Bulge

"Ay, sori po. Nag-bulge po kasi manipis ang ugat nyo." (Sorry Ma'am. It bulged because your veins are thin and collapsible.)

These things do happen. And it happened to me more than once. And I dread it.

The reasons why the staff at the nurses' station page us interns at unholy hours of the night are because of the following:
1. Skin test (determining if the test antibiotic is allergic to the patient prior to starting the dose)
2. IV push (pushing several cc's of medications via IV lasting as long as 30 minutes)
3. NGT insertion (inserting a plastic or silicone tube through the nose to the stomach)
4. Indwelling Foley Catheterization (placing a rubber catheter into the urethra of female/male patients to monitor urine output)
5. Straight Catheterization (inserting temporarily a rubber catheter into the urethra for urinalysis or bladder relief)
6. Medical Abstract (writing time-consuming clinical summaries for patients)
7. IV insertion (inserting a needle into the hands or arms so as to have an IV access)
8. Change of Dressing (cleaning and debriding wounds and changing the gauze for new ones)

These procedures have varied levels of grossness and nausea, with routine exposure to them made most of us jaded and callous with nary a tinge of malice to them. Most are easily and quickly done with a step-by-step operation.

Only the IV insertion proves to be the most challenging of the tasks. Ask any doctor. So, if the nurses can't do it, they'll call the interns. If the interns cannot do it, they'll call in the residents. And with such a totempole set-up, it is inevitable that the patient's hands have now turned into a dartboard of blotched IV insertions or an exploded minefield full of dark red and purple bruises. But most of the time, it's a one shot deal- so no complaints there.

Sometimes, the nurses coerce the interns to take the first plunge- especially if the veins at hand are hidden and difficult to ascertain, or if the patients have a terribly low threshold for pain, or if the relatives are a pain in the ass. The most dreaded patient to be inserted are the elderly (due to thin collapsible veins), fat people (because their veins are hidden inside those pads of fat), and children (because they and their mothers are so irritable that you want to suture their lips.) And if the patient's relatives would ask, "Magaling ka ba? Sharpshooter ka ba? Kailangan isang turok lang!," I'd tell them silently, "Ikaw na lang kaya mag-swero, you stupid ass!" Of course, I can't tell them that, so I would smile at them and would tell them that I'll try my best.

And so, sometimes you shoot, sometimes you don't. If you do shoot, it feels like as if a fishbone has been extracted from your throat. If not and it did bulge, I would always tell them that it's their veins' faults. It's their vein's fault that it's collapsible, that the vessels are deeply set, or that they do not stay in place. This is coupled with a distraught face, knotted eyebrows, a frustrated sigh and profusion of sorry's to ebb the tide of patient's anger for not shooting in one go. Doctors are human too.

The good thing is, most patients are very patient and understanding that they do not make a fuss or create a scandalous scene when they are entreated to another insertion. This should never be construed that we in the medical field are happy-go-lucky in inserting needles into patient's hands. We try our best to minimize it, but if it happens, we can only learn from it so that in the future, we can avoid it.

It's still a relief that here in the Philippines, there is no culture of lawsuits unlike the United States where a mere blotched IV insertion can be grounds of getting sued. But if the medical malpractice bills (3 already) will be passed, then doctors can be sued over this. If that's the case, then every nurse and doctor will pass this noble job of IV insertion to the Phlebotomist.

Dr. Rolour Garcia, a '92 graduate of West Visayas has this to say about traumatic IV insertion:

IV insertion is a skill that you don't acquire by practicing on a dummy, it's by doing it frequently over a span of time on real patients. You become good at it not because you graduated at the top of your class, it's simply because you have done a lot of it on a regular basis. The same is true for other procedures, whether minor or major as in surgical or obstretric cases (in procedures where a simple rookie mistake can mean life or death, newbies are always accompanied by seasoned veterans). Hitting a muscle instead of a vein is always possible if you are just starting and new to it. I would not even call it "practicing" because you have to start somewhere and beginners usually mess it up more than the veterans. Of course, there are other factors to why interns or doctors may not do it right the first time - like obese patients, collapsed veins (severe dehydration, Rolling Stones' Keith Richards) or simply, human error (sleep-deprived, too much caffeine). Having worked in a government hospital, I can say that most, if not all, patients understand that accidents or complications could occur, and without sounding impartial, doctors usually do a good job in explaining it to them. The problem here is when lawyers, legislators and insurance companies start "educating" the patients themselves that these are not just "accidents" but "negligence" that doctors should pay for with money and prison time. The government as well as the medical community may have failed in adequately educating the patient but that doesn't mean other sectors of society should take advantage of it.

As they say, practice makes perfect! So, during my current stay in IM, my IV insertion skill is being honed and polished thanks to the multitude of practice hands my patients have given me. My confidence (and thankfully, my success rate) have been progressively growing during these past weeks. At first, I dread when the nurses call for an insertion, but now, I treat it as a routine procedure. A little patient pep talk, lots of concentration, and presto! Shoot kaagad. Hopefully, it will stay way.

Curiousity Killed the Dog

Written by an autistic wannabe named Mark Haddon, The Curious Incident of the Dog in the Night-time (1993), is a very remarkable yet unadorned novel which anyone will have the utmost pleasure in reading. Some can even relate to the main character who is an autistic savant.

Roz Kaveney, a reviewer of Amazon.co.uk said this about the book:

Christopher is an intelligent youth who lives in the functional hinterland of autism--every day is an investigation for him because of all the aspects of human life that he does not quite get. When the dog next door is killed with a garden fork, Christopher becomes quietly persistent in his desire to find out what has happened and tugs away at the world around him until a lot of secrets unravel messily.

Haddon makes an intelligent stab at how it feels to, for example, not know how to read the faces of the people around you, to be perpetually spooked by certain colours and certain levels of noise, to hate being touched to the point of violent reaction. Life is difficult for the difficult and prickly Christopher in ways that he only partly understands; this avoids most of the obvious pitfalls of novels about disability because it demands that we respect--perhaps admire--him rather than pity him.

In a nutshell, the book picks up the life of Christopher as he interacts with the environment around him- from food, to family members, to pets, to strangers, to police and to numbers. You become an unwitting companion in his quest to find out who killed the neighbor's dog and he shares with you bit by bit the world and logic he lives in. When I read the book, I felt that Christopher lived in a glass bubble, transparent yet impenetrable, a world governed by his own unique set of rules and norms. He is quite the genius no one thought of and yet if you read this book, you will be soon enlightened that though this boy acts as if he was a retard and a complete unaffecting idiot, he really is intelligent albeit using a different set of logic. He has his reasons (some are partially qualified) as to why he does things and from the book's point of view, you won't feel frustrated or antipathic to the character (unlike if you meet a real autistic child and he caused trouble for no reason at all.) Well, if he was real, I'll make sure he'll be the one impaled on the pitchfork instead of the dog.

The book itself is fascinating to say the least and truthfully, it's unputdownable. You're curious who killed the dog and you're enthralled by the uniqueness of Christopher. You become captivated with how the mind works that even if bodily you are normal, the mind still controls every aspect of your existence. The book itself have several puzzles and "how-things-work" type of entries and reading them is a delight. Makes your mind more open to the inifinite possibilites of the uknown. Anyway, the book is a light read and definitely dedicated to those who have an IQ less than 90... and also to those who are above 90. A definite must-read.

Available at: National Bookstore & Powerbooks

Hotel Rwanda: Ramblings and Review

A few days ago, I watched Hotel Rwanda in exclusive pirated DVD at the comfort of my room. I was blown away. This film has to be one of the most haunting, terrifying and traumatic film I have laid my eyes upon. It's 2nd only to Schindler's List in the Top 10 Most Genocide-inducing Films Ever Made.

In a nutshell, the film is about the 1994 Rwandan Genocide and how one man tried his best to save the refugees huddled in his hotel, the Hotel Mille Collines, amidst the uncertainty of being chopped into pieces anytime and the frustration of how to escape hell before hell turns its eyes on them. The Rwandan Civil War cum Genocide, for us, has been obscured by media indifference and by the silence of the Western powers. Bill Clinton even signed an Executive act decreasing the number of American personnel deployed for international crisis. This was just after the killing started in April 1994.

The main reason why those gorill... i mean, Africans went amok and started killing their fellowmen was because of racial hatred. Yep, just like those fat obese rancid-smelling White trash Americans who discriminate any person whose skin is a bit darker than theirs. While in L'etat Rwandaise, the hate was vented on a more collective and orchestrated way. Think of the Ku Klux Klan gone national lynching and hanging anyone who is black.



Anyhow, the story goes that Rwanda was incorporated into the world of European colonies at the start of the 20th century, and they fell into the hands of the Belgians. Can you imagine that little snot-sized Belgium, the southern part of then defunct Spanish Netherlands, have the audacity to rule over the lands and peoples thousands of miles away? I mean, this was a country that was never a colonial superpower and back then, they had no vast resources or military might to speak about. They were the doormat of Europe during the bloody Napoleonic wars, WWI, and WWII. So, in a way, they have no inkling whatsoever how to diplomatically rule over a colonized race such as the Rwandans. They are not veterans in the imperial game, hence, Belgians were greedy and stupid enough to grab vast African territories without even thinking what to do with it. They weren't able to exploit the vast jungles of Zaire (former Belgian Congo) for the betterment of their country like the British in Canada or force their culture upon the natives like the Spanish in the Philippines. They employed cruder administration tactics than the Dutch in the Dutch East Indies (now Indonesia), British in India or the French in Indochina by pitting one peacefully existing tribe against another by means of racial parameters like nose sizes and height. They would say in florid French, "This girl is a Hutu since she has a nose the size of Lake Victoria!", or "This lady is a Tutsi because she's tall as the giraffes of the savannah!" Something like that. (I'm rambling, I know.)

Anyway, the Belgians separated the Tutsis and Hutus based on race, and during their rule, the elite Tutsis dominated almost all positions of government and civil society while the Hutus who were deemed inferior was said to be good only in planting kamote and passing wind. After WWII, Rwandans gained their independence and the Belgians left the reins of government to the already oppressed but majority Hutus. And that was when the Hutus thought of exacting revenge against the Tutsis. The Hutus killed many Tutsis in sporadic bursts of amok-ness (making them into Tutsi rolls) during the 60s and 70s prompting them to flee to neighboring Uganda and Tanzania. And during the 90s, rebel Tutsis (from outside) began to counter the Hutu rage, hence putting both tribes in a tightrope of racial tug-of-war. This is where Hotel Rwanda steps in.



Anyway, to put the story in perspective, the assassination of the Hutu president in 1994 sparked the grand genocide against the Tutsis. This was precipitated by hate broadcast in Radio Mille Collines aired by the Interahamwe (a Hutu militia trained by Hutu-dominated military to terrorize, torture and kill suspected Tutsis by means of machete knives.) They say that rebel Tutsis killed their "beloved" president and they must exact revenge on the accused by killing all the Tutsis they can find. And kill they did.



I can't even believe how a million Tutsis were killed by means of machete knives. They should have imported samurai swords from Japan instead of buying them from China. Anyway, it was more gruesome than Schindler's list. In the movie, I saw bodies litter the highway like flies, whole families lying on the ground face-down dead with their bungalow homes burning in the background, so many militia brandishing their machetes on the streets, naked Tutsi women being coralled in a chicken coop while being abused, and kneeling Hutus being hacked to death in just one blow ala Tiger Woods. It was already traumatic to see Jews being gassed to death, so much so that this movie is doubly traumatic because, fuck, the whole genocide happened just 10 years ago. It was a time when I was having a grand time in high school that this event took place halfway around the world.



It was not just I who was callous and ignorant and indifferent but the whole wide world herself. No one cared. No one gave a damn that a million Africans became Mah-ling in a span of three months. No one even gave a second look that over 40,000 floating bodies were fished out from Lake Victoria. Only Red Cross and other NGOs were brave enough to give a damn. You'll feel guilty watching this movie.



The movie (just a short review here) is spectacular and moving. The acting was superb and the flow of the movie was intense. You know that any minute now, they will all be hacked to death. You can feel the tension of being trapped with no hope whatsoever for these people (since the UN and the Western powers will not bring forces to quell the violence) just like during the Fall of Saigon when many Vietnamese tried to enter the American embassy. You know it's futile and you know it's not the end of the movie- it is the beginning... the beginning of hell. I cried when Rwandan schoolchildren were forcefully separated from their white teacher. One will have an idea that those black children will soon be killed by the militia. You will be riveted in your seat and you'll leave the room with a heavy guilty feeling. But don't worry, the movie is PG13, so no extended hacking sprees were included. You won't regret watching it. Read the reviews because most, if not all, say that Hotel Rwanda is one of the best films in 2004.

Today, the Mille Collines have opened its doors to tourists and the tourists themselves have been coming in droves again to Rwanda to see the black hairy Gorillas (sorry no racial pun intended) and the genocide sites. The government knows that covering that tragic event is futile, so it uses it as a tourist lure. And it's working.

Current genocide occuring in the world today (Yes! It's happening as you comfortably sit here reading this blog!): DARFUR, SUDAN (see pics below)

Twilight of the Gods

Last week, the fair gods of Mt. Olymp... i mean, Banahaw descended upon our humble hospital to do their celestial spectacle. It was our good fortune to witness with our eyes wide open their show. That stupid and insipid Filipino telenovela, "Hiram" shot their third to the last episode in the annex beside our building where the service wards are located. This means that through our glass wall, we were treated to a box office seat to their shooting. Curious enough, our residents were literally stuck at the glass wall trying to figure out who was who inside the annex.

It was already late, probably 8 p.m. when different glinting SUVs paraded in front of the annex and the ABS-CBN van parked its big rear in front of the back gate. We suspected a shooting was at the offing. They practically owned the street. A handful of tambays crowded the street along with their two-stroke tricycles jostling for space. Some our patients' bantays were all agog at our balcony where they witnessed first-hand how the teary-eyed Kris Aquino hugged the equally teary-eyed Dina Bonnevie. Why is it that unlike Korean telenovelas, ours is a continuous one-hour cryfest interjected with infinite permutations of scandal-inducing scenes like slapping, hair-pulling, and public shouting? Even actors cry for no apparent reason. It seems that we measure a celebrity's talent by how much tears, sipon and laway he or she can produce in front of the camera. A very mature way measuring it up.

There were only two takes and it went for like three hours. It was an excruciatingly slowwww process. There were crew members adjusting the lighting, the tomboy directress directing, some stars eating a light dinner in styro packs at the third floor balcony, and some actors milling around watching us eating dinner in our office. My female co-intern was floored that time because as she was making a phone call at the balcony, a male star (Aigenman was it?) waved at her while mimicking her call. She would hound me for the next hour with that diatribe.

After exhausting the initial excitement of seeing stars in the bare flesh, we sauntered back to the wards for our nightly rounds and patients' calls thinking that that was it. They were so far from our visual grasp which confirms the ugly truth that these stars like Kris are protected by an invisible bubble-wrap which no ordinary mortal can reach into. We had this mindset that the closest way you will ever see these stars was to watch them in the television, and not in front of where you're standing.

And also, it was surprising that these stars would start filming at a time when ordinary people are eating their dinners and getting ready to go to bed. It must be very tiring on their part to smile and pander at the camera when their bodies are in need of rest. Oh yeah, it's also tiring on our part to smile and be "patient" with patients when our bodies are equally in need of sleep.

So, at around 2 a.m., I walked to the admissions office to check and update our census if there are any new patients (and hopefully, to interview while they're awake.) I sensed a bit of wierdness that through the hallway, large black cables slithered like snakes in search for prey. I followed it and I was surprised to see a bright light at the end of the tunnel.

It was the feast for the senses. I saw Kris Aquino with two alalays fanning her and doling her with a half-full Starbucks frappucino while the Snow Queen was loudly talking in her natural Game Ka Na Ba accent to fellow stars like the quiet Dina Bonnevie. There were extras sitting by the wall- nurses, doctors, patients and relatives. I saw Heart Evangelista stood and took her cue. She lied down in an ER stretcher with ketchup blood in her stomach, just like Ann Curtis who was already lying down in hers. Obviously, in this episode both of the teen princesses will be fortunately shot at their entrails. In real life, that would be a blast.

I saw my partner at the end of the flood-lighted, cable-strewn hallway wherein I signaled her to come over my side so she could have a vantage point in observing these demigods. I just realized that these stars were real people, like you and me, made of skin and bones- not unreachable gods that TV project them to be. They actually sat on those bacteria-infested curved metallic chairs where the asses of patients and relatives once rested. They're not so special at all. And at 2 a.m. in the morning, it was unbelievable. They must be really tired now.

After they set up the flood lights (which heated the room to a microwavable level) and positioned those 70s cameras and after they prompted the extras in uniforms, the directress shouted "Action." Immediately, we saw the ER personnel hurriedly (leisurely to be more exact) brought the two bloodied stretchers into the Emergency room. And (ho-hum!) a teary eyed Kris went to this actress and Mr. Aigenman and hugged them. Instant tears! And cut! At one moment, she was clarifying her actions with her directress in a voice dripping with aristocracy and suddenly, she quickly changed into a crying and affecting victim.

At long last, we were able to pass the shoot so as to go to the Admitting Office. As we deviously passed by, I can't help but steal a long hungry glance at the stars. Dina Bonnevie was sexy as usual, I mean for a lady that old, she's still sexy. As for Queen Kris, I can see the fats of her cheeks were already sagging and a few stress lines furrowed at the edge of her temples. But she's still regal and pretty (for her age). And Heart was a waif-life creature exuding a warmth of the studio's floodlights. Mr. Aigenman was already teetering into dozing off. They were all human beings endowed with imperfections. It was a really nice epiphany.

And after getting an updated list (thankfully no one was added then), we returned to our office to retire- but not with a smile reminding us that we have witnessed something special and that we shall keep this fleeting memory in our hearts forever (yeah, right! Probably for a week!). A night with the gods was simply too much for mere mortals like us.