As I was doing my rounds on my first week as an internal medicine resident I discovered in terror that one of my patients, Mrs. Tonya Mae Horizon, was gasping. I shoudn’t have been too surprised—when she was brought in she was so dehydrated that the searing heat in the emergency room did not elicit a drop of sweat. Her pulse was thready, she was having explosive bloody diarrhea, and the left half of her face was converted into a huge purple mass with patchy areas of encrusted pus and decay. She would have gone into cardiac arrest had it not been for the swift resuscitative efforts of the Emergency Department residents, but she needed an ICU stat!

The ICU, of course, was full. We had to improvise: she was moved to a bed beside the nurse’s station in the ward, her teenage son was advised to keep watch at all times, and a medical intern had to check her vital signs every one hour. This hourly monitoring, also known as “Q-1” monitoring, involved manually taking the patient’s pulse, respiratory rate, and blood pressure.  Q-1 monitoring was horrific for the intern if there were many patients to monitor—like the usual twenty—because by the time you finish one round you are already up for another. Ideally patients at the wards should be stable enough to only require monitoring every 4 hours, ie “Q-4”, but the ICU’s were perpetually crammed like a hovel.

The most intense monitoring duties I ever had as an intern happened at the pediatric wards. Kids were not always cooperative, and I was terrified of parents glaring at me. But what I hated the most was having to lug around a huge plastic basket containing blood pressure apparatus cuffs in different sizes. The right cuff size should fit the arm snugly to get blood pressure accurately, and in pediatrics patient size could range from a toddler with kwashiorkor to an adolescent with metabolic syndrome colloquially described in those ancient times as “napabayaan sa kusina”. On one such duty night I was summoned by senior pediatric resident Dr. Felicia M. Butters for “not taking monitoring duty seriously”. As I approached her in the nurse’s station, sipping Chillz and eating a hotdog sandwich, I saw Dr. Butters gripping in fury a patient’s monitoring sheet. It was only 2:45 AM, she yelled, but why had I already written some of the patients’ vital signs for 3 AM? Apparently word had reached her that the monitoring interns were slacking off, so she decided to do a spot check in the middle of the night. She wagged her fingers at me in disdain, and threatened to tell on me. What if the patient suddenly dies at 3 AM, she asked, but the monitoring sheet reflects normal vital signs?

“You’re doing ‘Q-Tingin’!” she sneered.

Dr. Butters must have thought that she sounded super cool using the younger generation’s slang like “Q-Tingin”, but she was wrong. I didn’t do a “Q-Tingin”. “Q-Tingin” involved taking a cursory glance at a patient, and then writing down the assumed vital signs on the monitoring sheet. For instance, if the kid was playing brick game then the blood pressure must be normal enough. Therefore, 120/80. “Q-Tingin” was pure guesswork, pure laziness. What I actually did was the more sophisticated—but no less reprehensible—”Q-To-The-Future”, which entailed actually taking the patients’ vital signs at 2:30 AM, and recording it as the vital signs for both 2 AM and 3 AM. There was an unrealistic number of patients to monitor at the time, and I thought I should take matter into my own hands—sort of trying to game an unjust system and conveniently taking on the persona of a social justice warrior. When my friend, Myra Lala, went to Atlanta for her residency training in pediatrics she started manually monitoring her patients out of habit and was berated by her seniors. “You’re not a machine,” they told her. “Hook the patients to a cardiac monitor!”

Dr. Butters eventually calmed down. She dismissed me with a wave of her hand. I had to stop myself from saying that my 30-minute Q-To-The-Future was innocuous compared to some interns’ 3-hour Q-To-The-Future, which means getting the blood pressure at 1PM and recording it as the BP for 2PM, 3PM, and 4PM. That would have made her storm the interns’ quarters to start a massacre. All the interns would then wonder who the nasty whistleblowing little traitorous bitch was.

Mrs. Tonya Mae Horizon was a re-admission. Her previous resident doctor, Mikey, insisted that she had been well and much improved upon discharge weeks ago. I reviewed her thick records and discovered that she had been confined in the charity wards for almost a month for the treatment of the soft tissue infection on the left side of her face. But now Mikey had already been promoted to second year resident status so I, the new first year resident in the service, became Tonya’s primary doctor. I was a blank slate, a blubbering idiot with no significant clinical experience at this point, but I was face-to-face with the gasping Mrs. Horizon and I had to save her. Her oxygen saturation was down to 82%. Without immediate intervention she would go into respiratory fatigue and drop dead.

Running on adrenaline and a previous experience of having only one successful intubation (on a mannequin), I inserted a tube into her windpipe to help her breathe. I sighed in relief as air and phlegm, instead of rice and tocino bits, spurted out of the tube.

 “I inserted the tube in the correct hole! The correct hole!” I wanted to scream and cheer right that moment. I wanted to announce it to the world, and jump for joy while clapping triumphantly, but I would look kind of shallow.

This tube would then have to be connected to a mechanical ventilator, a machine that automatically pumps pressure and air into her lungs. Having no money to rent such a machine, someone would have to sit by her side and manually deliver air using a bag valve mask, a rubber balloon the size of a football. Continuously. Her only companion at this time was her son, Manolo. I instructed him that the bag would have to be manually pressed with both hands, with sufficient pressure, otherwise the patient would not receive enough oxygen. I promised the shell-shocked Manolo that I would suck ten dicks just to get her a bed in the ICU, where a couple of mechanical ventilators could be used for free. In the meantime, Manolo would have to be the machine. Still on a high from my successful intubation, I happily left them to see twelve other patients, four of which also needed to be in the ICU.

A few hours later, all the occult aneurysms in my brain ruptured at the same time when I saw Manolo lazily pumping the bag with just one hand. The bag was resting on the bed foam, and he was sort of just pressing it with his left hand like a quiz show buzzer. At times he would press it with his left elbow.

You have to do this properly, I started to raise my voice. I grabbed the bag and did a demo. “Witness your mother’s chest rising as I’m pressing the bag with both hands. See? That’s because I’m supplying her lungs with enough air, Manolo,” I scolded with the most annoying, patronizing voice on the planet. But before I could even continue with a self-righteous rant about how her mother’s life literally depended on his hands—as if melodramatics had ever really helped anybody in such a dire situation—Manolo raised his right forearm and revealed a stump because he had, in fact, no right hand.

“This cannot be happening,” I thought, my eyes popping out in disbelief, those same brain aneurysms sealing and re-bursting, not out of irritation but out of embarrassed mortification. I apologized profusely, and contemplated whether the polite thing was to ask how he had lost his hand, or to not ask how he had lost his hand. It didn’t matter eventually because I quickly began mumbling and stammering apologetic platitudes. It’s congenital, Manolo quickly explained to this bewildered monster, as he must have done so to the other bewildered monsters his entire life.

I was able to get a bed for Mrs. Tonya Mae Horizon in the ICU. She died just after 24 hours.

“We don’t know the exact cause of death,” my senior, Maria Badelle, whispered as we scampered to review her old and new records.

“Definitely an infection,” I said while flipping through the chart. “The huge mass on the face looks like a cellulitis, or maybe it’s an infection on top of a hidden cancer.”

“But it’s been drying up,” Badelle said. “She had been given almost a month’s worth of meropenem in her last admission.”

Dr. Gemma Lynne Roxas, the infectious disease specialist who previously handled her case, concurred with Badelle’s assessment. She confirmed with pride that in Mrs. Horizon’s previous confinement she was able to get funding for a full course of free meropenem, one of the most powerful antibiotics in existence that could eradicate most types of bacteria. They had sent Mrs. Horizon home totally stable, with the infection on her face completely healed.

“Or maybe it was just severe diarrhea,” I said. “Maybe it was severe gastroenteritis or food poisoning from something she ate.”

“But she was already sufficiently rehydrated. The diarrhea was notably bloody.”

“Colon cancer? Diverticulitis? Amoebiasis?”

“I don’t know,” Badelle said. “Do we have the results of the stool exam? The blood cultures?”

“Not yet. What should we sign out in the death certificate then? Dr. Bludgeonella will ask for details. What if I get audited? It’s my first week and someone already died!”

 “I… don’t know.” Badelle said, her veneer as an all-knowing senior slowly starting to crumble. “I don’t know Will.”

“I know what caused her death,” Magnesia, our intern said. Badelle and I shot her a look, waiting for an out-of-the-box diagnosis which, in retrospect, would make sense and explain every single thing about this case. Something really exotic, like “Churg-Strauss Disease” or “Bovine Spongiform Encephalopathy”.

“Well, why don’t you tell us Dr. Magnesia?” I asked, annoyed at her deliberate attempt to create build up for a punchline.

 “Poverty,” Magnesia said. “Poverty.”

Obviously Magnesia had a point, that disease has a major socio-economic component, that healthcare is a political issue, that the disease of one person is a disease of the society at large. But it was obviously not what we were looking for at this very moment. So even though I didn’t really mean to—it just sort of happened even if I had no intention of being totally dismissive—I rolled my eyes.

“What we need to write on the death certificate, Dr. Magnesia, is a disease,” I said. “We need a diagnosis, not a punchline!” For two seconds I felt proud of what I thougth was my own witty punchline, then cringed at this corniness.

“There’s only one solution,” Badelle said. “I think an autopsy on Mrs. Tonya Mae Horizon will clarify things!”

Mrs. Horizon’s sister said that yes, she would consent to have the autopsy. As soon as the words came out of her mouth she and Manolo burst into tears. Having the relatives consent for an autopsy was rare. Usually the relatives would just want to go through the grieving process as quickly as possible, and nobody liked the idea of their loved ones’ remains being cut open.

While I was happy that the cause of death would eventually be revealed by a pathologist’s post-mortem examination, I also felt dread. An autopsy was almost an automatic indication that I would have to present this case to a medical audit. In an audit, a dead patient’s case is presented to a huge audience composed of consultants, fellows, residents, and medical students. It was a free-for-all in the scrutiny of how you managed the patient. The general mood in each audit varied widely. Sometimes the consultants were in an intense fault-finding mode. In certain occasions, they would get distracted and end up making chika with one other.

A couple of weeks after Mrs. Horizon’s death Badelle and I went to the pathologist to get the autopsy report. We expected that we would be handed a thick sheaf of papers to help us with the presentation, but Dr. Cholo Mirasol, the senior pathology resident, asked us to sit down. “Make yourselves comfortable,” he said, as we looked around at the unrecognizable body parts and creatures swimming in formalinized transparent jars.

“Okay let’s start. The brain,” Cholo said, as he slid a huge glossy photo, face down, on the table towards us.

We flipped the photo up and saw Mrs. Horizon’s dissected brain.

“No significant findings in the brain,” Cholo announced.

We nodded.

“The eyes,” Cholo said, handing us another photo like it’s an illegal substance. “No significant findings.”

Badelle and I pretended to scrutinize the photo and nodded.

“The neck…”

Oh we’re doing it this way, I thought.

“The liver…”

Just as Badelle and I were starting to plot an escape out of boredom, Cholo said, “And finally, I want you to look at the photos of the cut intestines…”

Badelle and I looked at this last photo, and yelped.

II

Mikey gave me the following pieces of advice as I prepared to get grilled, skewered, eaten whole, and regurgitated in the audit: smile, give a faint nod, mumble yes, yes thank you yes, and in general put on the facial expression that says you’re willing to learn and that you appreciate their comments. All these, even if in your heart of hearts all you want to do is to get the hell out of there. The goal is to not sound disingenuous.

I looked around the conference room jampacked with senior consultants, junior consultants, fellows, senior residents, junior residents, interns, medical clerks, and medical students. This hierarchy of medicine reminded me of my mother’s comment some twenty years ago when she was trying to urge me to become a doctor: “Magdoktor ka dahil ang doktor, walang boss”. Hah! As I soon found out, it was an endless series of bosses of various virulence, like the boss fights in Super Mario Brothers. It was a ladder with many, many rungs, a staircase with many, many steps, a narra tree with many many rings, a pyramid with etc.

Cheapo, my batchmate, was supposed to raise her hand in the middle of the audit because I had assigned her to ask a planted question. I had to stoop that low—I had two hours to fill and was warned that many of the consultants would be attending. A few hours prior to the presentation I was contemplating on whether Cheapo should ask a legitimate question such as “So in thrombophilic patients presenting with lower gastrointestinal bleeding…” or something totally cheap like “Sorry I think I missed it, how old was the patient again?”

Cheapo, however, never got her chance, because the-powers-that-be in the audience started saying all kinds of things–to each other. Dr. Creutzfeldt K. Jacob, Jr. raised his hand, asked a question, trailed off to give his own explanation, murmured to himself, and then totally forgot that he had intended to ask something. A well-loved senior consultant, Dr. Marie Antoinette Garcia, who had just arrived from Sydney after completing a research grant, entered the conference room the middle of the presentation. This got everyone excited.

“Tonette! You’re using a cane na? Me too!” Dr. Boying Romero laughed as he raised his own cane to show everyone in the audience. Some snickered. Others found this intermission as an opportunity to chit-chat. The room was full but nobody was really paying me enough attention. I thought that this was what I wanted, but I suddenly had the urge to ring an imaginary bell and reprimand everyone: uhm, excuse me, excuse me, I prepared for 3 months for this presentation! Everybody listen!

A bunch of residents came in late, including my friend Gay Victonette Magbitang, who was looking quite morose. I saw her whispering something to all the other residents as she tried to squeeze her way to an empty seat. Later on she confessed that she was late because she had watched the live telecast of the American Idol finale in the residents quarters, and that what she was murmuring to everyone was, “talo si Adam Lambert, talo si Adam Lambert, guys talo si Adam Lambert.”  I became a bystander in my own presentation, at one point my head totally drifting into other stuff, like “I wonder if the canteen has laing?”

The moderator finally called my attention and said that my presentation was to continue. The intermission had been so long I had to ask Celito, my Powerpoint clicker, “Nasan na nga ko?” When the pathologist, Dr. Cholo Mirasol, finally took the podium to reveal his post-mortem findings everyone kept quiet and paid attention. I was super irritated that I, who had toiled in handling the patient, spent months constructing the presentation, and experienced the intense emotional roller coaster ride of this case, was apparently just the front act.

“I’ll begin with the external examination,” Cholo said in his booming voice. “This is the body of a 52-year old female. On the left side of her face is a violaceous patch extending from the zygomatic arch down to the neck…”

Cholo went through each organ system, describing in detail the appearance, the weight, the feel, the unique characteristics of each external organ and viscera. The heart was a bit large, with a weight of 412 grams. The liver was normal, smooth, with no evidence of fatty infiltration or tumors. The lungs were pink, with some evidence of congestion and bleeding. Photos and bullet points were flashed on the LCD. Some findings were physical changes expected of someone about to die, like tiny mucosal hemorrhages, or organs deprived of oxygen. Some were probably from the treatment, like the fluids in the lungs, or the chest wall bruising from the CPR. And to Intern Magnesia’s credit there was, indeed, evidence of poverty, like the physical signs of malnourishment, the wasting of the facial muscles, the sunbaked skin from the daily grind in the farm.

“And finally, the intestines,” Cholo said as he pressed the clicker.

Schlick.

The intestines were dilated. The walls of the colon were red and swollen. A yellow-green film that looked like sheets of pus covered certain areas of the intestine. Some areas had ulcers on them, some had clumps of reddish nodules. Samples were taken for biopsy and microbiologic studies which revealed:

“Pseudomembranous colitis,” Cholo said, referring to a complication that happens in the intestines of patients who received powerful antibiotics for other indications. Mrs. Tonya Horizon had been treated with curative meropenem for the infection on her face, which evidently worked, but in the process had led to the overgrowth of an opportunistic organism, C. Difficile, in her intestines. This infection had caused her diarrhea, eventually leading to death.

The audience gasped. Rarely had we seen how it actually looked like. Pseudomembranous colitis was curable with a different set of antibiotics, like metronidazole. In fact we had already suspected it and had given her this drug, but by then Mrs. Tonya Horizon had been dehydrated for far too long. The infection, a complication of the treatment for another infection, had killed her. After giving my case summary the audience gave a tokenistic round of applause and started to leave. I felt a lump in my throat as I looked at the dissected intestine that was still flashed on the screen.

On my walk back to the wards I started to feel guilty that the predominant feeling was relief, at having constructed a presentation which was, for all intents and purposes well-received. At having completed my first mortality audit without finding myself breaking down and crying and wanting to quit. I should be feeling something more than this, I told myself. That piece of intestine belonged to a mother, and her death shouldn’t be relegated to being a learning material. Then I berated myself for being unnecessarily melodramatic.

I would find out later on that I was not psychotic for not having experienced the full range of emotions I would have expected of myself. I was merely compartmentalizing—or at least that’s what I would tell myself—as the career I have chosen would be a series of heartbreaks. Because choosing to marinate in this sadness, in all the sadnesses through the years of training, might drive me insane.

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