Jitters

For the past few months, I've constantly re-vamped my work - I've been going on/off in different clinics, various schedules almost everyone is confused regarding my work schedule. They've always asked me "My bago ka na namang clinic?" I know they're confused. Me too.

Like before, I'm going through another series of changes starting next week. Today (as of this writing) is my last day here at Tokyo Healthlink in Makati. After less than 4 months of being their part-time Family Physician (from a reliever promoted to a regular physician just in the middle of June), I resigned one week ago due to personal, professional, and financial reasons.

My mother company, Health Delivery Systems Inc. recently has tied up with Philippine Long Distance Telephone Co. (PLDT) to be the third party outsource to man their different clinics in select branches. HDSI has recruited lots of specialist physicians, nurses to be assigned in different branches. I was offered this job & accepted the offer. In exchange, I had to leave Tokyo Healthlink.

Yesterday, we had our orientation regarding their electronic record system. Their system is very different, more complex in comparison to what we have in Health First. During the entire orientation, one thing was in my mind "Nosebleed ito!". There were more tabs to click, but with few available characters, more complicated steps. I got more & more confused because they have a system uniquely their own. Immediately I became worried, nervous about my performance on the first few weeks. Adapting to their system will take some time (but not too long, hopefully). Being the first doctor to "start the ball rolling" every tuesdays, punctuality is the top priority. I have to brace myself for a more toxic workload than in Health First.

After the orientation, I had many reasons to go back to HDSI Office. I signed my contract with PLDT, tried which size of long coat fits me for use at PLDT and anywhere else that is a client of HDSI (like in my case, at DMPI and Health First clinic itself), posed for a 1x1 picture & specimen signatures for our IDs at PLDT, filled an application form for an HDSI privilege card. I thought "Finally! They're starting to treat me like one of them" since I'm starting to get privileges.

However, this journey was not smooth-sailing. I went into argument with one of their HR personnel several times before; I almost thought of refusing this job completely. Since this is the beginning, taking an absence, looking for relievers is not being considered for now. I made some sacrifices, I postponed some personal matters. It was hard for me to accept at first & after crying through it, I thought that this job is the priority & it will be for my best.

But really, as early as now, I'm having jitters when I think of tuesday next week. Waah! Goodluck to me (& to all of us as well).

Advanced Cardiac Life Support (ACLS) Training

After successfully passing the BLS training, I can now proceed with the Advanced Cardiac Life Support (ACLS) training. During those 1 1/2 days, we were handled by 3 different ER physicians, and 1 anesthesiologist. Comparing to BLS, this is more difficult, more nerve-wracking, more stressful - more different algorithms to learn, more ECG tracings to identify, more drugs to give.

Prior to class, we were instructed to visit the website of AHA to read their supplementary discussions regarding ECG interpretation and pharmacology. They will not be discussed in class. Furthermore, we were also instructed to answer a pre-course evaluation, print the results, and submit it to class.

The class was already divided into two groups, alphabetically.

Day 1, July 7, 2011

2 to5:30 pm 

More videos were shown and we still had practice sessions regarding Rescue Breathing, BLS Surveys. No surprise, there were practical exams regarding them, but they were all a "piece of cake" (since we just had our BLS hours ago). Unfortunately since we started late, we also finished later than planned. Plus, we weren't able to discuss Acute Coronary Syndromes (ACS) as scheduled because we ran out of time. Prior to dismissal, we were all instructed to read our books, study the checklists (found at the appendix section) in preparation for the Megacode the following day.

I did try to read but I was distracted by something else, and it's not related to ACLS.

Day 2, July 8, 2011

8am to 7pm

I arrived at the place 30 minutes earlier. Everyone was talking about the Megacode, saying that they're unprepared because they just slept the entire night, they can't wait for the day to finish, blah blah blah. When we entered our classroom at quarter to 8, we saw that the mannequins, cardiac monitor, other equipment were ready. Gulp! It was going to be a loooonnggg day.

We met 2 different physicians - another ER physician and an anesthesiologist. One of them began to worry about our schedule since we failed to discuss ACS the previous day. Like a domino effect, the succeeding topics were adjusted as well. All of us bore the consequences - the discussions regarding the algorithms were fast, next thing we knew we were being tested individually as team leaders (but it wasn't graded). We were being criticised, corrected, reminded constantly.

My preparation for the course paid off - since most of our decisions, orders are based on correct ECG interpretations, I was able to go through the practice session well (when I was the team leader twice - cardiac arrest algorithm & arrhythmia algorithm). My groupmates had a hard time reading the ECG tracings that they kept on looking at me for answers or clues on what the tracing is. Ironically, some of them were physicians.

Thankfully, we had time "to put it all together" as a review before we went into the dreaded Megacode. We were given time for CR break, last few minutes to read our manuals. Then, it started.

My case was ok, but I had some flaws - my case was again Stable Tachycardia. I should've been lucky to get the same case twice but I screwed up. My instinct told me to do vagal maneuvers [when the QRS complex of the tracing went from regular-wide (I already gave adenosine 6mg) to regular-narrow] but I listened to my groupmate's whisper, telling me to give adenosine 12mg & I ended up doing that. Wrong! One cardinal rule - always follow your instinct. The other one was a SVT that was pulseless. I told the facilitator it was Pulseless VT and following the algorithm, I ordered for a shock. I was wrong again! It was PEA. I learned about my mistakes afterwards. I was able to see my paper and the remarks were high. Well, not bad but I'm not happy either because I felt I had an easier case, compared to the others. I had no excuse for messing up.

After the megacode, we weren't done yet. We still had the written exam to take. The rule was to obtain a score of at least 42 (or 84%) out of 50. Otherwise, you'll have to undergo remediation with 1 of the facilitators. I was the first to finish and I got exactly 42. Whew! It was more difficult than the BLS exam, because it asked questions all the way from the previous day's topics & it involved cases. Among 12, only 3 students (myself included) didn't had to go through remediation. We graduated from the course ahead of the others, claimed our IDs and certificates, and left the place; while the others have to wait more, go through remediation before they can get their IDs and certificates (if the facilitator is satisfied). I observed that if most of my classmates were prepared for this, we would've gone home earlier.

Once again, we were told to answer a course evaluation for the ACLS. Just like yesterday, I gave the course high remarks.

With regards to the current AHA guidelines, they are more simpler, easier to understand. There are major, major changes and it will take awhile for those changes to sink in & be actually applied. I just hope that everyone, physicians and non-physicians alike, will be able to apply it & be able to save lives.      

Basic Life Support (BLS) training

I underwent a basic life support (BLS) training last thursday at Global CE of America in Sta. Ana, Manila. This is my 3rd BLS training course, but my 1st training that is AHA (American Heart Association)-accredited. It's more expensive than my previous trainings but it's worth every penny.

Actually, I enrolled into 2 courses - BLS, and Advanced Cardiac Life Support (ACLS). Of course, you need to pass the BLS before progressing to the ACLS. During my enrollment, I paid half of the course fees and received the books for advanced reading. I started to prepare a week earlier, and read the BLS manual in just 1 day. Preparing for the ACLS was longer because I also had to review certain ECG tracings and pharmacologic drugs. We were instructed to arrive at class on-time since there are so many topics to discuss in such a limited time. Still, some students arrived late. Oh well... Old habits die hard.


Day 1, July 7, 2011
8am to 1pm


Our BLS instructor, a dermatologist by profession, started on time. After a brief "getting to know you" & laying down of the house rules, we proceeded to watching the videos followed by practice sessions with the mannequins. No lectures were done. The videos simply reiterated what was written on our textbooks, and it also serves as a review. Since AHA regards as all as professionals, they treat us as adult learners. No spoon-feeding. Personally, it's better that way because you're after the skill, the correct manner of doing it. Each part of the BLS algorithm was discussed & shown clearly - starting from 1-rescuer, we started with chest compressions then mouth-to-mask breathing, then 2-rescuer now with the incorporation of an automated external defibrillator (AED) & the correct way of switching roles. It was followed by the child BLS (which was faster) and finally the infant BLS. Like in the adult BLS, the steps are almost the same except for the manner of doing chest compressions, and the ratio of compression-ventilation when there are 2 rescuers. The video also showed how to relieve patients from choking - both in the adult and infant.

Of course, we are evaluated by 2 ways - a practical exam and a written exam. If you've read the book & watched the videos closely, the written exam will just be a "piece of cake". The practical exam is easy too. If you watched the videos closely and took the practice sessions seriously, then it will not be a big problem. You can be criticised by your instructors but they will be just few or minor pointers for further improvement.

In return, we also evaluated the course, the instructors, the place. I had no complains and I gave them high remarks in all aspects. I didn't put on any comments, and I couldn't think of other suggestions for improvement. I was completely satisfied & happy for what I came for.

In the end, I got my ID and certificate. Their valid for 2 years.

I was asked by the Operations Manager if I want to be a BLS instructor with them. I said sure (since being a BLS instructor is a "plus" factor not only for my resume but for practice as well. Oh yeah, source of additional income. Haha!). This seems promising for me. :)  

Clinic Blog 1: GERD

Almost 2 years ago, we organized a post-graduate course about Respiratory Diseases. It was well attended, and a successful one following its predecessor course which was an utmost or near failure. The last topic of the said conference was about Chronic Cough. What set it apart from the other topics that day was that it was the only interactive session and we asked help from UMED. The take home message was simply for cases of chronic cough, think of three differentials - pulmonary (PTB), allergy, or gastrointestinal (GERD). Thankfully, everyone enjoyed the fruitful and productive discussions.

Yesterday, I was able to apply what I've learned from that session. I had a female patient, with 3 months history of dry cough. She already took different classes of cough medications (mucolytics, cough suppressants, etc.) in the past, but nothing seemed to work. She also underwent chest x-ray with normal result, and sputum AFB for 3 days which all yielded negative results. Last week, she sought consult and was also prescribed with a broad-spectrum antibiotic (claimed to be compliant) because of upper respiratory tract infection. There was slight relief of symptoms but the cough was still there.

I extracted that when she was still working with her previous employer, she had several episodes of skipping meals and/or not eating on-time; she drinks coffee (1 cup a day), softdrinks, and loves spicy foods. She also experiences burning abdominal pain at the epigastric area radiating to substernal chest, bloatedness, and early satiety. She doesn't smoke, doesn't drink alcohol, and doesn't take any NSAIDs. There were no BM changes, dysuria, nausea/vomiting, weight changes. I was zero-ing on GERD. My physical examination further proved my point - (+) epigastric tenderness, tympanitic abdomen.  I explained my clinical impression to the patient (& her companion). I prescribed her medications now targetting against the acid reflux which could be the source of her cough & explained my management approach (lifestyle, eating habits, etc.).

All now I could do is hope and pray for her.

E-Records

Yesterday, I had the privilege to be a reliever in Health First Clinic in Shaw Blvd, Pasig for the first time. Just like in any typical clinic, there were consultations and pre-employment medical examinations to be conducted. I was surprised to learn that they strictly use electronic medical records (or E-Records for short) from queueing of patients to charting/documentation to laboratory/ancillary procedure requests to dispensing medications and billing of consultation charges. Thank goodness, I don't have to call out the patient's name because all I had to do was call the operator and page for the patient. Since the clinic has its own pharmacy, I had to enter electronically the medicines I will prescribe then the pharmacists will hand it to the patient. Unless the medication is not available, that's when I do it manually and the old-fashioned way. The same goes for laboratory requests - just type it in the computer, instruct the patient to go to the laboratory. Of course, laboratory results can be viewed in their intranet as well. Not surprising, the x-ray plates can also be visualised in the computer without going out of the room. Previous consultations are also stored in the database as well. Convenient isn't it?

How I wish all clinics have this kind of system in order to avoid clutter, piles of papers/charts in one side of the room, occupying a big space. Imagine the trouble of pulling out 1 chart when you have so many stacked up, piled up.

On the downside, hopefully they have a generator if in case there's power failure. And a back-up system if the system hangs or the computer has been infiltrated by a virus. For our mentors who are not used to paper-less system, this could pose as a challenge for them.

What Can I Do?

For the past three years, I only knew a little about the real health economic status of my country. Most of the patients I have encountered "can afford" basic laboratories, common medications. I was fortunate that the hospital where I went at have complete (well, almost complete) facilities. They follow-up at your out-patient clinic (as instructed), and everything goes well. In the ER where most patients are HMO holders or employees of affiliate companies, requesting for laboratories and/or ordering for medications was simple - just write it on the chart, nurses either encode the lab/get the medicine from the pharmacy, and patiently wait for the outcome. Sana ganun sa lahat, pero hindi.

This month, I started to work as a medical officer in a public hospital (primary-type, based on hospital bed capacity). Since most of my duty schedule was concentrated in the emergency room, I am always faced with the concern that the relative and/or patient has little to no money. I usually encounter a dilemma on how to come up with even just an initial clinical working impression (among my differential diagnosEs) when my patient cannot afford to pay for a simple laboratory examination. I cannot treat a patient who comes at the ER because he doesn't have the means to pay for a medication. Worse, the hospital has incomplete facilities - the laboratory can only process urinalysis, fecalysis, capillary blood sugar requests; the rest have to be sent or done outside. Likewise, the pharmacy has incomplete stock of medications. As faced with this scenario, paano naman kapag emergent na or urgent yung case? I pity the patient.

Just like in 1 of my previous duties - I saw an unstable patient. We sounded the "code blue" but we were really slow and delayed with our approach because of incomplete stock of medications. The relative was out & late in buying the needed medications. We can only use whatever is available. Eventually, the patient expired. I can only shake my head in disbelief & dismay. I believe we could have saved him. If only... I wonder if the management is really concerned about their patients. Of course, probably not. Imagine if there was a customer satisfaction survey conducted, the hospital could have failed in all aspects, big time.

I know that this is not unusual. For colleagues who have trained in public hospitals, this is very common & this always happen. Kawawa naman si Juan dela Cruz kapag nagkakasakit siya. He ends up six feet under.