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 Art of Letting Go

03.00 am, almost dawn. It was my first time facing death. Many stories about doctors who resuscitate their near-dead patients and managed to bring them back to life. But I didn't. It was my first time performing resuscitation on real patient but I didn't succeed.

Previously, a senior of mine calmly informed the family about the patient's worsening condition. That we had given all our best, all the medication and medical procedures we had known to save the patient's life. And after she had gone, it was my senior who calmly explain about the possible cause of death, about his deep condolences to the family, and that he will be there if any of the family need help on anything regarding the late patient. I was near speechless. Maybe it was my emotion, I was overwhelmed by disappointment and grief. It was more than a death to me.

Patients : People or Cases?

This month has been overwhelming by school schedules, reading catch-up, and extracurricular activities I have. Last 3 weeks I joined gym and tried to spend 3 times a week having workout session. On one side it has made me feel good about my body, I feel much more healthier and less tiresome, I have better mood, and it is a good way to relieve some stress too (yes, the gym guys are good looking! :p). On the other side, I go home after workout feeling tired and can't stand reading handouts for more than one hour. So I try to do a major catch up on weekends, but then I always use weekends as my excuse to hang out and have fun, so basically I am doing a very slow progress here. I have postponed my plan to take a diving course this month until all the exams are over and it turns out to be the smartest decision I've made so far.

Being so tiresome and sleepy in class make me want to post some tricks (some work, some not) I use to do when I can't stand to sleep during a long class, either it is a morning one or an afternoon one. Still on process on making that post, though. But tonight when I was reading surgery handouts, some case images of oral cancer have disturbed me.

Enjoying medical school to its max

"No matter what you do, this medical training will be a long process. So all we can do is enjoy each second of it." - Robert, a senior of mine and one of the smartest student in my faculty

Three years ago, when I learned about biochemistry, physiology, and biomedicine in med school, I keep on thinking that all I want is finish medical school as fast as possible and get myself to be a real doctor as soon as possible.

Yesterday, I read a very interesting post in Medscape website,which pretty much made me realize on how I actually enjoying this whole process of medical training. This post "Journey or Destination?" had me remember my first three years in medical school, which sometimes I keep on thinking about the goal, good test results, and how it will affect my life as a doctor in the future.

Now I am entering my fourth year, my next semester will be the last semester before clinical rounds, and it will be my last semester having lectures with the whole students in my badge. Rolling my mind back when I had lab classes and medical skill trainings, I start realizing that I am going to miss those whole process.

I remember my first year, still get used to call my lecturers "Doc" instead of "Ma'am" or "Sir", adapting myself in the euphoria of being accepted in med school, caught bad nightmares after doing my first dissection in anatomy class, getting overwhelmed by hundred of Latin words in anatomy and the complexity of human body structure, pretending to be a real doctor by practicing history taking and physical examinations to fake patients...

My second year, studying the difficult schemes of biochemistry, had interesting experiments in human physiology class, seen and tried ECG machine for the first time, paid full attention of roaches, worms, and ticks under the microscope in parasitology class, made the TB sputum preparations in fear of might getting infected, created my very first research proposal and spent nights finishing it, did my first catheterization and NG tube application (which is actually much harder to do it how it seem)...

My third year, did my first phlebotomy (and get my blood sucked by my friends too -- in several attempts), did my first urine, blood, and serum analysis in clinical pathology class, seen the actual tumors and human diseases with my own eyes in pathology anatomy class, finished my research project (about breast cancer) after months of the long process, did my first 5 hour clerkships in neurology, emergency dept, paediatrics, and internal medicine ward, and more exhausting nights of pre-exam nights...

In just three years, I have learned, seen, watched, heard, experienced, felt, dissected, smelled, and done lots of things that I haven't done or even imagined before. I have felt wowed, overwhelmed, jawdropped, amused, excited, upset, desperate, and all of those colorful emotions related with my training. We have been carefully prepared, so we would be the doctors who can face the real patients out there, once we are graduated. This whole medical training program, along with the lecturers, fellow med students, and generous seniors have created an unforgettable experience of a lifetime.

The process of training will be continued even for years after I completed med school, either by formal or informal lessons. As for today, I decided to put more attention on here and now, while keep aiming at my goal.

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.

My Den

My den is a sea of unread books.







Less than 2 months left to read all of these books. I think I just need to document this as one moment in my med school. My children might want to know this one day. Or it is me as a doctor in the future who will look back at these pictures and may regret on my bad time management and my lack of reading.

For the moment, I think I need a new bookshelf. A big one.

"Cadavers; thank them."

Woke up 1 hour late today, as a result I arrived 10 minutes late to the class.
It was neurology. The lecturer turned out to be a silver-haired professor, who -- just like the other neurologist -- is a brilliant person with a "character".

He was a strict person, pointed laser pointer to anyone who talked during the class, especially those who sat on front rows. I guess he is around 70 or so, but still has a good memory about the complicated neurology.

Near before the lecture ended, he gave a short message about how he want us to be. He said that he was a bad student, who usually sat on back rows. He told us to be doctors who have self-confidence but also pay a full respect to the others. We should always call elder patients with "Mr."/Mrs."/"Sir".
He also mentioned that the lecturers, the professors, even the dean are not our teachers. They are just our guide in medical school. The real teachers are our patients who will teach us in the real school: the real life.
"The most honorable teachers are the cadavers. Without them, there would not be any medical students and no medical books would have been written. They are the greatest teachers who still teach us even after they have died. Thank them."

"Roh Terletak di Mana?"

Hari pertama clerkship, kuliah hari ini adalah Farmasi klinik (tentang obat dan resep), Interna (penyakit dalam), Pediatri (Anak), dan Psikiatri (kedokteran jiwa). Some quotes of the day:

-Psikiatri-
"Roh atau soul itu beda dengan jiwa atau mind. Kalau manusia mati, maka jiwanya akan mati karena jiwa itu ada di otak."

Q: "Jadi roh itu ada di mana?"
A guy who sat behind me: "Melayang-layang."
Me: --"

"Selama ini kita menjudge orang-orang psikopat tanpa tahu sebenarnya psikopat itu apa. Padahal dari 10 orang psikotik hanya 1 orang yang benar-benar schizophrenia."

Q:"Apakah kalian masih menstigma penderita psikosa?"
Some students: "Yaa.."
Q: "Kira-kira kenapa?"
A1: "Tidak tahu..."
Q: "Tidak tahu alasan menstigma atau ketidaktahuan akan psikotik itu sendiri?"
A2: "Karena takut..."

"Di sini adakah yang suka melakukan kegiatan yang berulang-ulang? Atau terlalu sering negative thinking dan emosian? Itu bisa salah satu gejala psikopatologis. Hati-hati karena kumpulan gejala-gejala tersebut bisa menjadi gangguan psikologis."


-Pediatri-
"Virus juga punya hak untuk hidup. Jangan saling membunuh antar makhluk hidup. Jadi kalau dibilang infeksi adalah upaya tubuh membunuh mikroba itu kurang tepat, seharusnya adalah upaya tubuh mempertahankan diri."

"Nyamuk itu juga punya hak rekreasi loh."

"Pemeriksaan fisik itu nggak penting punya stetoskop yang ada mickey mouse-nya. Yang penting adalah pemeriksaan dengan menggunakan otak, bukan hanya menggerayangi pasien saja."


-Interna-
"Mau jadi dokter atau pengusaha?"

One Passed, the Others Follow

Finally the long journey of exam week has passed. And now the tension changes into waiting for the result, the big surprise that might would make my heart popped.

On my last exam day, it was raining hard, so I just walked home and planned to take a sleep revenge. But the fact was, I couldn't stand seeing my messy room after days of studying and lack of cleaning. Plus, regarding to my last post, I realize that sooner or later I have to do a major cleanup. The next thing I do is cleaning the floor part, every window corner and every inches of the table's surface, and I organized this semester's piling papers and textbooks.
Couple of hours later, some calories had been used (I consider this as a little informal form of exercising), my room was squeaky clean, and it did smelled good. A bit me-time, and I slept like a baby. Woke up 2 hours later, had fun watching new movies with roommates. What a bliss.

It's just tonight that I realized that there are some other things-to-do, waiting impatiently for me to finish them. The research project, arranging a vacation trip, preparing for the exchange thingy, and some other self-improvement plans. This is mid-January, and the heat is on.

Photo:This one was taken in front of a public place in Taipei, Taiwan. I can't remember whether it is a National Museum or other kind of building. But I miss Taiwan so badly, for sure. Amazing places, kind people, great food, and if you're a shopper, their traditional markets are definitely a must-go.

I Definitely Need a Fridge-ologist

It's been a while since my first post here. Medical school on third year is getting thougher and I had some problems on managing my schedules, research time, studying time, and maintaining my sanity, so here I go.

So I've had my 4 exams out of 5 exams this week. Today's exam was public health. Public health itself is interesting for me, but to me honest, statistics is not my cup of tea. I am so bad in numbers and formulas. Last night I struggled hard to memorized the terms, the names of which analyizing system is used, and the formulas. And today my exam was a bit saved my my calculator, which helped me a lot in calculating numbers without knowing the formulas.

Anyway, the reason why I make this post while I am supposed to be studying for tomorrow's exam (which is Pharmacology - the terror), is that I just found some reasons to do a major room clean up. Yesterday I realized that the dust on the back part of my cupboard is almost 2 cms piled. And found that the milk that I stored in my fridge has deteriorated. It smelled like yoghurt and fortunately I did smelled it before I drink it.


Ew. Just now, I was going to open this jar of fruit coctail and was surprised that it has been so condusive for a thick massive colony of greenish fungus to grow. I opened the jar lid and it seems that this fungus released greenish spore and I don't want to risk being toxicated in this exam week. So I close the lid and throw out the jar. The expire date is November 31st, 2010, but I thought if you keep food in the fridge it should last longer, isn't it?





Moreover, I just realize that as soon as I get my free days, I would clean up the fridge and especially melt the mini ice cave inside it. It's really annoying especially when I want to store some sausages or ice cream inside the freezer and the ice is clearly dominating the small box. I need to put more effort to put out the sausages which are trapped inside. The last time I turned off my fridge for a day to melt the ice, it was like a major flood inside my room. So I need to prepare more before doing the same, prepare the space, the dry cloth, and of course move all the stale-able food (e.g. fruit) inside to somewhere else.


I love the little extra pleasure by owning a mini fridge inside my room, it really helps me to store some fresh food so I can cook some dish myself, and enjoying a nice cold juice or milk in the morning is my bliss. But it would be much better if I don't have to spend much time to take care of it.


Now I'm going back to Endocrine drugs.

"Are your parents doctors?"

  Yes, this is the typical question I've been familiar with these 3 years in med school.

It was back then on the first day orientation and the new students were getting to know each other. I realized that some of them have already known each other, either it because they are from the same high school, or they have been connected through their parents. Later on, I also discovered that more than half of my friends' parents are doctors. Some are even our lecturers.
On the next year it was the lecturers who joked, "So, anybody here whose parents are doctors? Or should I asked, anybody here whose parents are NOT doctors?"
Should I answer it?

In a matter of fact, my parents are not doctors. My mother is a teacher. She teaches private courses for elementary students in our house, and she has been teaching for almost 30 years. My father is a typical employee in a flavor and fragrance company. The ironic part is that his specialty is in tobacco industry, while you know, I am going to be the one who will continually say smoking is bad for your health. But that's another story.


There is a common anecdote in our faculty, in Indonesian, it is FK=Fakultas Kedokteran (Medical Faculty) and its definition sometimes being interpreted as FK= Fakultas Keluarga (Family Faculty). And it's indeed describing the fact inside my school. So I have an anatomy lecturer whose happened to be a father of my best friend whose aunt is also teaching in the same medical school. Another friends of mine have surgeon parents, neurologist dad, obstetrician father, radiologist mother, etc. And there is nothing bad, about it, really.

There are some times when I envy them, because they have had the opportunity to learn more about medical stuff since their early age, digging into the deepest part of their parents secret to survive in medical school, being introduced to their parents relatives who later on become their lecturers and supervisors. I see that sometimes you are lucky if you are able to know some professors and experts before the clinical day comes. It's not a definitive factor of a successful doctor, of course, but you know how important having dependable references is.

On the other hand I'm glad that my parents are not doctors. When I got C+ on my anatomy exam, my parents kindly said "We know you have tried your best. Keep trying and remember that the knowledge you have inside your brain and your heart are far more important than that alphabets." While I know some doctors expect high grade from their children, and it can be frustrating sometimes, for the children. Having a non-medical family enables me to have normal conversations, without using any complicated medical terms (which I've had it DAILY with my school friends), sometimes they ask about medical stuff, the other times it's me who give some advices for them. I realized I have learned so much from my family about how to build a good communication with my future patients, who are more likely have medical education background.
And it's funny how my family couldn't wonder why I have to study almost every night, which is so-not-me back when I was in high school. The used to ask "Do you have exam tomorrow?" if they found me studying on late night -- while actually the exam was 2 months later.
I am the new and the only nerd in my family.

There are so much good and bad side of everything, including about having doctor parents. While I am so grateful of what I'm having right now, because it's about their role in family, not about their professional background.

Now how do you think? :)

Photo: It was a vegetarian lunch box I had on my medical students conference to Taiwan. Can you believe that the huge meat-look-alike in the center is actually a huge mushroom? Neither can I. By the way, it tasted sooo good that I thought I could be a vegetarian forever. But I'm just a natural omnivore. *