Ups and Downs in Pediatrics

From my own picture collection, taken in Collosseum, Italy.
Siblings playing with their parents' video camera.

It has just been two weeks since my first day in Pediatrics rotation, and I can't help being in this kind of love-hate relationship with my daily job. Our daily schedule is tight, we have to be present in the hospital around 6 am and start making daily subjective and objective examination to all the patients in the ward. There are 29 co-assistant in total so we will have several patients we will examine daily. Then we have to write it all down in the patient status, including the diagnostic and therapy planning. It is a very effective way to learn about clinical medicine, thou. Then, most of our days will be spent helping the residents observing the patients ( every 3 or one hour, depends on the diagnosis), assisting in some clinical procedure, or participating in group discussion. Everything will be ended around 3 in the afternoon and on some days we have night shifts, mean doing almost the same job we do during daytime, only during the whole night.

One Day in the Clinic

The doctor carefully explained about the medication prescribed. Haloperidol, Folic Acid, Clobazam.  None of them were familiar to the mother. She stared to a space that did not exist. Her ears were listening to the doctor's words, every single word. But her mind was spread into several thoughts at the same time.
She might need to stay for a month, or maybe more, in this city, 4 hours away from her home. She didn't have any place to stay, yet. Her husband might have to work harder than before. She would look for all the therapies, anything that could fix the problems. She might will have to leave her younger daughter at home. Her son might will never able to enter regular school, be a regular child.
Who will afford all the medication and medication fee, anyway?

And just moments ago, she discovered that her son was diagnosed with mental retardation.

Fiets in The Netherlands

the bike racks

Bicycles are not uncommon in every region of the world. But there is something special about bicycles in The Netherlands. They are not a one-moment trend. Neither a stylish accessories about what's in and what's not. Bike is a need. It is cheap, healthy, and fast. People ride bikes anytime, to any destination. Even you can find some men in neat suit going to workplace daily on bike. Students, the older ones, professors, professionals, anyone. People can choose an expensive multi-geared bike with fancy model or they can basically opt for an old--but fast one.

It is common for little children to start with 3-wheels bike, then usually children in school age will learn to ride bikes with foot-brake, the ones without hand-brake and you need to turn the pedal backwards to brake. I have tried them once, and it was not easy, as I did not usually ride bike in Indonesia, where I came from. There are also special bikes designed for people with disability. Usually they are three-wheeled, with different models and size depends on their disabled limbs. Some children with special needs also use custom made bikes to stimulate their movement, strength, and coordination. Another extra benefits of bikes. 

The Generous Patients

Hari ini hari kedua clerkship di bagian interna dan paru. Hari pertama kemarin hanya dilewati dengan teoritis dan melihat contoh kasus pada pasien nyata, jadi aku sedikit berharap semoga hari ini bisa melakukan pemeriksaan fisik ke pasien, setelah bertahun-tahun hanya belajar ke pasien "bohongan" yaitu kakak kelas atau staff yang berpura-pura jadi pasien. Tentu hasil pemeriksaan yang ditemukan akan beda dengan seandainya yang diperiksa itu pasien sungguhan.

Paginya diawali dengan kuliah singkat tentang anamnesis, lalu kita dibagi menjadi 4 kelompok, masing-masing 3 orang, dan diperbolehkan melakukan anamnesa ke beberapa pasien yang ada di ruang interna wanita. Agak kecewa karena dosen pembimbing kami tidak memperbolehkan kita melakukan pemeriksaan fisik kepada pasien. Alasannya masuk akal sih, pasien sudah terlalu banyak di-"jamah" oleh tenaga medis dan calon tenaga medis yang ada di situ, sebut saja para dm/co-ass, ppds, mahasiswa perawat, perawat, dokter yg bertugas, dsb dsbnya. Terbayang kalau aku yang harus berkali-kali diwawancara tentang penyakitku, ditanya hal-hal yang sama terus, dipegang-pegang dan diliatin padahal sedang mau istirahat dan bosan juga pastinya. Iya juga ya.

Lalu kami ke bangsal interna wanita. Kelompok 1 mendapatkan pasien seorang wanita lanjut usia yang perutnya membesar. Kelompok 2, seorang dengan kaki yang membengkak dan napas pendek-pendek. Kelompok 3, yaitu kelompokku, dengan wanita yang badannya kekuningan, dan kelompok 4 dengan seorang wanita yang (katanya) anemia.

Sebelum memulai anamnesis kelompok, dokter pembombing kami meminta ijin kepada tiap pasien, bahwa kami akan menanya-nanyai mereka, dan apakah mereka keberatan atau tidak. Tiap pasien ternyata setuju dan dengan baik hati mau menjawab pertanyaan kami yang sering kali berbelit-belit, diulang-ulang, bahasanya mbulet, dan mungkin sedikit membingungkan. Yah namanya juga belajar, dan grogi juga sih. Pasien-pasien ini lah yang pasti pahalanya begitu besar kelak, karena kesabaran mereka.

Setelah itu, kami istirahat selama 30 menit lalu lanjut ke bagian paru. Setelah kemarin hanya diceramahi dan kuliah singkat, aku sedikit pesimis dengan materi yang akan aku dapat hari ini. Memang, ruangan tempat kami diberi pengarahan paru itu nyaman sekali, kursinya empuk, adem karena ber-AC pula, tapi dasar namanya rajin (:p) keinginan utk berkeliling dan ke pasien yang beneran masih membara.

Kami akhirnya berlatih pemeriksaan fisik dengan "pasien" seorang karyawan di departemen tersebut yang sudah sedari dulu membantu para clerk di sana -- sejak tahun 1972, katanya. Wow. Bayangkan berapa ratus dokter yang sudah memperoleh ilmu langsung dari sang Bapak, tidak dengan kata-kata saja, tapi dengan tubuhnya sendiri.

Ternyata dokter pembimbing kami harus menghadiri acara lain yang mendadak, jadi kami akan dibimbing oleh seorang dokter pengganti. Dokter pengganti ini sering memberikan pertanyaan, tapi juga tidak bereaksi lebay saat kita menjawab salah, melainkan menjelaskan satu-persatu sampai detail. Dan ternyata kami dibolehkan untuk memeriksa pasien setelah sesi kuis itu! I was so excited!

Kami ke bagian paru, dari pintunya saja sudah tertempel poster tentang keharusan memakai masker bagi yg sakit atau yg akan mengunjungi orang sakit, hand-sanitizer pun lebih mudah dijumpai menempel di tembok-tembok bangsal paru pria ini. Beberapa orang batuk-batuk dengan kerasnya dan banyak yang memakai masker. Pada saat itu di bangsal tersebut ada pasien yang baru saja meninggal dunia. Mungkin karena suasana yang seperti itu, seorang teman kelompokku berkata "rasanya hampir semacam merinding di sini."
Kami dibagi menjadi 2 kelompok, kelompokku akan memeriksa seorang pasien pria yang terlihat kurus dan lemah. Lagi-lagi, aku sangat bersyukur pria ini menyatakan mau diperiksa oleh kami dan berkenan menjawab pertanyaan kami, walaupun itu mungkin tidak nyaman baginya.

Singkat cerita, dari pasien ini aku bisa menemukan sendiri tanda-tanda penyakit yang selama ini cuma bisa kubaca di buku. Fremitus vokal menurun, pengembangan paru tidak simetris, bronchofoni positif, dsbnya.
Tanpa Bapak ini, mungkin semua itu hanya ada di awang-awangku saja sekarang.

Hari ini aku belajar, bahwa bukan dokter dengan jas putih dan tampang pintar yang harus dihormati, melainkan para pasien ini. Mereka yang sering tampil apa adanya, bukan pada saat tercakep/terklimis/tersehat mereka, tapi berkenan memberikan ilmu yang berharga kepada para calon dokter. Ilmu dari mereka lah yang akan membantu para calon tenaga kesehatan untuk mengobati orang-orang sakit berikutnya. Jadi kesembuhan pasien di masa depan bergantung dari kedermawanan para pasien di masa-masa sebelumnya.

By now, I'll proudly say that these patients are my greatest teacher. There will be no greatest way to show my gratitude except by always giving my best to be a good doctor.

Ih, amit-amit deh kalau ntar jadi dokter yang money-oriented. Bisa malu para guruku ini natinya.

Don't Sweat Small Stuff

Overheard the casheer girls' talk in the hospital this afternoon when I was waiting for an appointment with a dentist.

"So what do you think if when the patients want to know which doctor is a reputable one in this hospital, we answer that there is no good doctor here?"

"Yeah, that might be a good idea. Those doctors are nothing without us. Even we look less important for them, it's us who actually play a big role on whether the doctors will have good reputations or not."

"For even if we looks uneducated and less smart than them, they should not underestimate us."


Me, sitting there, so glad to have the chance to heae such honest comments from real people around the doctors. It is so true that we should not underestimate anyone in our life, for every single person have the possibility to affect pur life, either in positive way or in negative one.

I promised myself that very second not to inderesrimate anyone around me, either it is a patient who is not able to pay, a junior coleague, a casheer, even the janitors. Lesson learned. 

Waiting Is Not That Bad

If there is one thing I would avoid the most in the world, it would be waiting. Seriously, I can whine all day long because of wasting several minutes to wait for someone or something, I could have use those minutes to do something else. But recently there are some interesting stories I got during my waiting for a person, in the hospital and in a car. Here they go:

1. It was another hours of waiting for my research's consultant. Sitting next to me was a lady whose nose was covered by cotton-aid. This was quite uncommon because most of the women consulting to that Oncology Clinic are breast cancer patients. I can't stand my curiosity and asked her whether she is going to see the doctor because of breast cancer. It turned out that this lady had a lump on her nose and it had been resected the last week. I had just studied about skin malignancy that morning (Malignant Melanoma and Basalioma), so I began to ask some questions relating to her skin lump. One thing surprised me was that this lady is a housewife, which means that she spends most of her days inside her house. While the only predilection for skin malignancy in my mind at that time was UV exposure. She said that she didn't use to wear any sun-screen lotion nor cosmetics when she is outside. But does a minimal exposure to sunlight could end to such skin cancer. I should learn further.

2. Several days later, in the same Oncology Clinic, waiting for the same research's consultant, a woman beside me had been waiting several minutes longer than me. I smiled her once previously, but after an hour of waiting for the same person, side by side, I started the conversation. She looked fine and I didn't notice anything wrong with her face. But after she said that she suddenly lose her right eye's visual after a series of chemotherapy, I noticed that her eye looked perfectly normal while the left one looked a bit retracted. Turned out that she had done a mastectomy a year ago, continued by a series of radiotherapy and chemotherapy. She had consulted an eye specialist doctor in a private hospital before but the examinations showed nothing wrong with her retina and all. I started to think whether it was the side effect of the chemical they used in chemotherapy or it was the tumor which had metastasized to her brain or eye. I literally googled about it soon after I arrived home but couldn't find the most possible and satisfactory explanations. I should learn more.

3. It was this morning, in a travel service when I was going to my hometown. The driver and I were waiting for the next passenger, he asked about med school etc. Then he told me about his 9-month old son who has been suffering cough for the last 4 days. His son also had a fever. A doctor had given him drug prescription. The driver showed me the prescription paper, and although I have just finished pharmacology exam, I still think that I couldn't diagnose and determine the drugs now. It was either under confidence, fear of giving the wrong drug advice, or simply because I realized my own lack of knowledge. I should have learned more, and I will.

The most important thing I've learned is I like the interaction with those people seeking for medical help. I like the heart-to-heart talk, the trust they put in me, so that they could share their health problem. Some even shared their financial problem. This is the privilege I'll have as a medical doctor in the future. I just wonder whether I would have an overly busy schedule with too much patients waiting, so that I would miss those essential talks. Those essential talks which I rarely find it on some senior doctors who examine patients in just 10 minutes. I wonder if being in their position is inevitable, or I am free to choose what kind of doctor I am going to be. I have those ideal goals, but I know being overly idealistic means being ready to be disappointed by the reality.

*About my research: I've finally finished it and collected it right on time! Now talking about holiday and a vacation trip to Singapore...well I'm so totally excited! :)

The Hospital on 10 a.m.

I began to thank goodness I have just made a blog. As I usually think and ask questions a lot, sometimes I whine and become very critical about things around me, having a blog to express all of those thoughts seems to be quite relieving. Now I can guarantee people won't get bothered by my too-honest words that much anymore when I'm around.

This morning, after my last theoretical exam this semester (it was pharmacology), I went to the Oncology Clinic in the General Hospital. I was going to meet one of my research consultant -an oncology surgeon-  to get my last revision and his approval signature. I have made appointment by SMS the day before, so I thought the waiting wouldn't be too long (last time I waited for 5 hours straight before he finally finished the surgery). Instead of being bored and wandering my thoughts around, I decided to write my thoughts. Yes, I wrote my thoughts in the middle of busy hospital, with the patients and nurses around. So here is my short note:

<<Soap opera is showing actors with fake tears, fake ill faces.
While the women around me (breast cancer patients) show the real pain. The sign of healing process  after their mastectomy or breast biopsy.
 Some patients are inside their room, waiting for being healed. Some are counting their last days and their lifetime's blessings. Seconds nearer to their final goodbye.
While the children are playing outside. Toddlers talking with their imperfect sentences. They are growing, so far from what we called "death". The increasing ages, one is dying, the others are beginning their youth. Embracing the two sides of life: health and illness.


Medical reps are asking for doctors' names, digging every information of who, where, and when they can meet their future clients. Sometimes pens and notebooks with the company's label on them do help.

Nurses and patients sharing smiles, talking about which doctor is the most good-looking ("Is he single??"). Gossips -- the only thing which can diminish all the boundaries among women who haven't known each other before.

One patient sighed "I lose my appetite because of this chemotherapy."
A senior nurse replied --  just like what she always says to patients who suffer because of these chemicals " You should eat ice cream. Trust me, ice cream is delicious, it helps you to bring back your appetite, and it contains vitamins. Once you're back home, buy two ice creams every day--one for your son, and one for yourself."

A lady who was registered to have her lump biopsied today disappeared. A nurse looked for her from toilets to waiting rooms, north to south. When finally she found the patient, she said "Where have you been? We've been looking for you all over the clinic!" And surprisingly, all the patients waiting in that room, laughed at this worrisome lady. The lady smiled. I smiled. 

Me, waiting for half an hour already, is still waiting for the doctor. These papers with the empty space above the doctor's name (and his uncountable titles) is waiting to be signed. The precious signature which have to be paid by hours of waiting.

On the other hand, I'm enjoying the scene of the real life. Recorded by my ocular lenses. All captures will be organized in folders, in my hippocampus.

That's how the TV should be jealous, because that soap opera they are showing means nothing, compared to the real acts of these professional actors of real life.

Hospital doesn't seem to be that boring after all. Or as I thought it would be. >>



An hour later, I got the doctor's signature. I felt satisfied enough that at least this time my hours spent worth. So I went home and make my late lunch.

Photo: Baked beans, toast, sausages, scrambled egg, and yes, oatmeal. I just love baked beans so much, even the canned one. SO I think it is completely normal to have baked beans and toast for lunch instead for breakfast. Period.