My Discovery of Medicine 1: Beyond the line of duty

This was written for my final comprehensive examination to graduate from Faculty of Medicine. We were told to write a reflection on our self-progress..and I think I went overboard, but I am quite happy I went overboard. This excerpt was used also in the book "Mendengar Tanpa Stetoskop" (ISBN:978-602-14463-0-0) in Indonesian. There`s also a video series following a group of medical interns around Indonesia with the same title. Check it out! It`s a good window to glance the Medical Education world. 

I modified some parts of this reflection for publication purposes. This begin with some personal experiences while I was still a medical student. Then it continues to show how it influences some realizations and hence the reason why I am convinced enough to always keep them mind and practice.

 I think some things I wrote here are obvious by nature, but I would like to share with you the story of how those obvious thing became a deeply influencing memory to a person. How something turn from "yeah, I know that because I heard that before" to "I know how that feels". The difference is subtle, but "knowing" and "feeling" is very distinct for my personal development. Medical education is long and notoriously arduous, there are many reflections I made before and during the journey. This is just one of them. I think I`ll publish more of those in the future under a series or something.

My Discovery of Medicine 1: Beyond the line of duty

The patient had been there for more than 1 week. I was not the first one to clerk him, my friends did that before me. But they have rolled onto the next hospital and so it was my turn. The patient first presented with blood in his vomit. He had history of hepatitis C complete with liver cirrhosis. It was quite difficult to obtain information from him with his decreasing consciousness. I took a look on his naso-gastric tube liquid container; it was reddish black, not a good sign. His blood pressure was low, even more worrying sign. I contacted the resident and told her what was happening; she instructed me of some management and carefully detailed the methods of administration for me to do. I understood completely, in this district hospital, patients were horrifyingly abundant. I felt worried, not actually scared, because I knew that the residents instructed me the right thing based on appropriate guidelines.

But my night did not end there. On the exact opposite side of the room, another patient had shortness of breath. I had no idea what was wrong with that patient. I went to the nurse station and read his case-notes, he had pyogenic empyema. I recalled back my memories from the pulmonary rotation days. Not much there, I think I had too many TB patients. Never mind, I thought, inform resident, check what type of respiratory failure, order some blood check. As i was writing them, one of the nurses called me that the patient was already on respiratory arrest. I went in the room, started CPR reflexively and asked the nurse to get me a bagging mask, simultaneously communicated with the patient's family of what is happening. They went berserk with cries and prayers. They surrounded the patient, making me suffocate in the already small space of that ward. I excused myself, and asked the nurse to do chest compressions, while i rushed for the bag. I came back, started bagging, and informed the family of the situation and gave them the option to stop me. They gave up. I gave up with them. His pupils were fully dilated, ECG was flat. He passed away.

After that, I administered various managements to the first patient. I read up on some blood pressure modifying medication and applied them. Went around the other wards when needed, but always came back to the ward to check on his blood pressure every 30 minutes. 2 hours later his blood pressure dropped lower, the nurses helped me measure for confirmation. 1 hour later his condition was worsening, and as I called for help, this time the nurse brought a bagging mask. However, the patient passed away after the family decided to not resuscitate him. I thought maybe this family saw the entire ordeal of the previous patient and decided to spare their relative the pain. Which is a very somber thought but I could not help to draw the possible connection. Also, I felt that the nurses were more willing to help me after they saw me so desperately helping the previous one. They talked to the family members and very readily prepared the appropriate equipment. Later on I figured, obviously the nurses have faced such condition much more often than me, and were literally physically and mentally more fatigued. 2 patients passed away, in the same ward, just a mere 2 meters from each other. On a light chat event between me and the nurses, they told of how often such things happen. There are cases where patients progress for the worse when there is no doctor to see them due to their workload, and to top it off, there is no family member that fully understands the situation. Hence, the commotion ensues.

From here I realized that being a doctor is a heavy job, for both the body and the spirit. But above all that, the situation is also hard on the patient's family. They are absolutely clueless on what is happening to their relatives. They do not have the 6 years of education that I was privileged to have. The nurses are also tired and in some extreme cases have accepted the fact that some patients may not survive. From this I think it is then important for me to realize that I have to help them ease that burden. First, always inform family members of the patients progress, this seem to reduce (although not completely eliminate) unnecessary panic or commotion. Also, well informed family could save time during emergency situations because they might be able to make decisions faster (although not by much). Second, always earn good relations with the caretaker unit, nurses, pharmacists, etc, they are my investment and my patients' investment for well-being. Third, despite the hard work, I must find a way to rest myself physically and mentally, because without them, I would not be able to perform above the average doctor, which includes the earlier 2 steps.

“Performing beyond the line of duty” that's a phrase that I often hear in movies that I think applies very well in the medical world. The previous recounting of my experience reminded me of another event that etched quite deeply in my mind which was during a night-shift duty in the emergency room, resuscitation section. It was the end of 1^st year clerkship, and the story went that at the beginning of the shift, there were 5 patients, 4 of which in a critical condition. My friend and I spent 2 hours manually bagging a patient with lung cancer that progressed to respiratory failure. After that, we assisted in managing a patient that attempted suicide, whom, after 1 hour of resuscitation efforts, finally managed to succeed. In the end, 4 of them passed away at the end of my shift. Granted they were all very difficult cases or chronic diseases with difficult complications, it was still an appalling experience for me to see 80% mortality rate in one night shift. After that night-shift, I couldn’t sleep, and decided to take a morning jog instead. During that, my mind raced to realize that, even during the entire previous year of clerkship, most patients that I found were already in a chronic condition with bad prognosis, more in terms of their quality of life more than their life itself.

I then briefly researched on the numbers of mortality in Indonesia even after the advances of medical sciences. I found out that at least we must be doing something right, because the age expectancy has increased over the years. However, I then observed a rise on degenerative diseases that are more complicated in nature in terms of their progression and prognosis. For example, diabetes mellitus type II is a disease that slowly progress that somehow would not disturb their patients quick enough to make them realize that their compliance to medical management (both pharmacological and non-pharmacological) is crucial to ensure good quality of their life. However, our medical services still face many patients that default their management and came with complications that are often irreversible. From this I realize the need to educate my patients. I should find out ways to be able to reach their level of communication individually to ensure that they also play a part in their health management. First, I need to cover the wide array of management necessary for a disease. I think I will start with the most notorious one, diabetes. Second, I would habituate myself to convey to patients how important it is for them to work together with me to ensure their health. I will try to avoid ordering words, but instead try to reach an agreement. Finally, I would try my best to follow them up using appropriate documentation methods.

Following up on the previous topic of the wide variety of diseases I have faced. I often feel overwhelmed in realizing that as a doctor in Indonesia, I would be facing a metaphorical battle in two fronts now, infection and degenerative diseases. On the sidelines, diseases such as vitiligo, rheumatoid arthritis, scleroderma, and many others are somehow more unobserved, not because they do not exist, but because they exist in smaller numbers in comparison to the major players like cardiac-related diseases or infection. It should be noted that many of those diseases, both infection or degenerative, still lead to many confusion in our daily practice on how to manage them individually and whether the treatments that we figure from many western sources are actually applicable to my patients. The use of Evidence Based Case Reports that were taught to us during the clinical years was an immense help, but I could not help but feel how we should be applying that method to more local papers than international ones. Often, in the last section of “applicability”, there is a slightly forced answer on how the paper would be applicable to the patient that I am facing then.

I have found out since then that research is the big elephant in the room for the Indonesian medical society. Many people have realized its importance, but only a small amount of people are capable of doing it due to many barriers such as opportunity and of course, financial barriers. From my time in Newcastle I learnt that everywhere in the world, research is facing a problem because people have not realized its importance, especially in developing countries like Indonesia. Thus, to see this through, I realize I should first, at least make the habit of making research to always exist in my target. Second, it should be possible to at least come out with a research proposal at least once a year and try to get it through to funding bodies, or suggest them to research groups that needed the input. Thus, third and perhaps most important, I need to insert myself to research communities, perhaps take part in seminars or research meetings, either inside or even outside Indonesia.

Finally I would like to come up with my biggest fear from my future in being a doctor. I would like to describe my feelings as if being a doctor is fighting a battle in the large war against diseases. Individual patients are saved daily, but what if in the big picture; we are actually losing the “war”? This feeling best depicted using the race of antibiotics vs. antibiotic resistant microbes. As the world develops more antibiotics, the unregulated use of them would lead to stronger microbes, which would lead us to spent, more money to develop stronger antibiotics. The microbes needed no resources to become stronger, but we spend so much capital to find out what’s our next step to eradicate them. This is proven in both developing and developed country through the many papers they’ve written about how to regulate their antibiotic use.

Diseases such as Systemic Lupus Erythematosus are chronic, cannot be fully cured but can be managed. This is largely due to the largely unexplored realm of auto-immune diseases. I view these diseases as very depressive case. No matter how good a medical treatment I give, the patient might just be that one with the “different genetic sequence”, or “the undiscovered population”, that lead to death. I realize this also occur often in cancer patients undergoing their radio or chemo or surgical therapies. Often I feel how sad they must be to know that their life is an uncertainty. And sometimes, it made feel, what is it really that I can do as a doctor? What is it that I am supposed to do?

In the end I realize, the major quote in medicine “to cure sometimes, to relieve often, to comfort always”. Which is quote from dr. Edward Trudeau, founder of the tuberculosis sanatorium, which also intriguingly was used as a real medical article published in 1985 by Normand P. Da Sylva MD, about assisting narcotic addicts to their supposed recovery. The sentence that helped me feel better was “Let us not forget that many diseases cannot be cured; they only lend themselves to some form of management.” So from here I see that first, I need to obtain a somewhat stronger spiritual stance for myself to avoid myself from getting unnecessary stress from incurable ailments. Second, need to ensure that I evaluate the right things from my patients. Some patients may need more quality of life evaluation than their medical progression. I should realize that people have different priorities. Finally, I need to ensure that I enjoy medicine not only to cure diseases. Don`t get me wrong, of course of utmost importance is the ability to solve the patient`s medical problem, in all periods including, but not limited to, the preventive and curative periods. But beyond that line of duty, there is also my view of the importance in assisting patients live their life to their fullest despite their medical condition.