICU, and 5 sleepless night from being on call. Those are the statistics of my work last months. I couldn’t remember how many patients total though, probably around 50. There are 2 kinds of patients which I just realized that my opinion about them make a different in how I treat them. One type of pts are pt who gets their diseases because of their bad lifestyle choices such as drug, tobacco or alcohol addicts, sexual promiscuity, etc. They came to the hospital with the disease most likely resulting from their lifestyle such as lung cancer from years and years of smoking, sexually transmitted disease (such as AIDS, Hep B, syphillis, etc) from being sexually promiscuous with many different partners, etc or  having heart attack at young age from cocaine use, etc. The other type are the ones came to the hospital with sickness that hit them without any reason: 35 y.o with colon cancer metastasize to the liver and now dying, 39 y.o with recurrent breast cancer terminal stage, dying, 62 with cancer in the anal canal, now with kidney and liver failure, in pain and also, dying. I found that I will sympathize more with the later group of patients and even though I try my best to not differ in the way I treat the 2 groups, I found my feelings about the cause of the diseases affect my care a bit. Even though I will give them all the treatment they need,  I probably won’t go out my way just so they can get their pain meds right away if they are an alcohol addicts, being in pain now while I will go and push the nurse to dispense the meds sooner for the  liver cancer patient also in pain. I tend to talk with the cancer pt and their family more because I could feel their burden and sadness with what’s going on.

When I think about those things, I realized I have to change it. I think a physician’s job is to take care of their patients, make them better no matter what. Sometimes it’s sad knowing that your pt will go back to the street, sell/use cocaine again once you fixed them and make them better. Sometimes I will get a patient who is from the jail. It’s ironic knowing that you are helping a murderer, rapist get them healthy, not knowing if they will or will not do the same crime again. But I know that as a physician, the calling is to heal. God put me in this place so I can help everyone that comes to me and be my patients. I have to work on not being judgemental to others.

For I was hungry, and you fed me. I was thirsty, and you gave me a drink. I was a stranger, and you invited me into your home. I was naked, and you gave me clothing. I was sick, and you cared for me. I was in prison, and you visited me. Then these righteous ones will reply, "Lord, when did we ever see You hungry and feed you? Or thirsty and give You something to drink? Or a stranger and show You hospitality? Or naked and give You clothing? When did we ever see you sick or in prison and visit you? .And the King will tell them,’ I assure you, when you did it to one of the least of these my brothers and sisters, you were doing it to Me!’

                                                                                                   Matthew 25:35-40

Other than cancer patients, large part of my patients are sickle cell patients. They are very interesting, also challenging at the same time, group of people. In the beginning, I, like other people in my oncology team (resident, interns, fellow and pharmacy students) had some share of being annoyed by them sometimes. Most of the sickle patients are young (in their 20s), demanding, angry, rude and disrespectful sometimes. First it was hard for me to understand how could a patient treat us, the physicians, like their enemy? Sickle pts usually are admitted in ‘pain crisis’ where they are supposedly in a lot of pain and need a lot of pain medicine. The pain meds that they usually use are very strong medicine that may cause respiratory depression, even death if given too much. On the other hand, for the user, it may cause addiction, since it is a morphine derivative, it will give them ‘the high’ feeling, like someone using opioids such as morphine. Some of the pts get addicted and try everything to get more and more of the medication. That’s where the challenges of the treatment come. We (physicians) want their pain to be well controlled but we don’t want them to abuse the medicine and develop respiratory depression, and die. We try to keep everything in balance, control the pain but not making the pts ‘high’ on the drugs or get addicted. Sometimes they keep asking for more and more meds and we have to say no, that’s when they get angry with us.

Sickle cell disease (SCD) disease is an inherited disease affecting african american people, their red blood cell (RBC) will change shape into ’sickle’ shape , like banana or crescent moon when they are dehydrated, has infection, or hypoxic (has low oxygen level in the body). The RBC then clumped together since they are not as maleable as the normal ones. They then can clogged, causing blockage/obstruction of blood flow in small blood vessel. That’s when they get into sickle cell crisis and experience intense pain in many parts of their body because blood doesn’t flow through. NOt only that, sometimes children with SCD will have stroke, Avascular necrosis of the bone, ulcer, etc. One of my sickle cell pt had her leg amputated because of the ulcer that spread to her knee. She is only 20 y.o. There are many other severe complications that SCD can cause which I won’t go over since it will take me hours.

The more I read about the disease, the more I could appreciate where they come from. I could understand why many of them are rude, angry, unappreciative. Myself, I don’t know what kind a person I would become if my whole life I have to experience multiple pain crisis, living from one hospital stay to another (many of sickle pts go to the hospital about once a month in pain crisis or infection) spend so many days of my life in pain. Partly because of their condition, most of the sickle pts in the hospital are indigent people with no insurance or on public aid (government supported aid for low income people)

This past three weeks, taking care of sickle cell  and cancer pts makes me appreciate more of what I have. Good health, good career, great family (with all the bad and good things about it , and wonderful friends shouldn’t be taken for granted. I feel that God has given me so much blessings, the least I can do is to help others who are less fortunate than me.