I picked up my glasses which had fallen to the floor, used my palms to flatten the hair strands that had stuck out in all directions, and put on my shoes. After checking that my keys, wallet, and phone were in their respective pockets, I closed the office and made my way to the Pediatrics ward. I had one last task to accomplish for Ofelia.

Eight hours earlier, I did rounds on my one-year-old patient and noted that her condition had not improved significantly since she went into cardiac arrest for six minutes the previous day. It was time to discuss the prognosis and options with her mother.

“Mommy, hindi po maganda ang lagay ng anak ninyo. Hindi pa rin po siya gumigising. Ang mga gamot sa suwero lang po ang nagpapataas ng blood pressure niya.”

There was no reply. Only a gentle, steady streaming of tears from both eyes.

“Pasensya na po, Mommy. Mukhang nag-impeksyon po talaga ang shunt na inilagay natin sa kanya. Naaalala mo ba  ‘yung napag-usapan natin noon tungkol sa mga posibleng komplikasyon bago ko siya operahan?”

A nod, and a muffled cry.

I wondered, how much did she remember? Did it even matter?

Four weeks earlier, Ofelia lay in almost the same state: hooked to a mechanical ventilator and hovering between stupor and coma, the effects of excess cerebrospinal fluid accumulating in the brain from tuberculous meningitis. I explained to her mother that we needed an emergency procedure to insert a ventriculoperitoneal shunt, that would divert the excess water out of her brain and relieve the hydrocephalus that was keeping her unconscious. I discussed the risks, too, and made it clear that the benefits outweighed the former in this case.

Ofelia’s mother gave consent, but expressed apprehension because she and her husband were unemployed. They would not be able to afford the cost of the operation. Thus, I had to wait as the Neurosurgery and Pediatric services looked for sponsors who could shoulder the cost of the shunt.

Twenty-four hours later, we obtained the funds we needed and brought Ofelia to the operating room. My patient made rapid recovery and was discharged seven days later.

Her mother, most of all, was happy, being able to bring Ofelia home awake, breathing, feeding, crying, moving briskly on her own. Being the surgeon, I also felt satisfaction and pride, having been able to save a child from dying.

As it turns out, the good news was short-lived.

Ofelia was brought back to the emergency room three weeks after being sent home because of fever and seizures. More worrisome, the shunt’s valve had eroded through her scalp and was now exposed to the environment, providing bacteria an easy route to infect her brain.

Initial laboratory workups confirmed what I had feared: the shunt had become infected. She had signs of pneumonia, too. The infection had overwhelmed her immune system, causing her to stop breathing and her heart to stop beating just as she was waiting to get a CT scan. She was revived after six minutes, but from then on, she had become too unstable to be taken out of her hospital bed, even to obtain x-rays. Only the mechanical ventilator and intravenous medications were keeping her respiration and heart rate within normal limits.

Reviewing my patient’s chart, I was disheartened to learn that the parents had signed a DNR waiver. They would no longer want to facilitate laboratory workups and they would only want the nurses to administer whatever was left of the medications (almost all of which were obtained from donors, too). If Ofelia went into cardiac arrest again, they would not want her resuscitated.

“Ipapaubos niyo na lang daw po ang mga gamot niya, Mommy? Kapag itinigil na po natin ang mga gamot, titigil na rin po ang paghinga niya at pagtibok ng puso…. Kung ganoon po ang mangyayari, hanggang dito na lang po talaga tayo. Wala na po kaming magagawa para sa anak ninyo.”

“Dok, kung meron lang po talaga kaming panggastos, gusto pa po naming ituloy para mabuhay pa po ang anak namin, pero walang-wala na po talaga kaming pera.”

She continued to cry.

“Ok po Mommy. Pasensya na po, pasensya na po.”

Eight hours later, I made my way back to Ofelia’s bed. Her mother remained seated where she was when I last spoke to her. She had never left the bedside.

“Mommy, tatanggalin ko lang po ‘yung shunt ng baby ninyo. Kung OK lang po, lumayo po muna kayo saglit para hindi niyo na po makita.”

She nodded and stood up. She had stopped crying, but by now both eyes were red and swollen.

Ofelia’s body was wrapped in hospital linen, but her face was exposed, noticeably pale but almost beaming as it reflected the ward’s dreary fluorescent light. All the tubes had been pulled out and all the micropore tapes removed. I began to unravel the linen and was surprised to see that she still had earrings on. She was clothed in a multi-colored floral dress. She could have been just sleeping, peacefully and enviably still amidst the chaotic world in which she’d soon grow up.

But no, she was dead. She was my patient, and she now lay lifeless. It seemed I could only cheat death once for this kid. The scene reminded me of a painting I saw in the National Museum a couple of months earlier: that of a dead infant, eyes closed but smiling, donned in a flowing white dress, and surrounded by flowers in bed.

I turned Ofelia’s head and upper trunk to the right side, the same position I put her in when I did my first operation, except now it was easier because her body had begun to become stiff. There was no resistance at all. Her skin was cold against my gloved hand. I extracted the shunt with ease, pulling it out by grasping its exposed valve through the eroded skin. I sutured the skin and was done in a minute. I had probably spent more time looking at my patient. Contemplating on my mistakes, what I had done and what I had failed to do. Then I prayed.

Only when I looked up did I realize that mother did not go away as instructed. She merely transferred to the other side of the ward and had observed the entire procedure through the glass-and-wood dividers.

I beckoned to her.

“Tapos na po, Mommy. Pasensya na po talaga…. Salamat po.”

I proceeded to the nurses station to write on the chart. Then I walked away, specimen bottle containing the shunt tip in hand, head down and gaze on the floor, each step successively heavier than the last, overcome by grief, frustration, disappointment, and anger.

I wanted to run.

My parents are used to the attention. After all, I achieved the same recognition in 2001, as did my sister in 2002, my other sister in 2005, and my brother last year. My parents could not be any more proud as they march with their fifth consecutive valedictorian (and 5^th UPCAT passer, too). It is a feat never before accomplished in our school, and I daresay never to be replicated, considering that 300 to 400 high school students graduate each year.

Baticulon Family

Teachers, parents, and students have labeled us a family of geniuses. Acquaintances often ask, “Kanino ba nagmana ng talino ang mga anak niyo?”(From whom did they inherit their intelligence?) or “Paano ba magpalaki ng mga matatalinong anak?” (How do you raise such smart children?) to which my mother or father would reply in polite jest, “Hindi ko alam. Pinipigilan ko na nga mag-aral ang mga iyan sa bahay!” (I don’t know. I even try to stop them from studying at home!)

Truth is, I prefer that we be known as a family of hard work and determination.

Back when I was in high school, my father earned between 12 to 15 thousand pesos a month working in the construction site. Even with overtime pay and occasional bonuses, the amount was barely enough for a family of seven, all five kids studying. On my mother rested the burden of having to budget my father’s salary. On weekends, she sold pancit and other food items in the village wet market to augment our family income.

We lived with my paternal grandparents because we never had enough money to rent or buy a house to call our own.

Often, my father had to ask for bale from his bosses and my mother had to approach relatives and friends, to borrow money for tuition, dormitory fees, or allowance. June (enrollment) and March (graduation) were perennially difficult times. They bowed their heads, begged for consideration, swallowed their pride, and bore every harsh word; what’s important was that every quarter our respective class advisers would allow us to take our periodic exams.

My parents would then say to us, “Kaya mag-aaral kayong mabuti, kasi kayo lang ang pag-asa namin.” (Study well, because you are our only hope.)

We children never asked for new books or uniforms – these things we obtained second-hand from generous friends we met by becoming active in the student council and other student organizations. We saved part of our allowance if we needed supplies for a school project. Every book, intramurals jersey, field trip, or JS Prom had to be justified. But these “shortcomings” (if one would even dare to label them as such), never left any of us wanting.

Despite being obviously tired from work and having to commute to and from his project site, my father would help us with our math and science assignments. His skills always came in handy for school projects that involved woodwork and electricity. And if we wanted to attend an extracurricular activity that had a registration fee, he always fulfilled his promise to find the means to pay for it.

Every morning my mother would wake up to prepare our baon (cheaper than having to buy lunch from the canteen every day), and every night before she slept, she made sure that we had clean and pressed uniforms to be worn the next day (because we only had two sets each). When we needed formal clothes for school programs, she would ask among her friends till she found two or three we could choose from. She scoured bookstores for urgently needed project materials and processed our college application forms.

My father and my mother have never missed a graduation or recognition ceremony.

The key to raising five valedictorians is that our parents never forced us to study. We studied hard and we studied well because seeing our parents’ sheer dedication, each of us wanted a better life for the entire family. There was no need to dictate which path to take. We pursued excellence, because at the end of each school year, every medal, plaque, and trophy was a token of gratitude to them.

Having just celebrated 30 years of marriage last December, my parents stand proud with one UP doctor and two UP engineers, all cum laudes, with two more engineers on the way. While debts remain to be paid, life is beginning to change for our family. We have been able to acquire our first car. My youngest brother and sister can go through college without the anxiety of lacking money to pay tuition. My father can now buy his polo and my mother her blouse without having to worry about scrimping on our budget. And we no longer have to fret about having to divide 1 liter of soft drink or the meat pieces in the sinigang equally among us children.

What remains constant is how we learned to rely on one another for support, be it “Pautang muna, OK lang?” (Can you lend me some money?) or “Puwedeng patulong ako sa project ko?” (Can you help me with my project?)

Faced with the tough challenge of having to best four prior valedictory speeches, my youngest sister will brandish the most important gold medal in today’s graduation ceremonies, but there is no disputing that two persons in the audience deserve as much awe.

My father and my mother—for their love and support that know no bounds—to them we owe all recognition.

Ronibats is the eldest son of Engr. Pablito and Rosemarie Baticulon.

Author’s Note: The eighth person in the family photo is Ate Bel, who helped my parents raised us from the time I was two years old, until she started her own family last year. It’s another story to tell.
Photo Credit: Ian DV Photography

“Tatay, mas gusto mo bang kalahati lang ng buhok ang tanggalin ko, ‘yun pong sa kanan lang, o uubusin na lang natin lahat para pantay ang tubo?” I asked Eric beforehand, as we wheeled her daughter into the OR.

“Kalbuhin mo na lang Dok, para mas madaling linisin.” This response was not unexpected; he worked in the army’s reserve command, he told me. Still, I could sense regret in Eric’s eyes as he watched the strands fall in clumps to the trash bin underneath Ofelia’s partly overhanging head.

Ofelia was diagnosed to have multiple congenital anomalies at birth, among which was hydrocephalus, for which a ventriculoperitoneal shunt was inserted when she was three months old. At age two, she also had to undergo open heart surgery and a series of limb operations to release the contractures on her legs and feet. She only finished kindergarten and stopped schooling afterward, but she could communicate intelligibly with her family. She could not walk but she could feed herself, and for the most part, required assistance for daily living, provided by cousins, uncles, and aunts while her father worked as a gardener in the army camp.

Friday morning however, she suddenly complained of severe headache followed by intractable vomiting. By the time she was taken to our hospital, she was barely awake, muttering incomprehensible sounds with new-onset weakness of her left arm and leg.

Imaging showed a large cyst in the right side of her brain. It did not appear to be malignant, but it needed to be drained to relieve her brain of compression, hence the referral to Neurosurgery.

“Pang-ilan niyo po siyang anak, ‘Tay?” I asked in the wards during history taking.

“Nag-iisa lang po iyan, Dok.”

He kept staring on the floor and his shoulders hung low, far from the snappy military stereotype. He walked with a limp, too. But one only needed to notice the burnt skin and the calloused hands to unravel the story of paternal sacrifice.

“Kailangan po niyang operahan, ‘Tay. Magkano po ba ang dala ninyong pera? Libre po kasi dito ang kama at wala pong bayad ang mga doktor, pero ang mga gagamitin po sa operasyon at ang mga gamot, sa inyo po lahat iyon.”

“Limanlibo lang po, Dok.”

“Kung makakakuha po ba kami ng libreng shunt (which costs Php 12,500), papayag po ba kayong ipaopera siya?”

“Opo, Dok. Tulungan niyo po kami.”

That was Saturday morning. I was not on duty and had been anticipating to go someplace quiet in the afternoon, to finish my long overdue research protocol and shorten my list of unread books, neurosurgical or otherwise. Perhaps I could go home at night or share frustrations with good friends over alcohol.

But seeing Ofelia, I knew outright that the plans would have to be put off. Among all neurosurgery residents in the hospital, I was the one who knew her best. I took her history, I examined her, I talked to her father and explained to him the risks and benefits of our contemplated procedure. In the words of one of my consultants, “I am now the world expert on Ofelia Reyes.” There was no question about it. I had just made an implicit commitment to operate on her in the soonest time possible, lest she deteriorate beyond medical care.

Ofelia was lucky: the Pediatric Neurology service had one remaining piece of the type of shunt she needed. But due to the heavy traffic of emergency cases in the OR complex, it was already past 10 pm when we finally had the chance to bring her up for surgery.

No doubt, I was dismayed. It was another free Saturday lost, just like many other weekends that had come before. Despite being on my fourth year of residency training (“Senior ka na, big time!” my classmates would often exclaim when we pass by each other in the wards), I was still bound to the hospital when duty called for it.

“Wag ka malikot, Inday,” Eric tried to restrain his daughter’s non-purposeful flailing of extremities. I was not sure if she could understand him, but from experience I have learned that the sound of a familiar voice eased the pain and anxiety of patients drifting in and out of wakefulness.

Ordinarily, I would have waited until the anesthesiologist had put my patient to deep sleep before shaving hair, but the assigned resident at that time had to run to an emergency case in another wing of the OR complex. Since Ofelia barely moved her head, I decided to start. I wanted to finish the procedure as fast as I could, so that I could minimize the risk of infection later on.

As I put down my scissors and reached for the knife blade to shave Ofelia’s now trimmed hair, it occurred to me that I forgot to ask Eric one question.

“‘Tay, nasaan po ang asawa ninyo?”

“Wala na po, Dok.”

I stopped, left hand on Ofelia’s scalp and right hand with the blade in mid-air.

Suddenly, I realized that this teenage girl lying before me was the only remaining family Eric had. He could not afford to lose her, not after all the surgeries she had to undergo, not now, not this soon, not for something that could be remedied in an otherwise ideal health care system.

“Ano po ang ikinamatay niya?”

“Komplikasyon po ng diabetes, Dok. Dito rin po namin dinala pero malala na raw po.”

I continued shaving, exerting just enough force and pressure with each definitive stroke, calculated by experience to remove hair without wounding the scalp — an ancillary skill learned only from years of hard work training to be a brain surgeon. “Ofelia, pasensya ka na ha, konting tiis lang. Aalisin lang natin ang buhok mo para malinis tignan pagkatapos.”

“Game na tayo?” I asked the anesthesiologist.

“Yes sir.”

“Sige po, ‘Tay, tatawagin na lang po namin kayo sa ward kapag may kailangan po kami. Huwag po muna kayong aalis ha?”

“Kayo na po ang bahala, Dok,” like what all family members say before saying goodbye, which they know — though they would not say out loud — could be their last.

I started at 11 pm and finished a little past midnight. As I wrote my post-operative orders in the chart, I had to remind myself that the date had changed.

When I did rounds in the morning, Ofelia was more awake, able to answer questions and follow commands.

“Dok, pwede na daw ba siyang painumin? Nauuhaw daw po kasi siya,” Eric asked, still in the humblest of voices.

“Sige po, susubukan po natin. Titignan po muna natin kung kaya na niyang uminom ng tubig paunti-unti.”

Ofelia’s bald top and crown reflected the sunlight which shone through the ward’s wide open windows. Sunday morning, and I could hear Bono singing in my head.

It’s a beautiful day.

“You have to realize, not everybody sees the world the same way you do.”

“Pero kapag doktor ka naman Sir, wala ka nang nalalamang holiday at suspension. Kailan pa nila matututunan ‘yun?”

I was assisting my consultant in the operating room when we had this conversation. It had been almost a year since I was designated resident-in-charge of the rotating interns in Neurosurgery; an unexpected break during the operation provided an opportunity to vent my frustration. I had been receiving negative feedback from the section’s consultants of late.

The clinical rotation in Neurosurgery lasts only a week. The interns would go on 24-hour duty in the ER once or twice during the rotation; the rest of the week, they only needed to report during office hours, 7 am to 5 pm during weekdays and 7 am to 12 noon on weekends.The only major requirement is to examine one patient and to present the case to the consultant-of-week in a two-hour discussion. In the dichotomy of clinical rotations, this would definitely fall under the benign category.

But almost invariably, the consultants would complain to me that the rotating medical interns performed way below expectations. Often, I could not say anything in defense of the students.

Despite ample warning, many of the interns would show up for their preceptorials with a crammed Powerpoint presentation. Only one or two (from a group of four or five) would actually take time to get a detailed clinical history and perform a comprehensive neurologic examination. Fundoscopy, mental status assessment, and gait testing are often forgotten. Once, a consultant walked out during the discussion when the interns presented a case of spinal cord compression without doing a detailed sensory and motor examination. Presentations are copied and pasted verbatim from the Internet or from basic neurology textbooks. And only the assigned member would actually review the cranial CT and MRI plates.

What’s more bothersome are some interns who neglect their basic responsibilities: reporting for duty at 8 am, not reporting at all during weekends, failing to complete clinical abstracts and discharge summaries despite repeated requests from nurses and patients’ watchers, going to the operating room to play with their handheld devices or chat with co-interns rather than to actually observe surgeries, and lack of genuine effort to monitor critical patients conscientiously. Of course this is not true for everyone. But in the hospital which exposes medical students to the most number of neurosurgical cases in the country, outstanding interns who impress consultants and residents have become the exception rather than the norm.

“Baka naman kasi masyadong mataas ang standards mo,” one of my co-residents remarked.

I understand that not everyone will become a neurosurgeon after medical school, but students should at least strive to learn core concepts in neurology and neurosurgery, so that when they practice as general physicians, they would know how to manage emergent cases and refer as necessary. I daresay nobody would disagree that there’s a problem when interns do not know how to do a complete cranial nerve examination or give an accurate Glasgow Coma Score.

Perhaps part of the blame lies in the current medical curriculum, such that seven days in the section is too little time to review what one should have learned in the last four years. Do the interns expect didactic lectures at this stage of their medical education? Do they realize that after medical school, it is self-directed learning that will serve as one’s constant source of new information?

Excuses for failing to do one’s basic responsibilities do not even merit a discussion.

It is possible that the students do not feel the need to exert extra effort in a relatively benign rotation, compared for instance with the Big Four (Medicine, Surgery, Pediatrics, OB-Gynecology). Benign rotations are seen as time to catch up on the “more important things” in life. Students seize the opportunity to spend quality time at home, book weekend getaways with friends, or party all night without having to worry about patients decked to them. Minimum necessary effort is exerted to be able to get by and pass the rotation, and there is of course no fault in doing just that.

In my time, I was a diligent medical student regardless of clinical rotation. Hence, I often find myself thinking, “Natutunan ko naman ‘yan nung estudyante ako,” or “Ginagawa ko naman nang maayos ang trabaho ko nung intern ako.”

Is it too much to expect more from future doctors training in the national university hospital?

Medical school is no place to nurture mediocrity. Good enough should never be good enough.

As a doctor, to make a patient feel better is the minimum necessary requirement. That is our implicit obligation when patients entrust their lives to our care. But what patients and their families appreciate is the extra effort we make to fulfill this promise:

Sitting down when we listen to them narrate the events and enumerate the symptoms leading to their hospitalization; staying an extra hour to follow up results of blood tests done during the day, and to update them, so that they would not have to stay up all night wondering if everything was all right; dabbing the micropore tape with alcohol and gently peeling away rather than yanking out the sticky tape from their skin; negotiating with Radiology so that imaging studies could be done earlier in patients who need them immediately; not hesitating to take over as nurse/nursing aide/utility worker (e.g., push the stretcher and oxygen tank, inflate the ambu-bag, transfer patient to the stretcher) when there’s a shortage of human resources in health care; giving a genuine smile and a promise of hope as we leave their hospital room to go see our next patient.

But before you can go further, you need to be able to fulfill your basic responsibility. As a medical student, that responsibility is to study well. The pervasive nature of mediocrity is such that medical students who get by with “Pwede na,” “Ayos lang iyan,” and “Bakit ko ba pahihirapan ang sarili ko?” later on become the doctors who deprive their patients the opportunity to receive the best possible medical care at the soonest possible time. Remember that every minute of delay translates, not just to inconvenience at your patient’s end, but to another minute of unnecessary pain, or anxiety, or hopelessness.

By choosing to become a doctor, you make a commitment to pursue excellence, to go above and beyond expectations whenever possible. That commitment starts, not when you pass the licensure exam, but on the day you turn page one of your Anatomy book.

As your patient lingered between living and dying, inasmuch as you wanted to offer family members hope, you also wanted them to understand that there is, and will always be, a limit to what you can do as a physician.

You just cannot save them all. Neither an apology nor an excuse, it’s just the way things are. In this age of gene therapy and molecular medicine, countless questions on the natural course of diseases remain unanswered by science. Why this patient? At this time? Despite everything that has been done? Death prevails, and you are reminded of the fragility of human life.

You put yourself in their shoes, to try to see things from the point of view of grief. Removing the science of increased intracranial pressure, cerebral ischemia, mechanical ventilation, inotropic support, and multi-organ dysfunction from the picture, all that is left is a patient, husband or wife, father or mother, son or daughter, brother or sister, friend or beloved, taken away with an abruptness that magnifies the pain many times over. You begin to understand, so you bear their every word, and respond with silence.

Do they realize that you are also wounded by this loss? What wakes you up each day is the hope that your patients live longer, happier, and more meaningful lives. Conversely, their suffering becomes your burden, and their death, your failure.

No doctor would want his patient to die.

You can always objectify the circumstances and shield yourself with apathy, but that would take away the essence of what it is to become a doctor. To heal is to comfort, outright impossible if you nullify all emotion.

At the end of the day, you can only take so much grief. You end up scarred, but that is the price you pay for choosing this path. You pick yourself up and move forward, otherwise you become unfair to the other patients who entrusted their lives in your hands.

You had been monitoring him since he was transferred to the recovery room.

“Opo, sir,” you replied.

I looked at the monitoring sheet, and indeed, you indicated in it that the patient was Glasgow 15 throughout (i.e., every 15 minutes during the first hour, and every hour thereafter). Only 20 minutes had elapsed from your last monitoring till I came to check on him.

Just looking at the patient though, I knew immediately that something was wrong. I needed to tap him vigorously to wake him and he could not sustain attention. He was restless and kept on vomiting. After a quick neurologic exam, I assessed him to be Glasgow 11.

“Ngayon lang po ‘yan sir, nagfo-follow pa po siya kanina.”

There was a sincere look of alarm on your face. I asked you to retake the patient’s vital signs, and observed as you wrote the more accurate neurologic status on the monitoring sheet. I called for the nurse-in-charge, but he, too, could only tell me that the patient had been “fully awake” earlier.

Gising na gising? Parang ikaw at ako, na nag-uusap ngayon at nagkakaintindihan nang masinsinan?

In resignation, I reviewed the patient’s chart and requested for an emergency cranial CT. The scan revealed a post-operative hematoma, necessitating transfer of the patient to the intensive care unit.

When all this was done, I went back to the recovery room to talk to you and your co-intern. My intention was neither to reprimand nor embarrass. I was not angry. More than anything, I was disappointed. You should know that I knew you to be a conscientious medical student, compelling me even more to ask you questions, so that we could figure out why there had been a lapse in clinical judgement.

I tried to level my expectations, but no matter which way I looked at it, a four-point stepdown in Glasgow score should not have been difficult to detect. Assessment of sensorium was integral to our Neurology courses in medical school. Could the patient have deteriorated rapidly, in between the times you and I examined him? Perhaps. I would never be able to say for certain. But if you did make a mistake, I wanted to make sure that you realized it.

Let me tell you about the first time I cried for a patient.

I was a medical clerk then, and it was my first week in my first clinical rotation: Internal Medicine wards. A brand spanking new medical clerk, wearing a pristine scrub top and armed with a fully loaded carabiner, clanking and jingling with my every step.

The most senior intern on duty gave me my first task of the night: I was to accompany an intubated patient to the Radiology department so that he could get an x-ray. Earlier that afternoon, this 50-year-old male had a cardiac arrest but he was revived after a few minutes. We needed to check that the endotracheal tube was in the right position and to find out if there was radiographic evidence of new-onset pneumonia.

I took the patient’s blood pressure (borderline, 90/60 mmHg) and then asked the utility worker to help me push the patient’s stretcher and his oxygen tank from the Medicine ward to Radiology. The cardiac arrest earlier surprised the patient’s family, which was probably why the entire clan accompanied us. One of them compressed the ambu-bag.

Unfortunately, there was a long line of patients waiting to get an x-ray that night. Forty-five minutes had passed and we were still waiting to be called.

Ayos lang. Hintay lang muna tayo.

I knew I was a smart student; the task at hand should have been easy.

Then shit happened.

Suddenly, it seemed I could not hear my patient’s arterial pulsation anymore. There was no flicking of the dial on the sphygmomanometer. But I was not sure. I tried both the bell and the diaphragm of my stethoscope. Still, there was hardly any sound with either. Perhaps there was no sound at all. I put my stethoscope on my patient’s other arm (Parang wala) and then on his chest (Parang wala pa rin).

“Dok, ano pong problema?” asked one of the relatives.

“Chini-check ko lang po ang puso ni Tatay.”

I did not look up. Copious amounts of sweat began to form on my forehead and neck. Drops started to fall on the patient and on his stretcher. Panic had set in.

A surgery resident apparently noticed my frantic attempts to hear a heart sound and said, “Code na yata ‘yang patient mo.”

Code? Are you implying that my patient’s heart has just stopped again, right here and right now, under my watch?

“Sandali lang po,” I told the relatives who had now created a commotion. Imagine the mixture of “Tsk, tsk” and muffled cries I received in reply.

Distraught, I went back to the Medicine ward to look for my intern.

“Sorry Ofelia, pwede mo bang silipin ‘yung pasyente ko? Parang hindi ko yata marinig ‘yung BP eh.” (Even at that point, I could not commit!)

“Ha? Eh nasaan na ‘yung patient?”

Shit.

I left my patient, who was possibly in cardiac arrest. Not the smartest thing to do, eh?

That was how my senior intern and I ended up running all the way back to Radiology, where she auscultated my patient’s chest and said, “May heart rate pa naman, pero sobrang faint at brady. Code na ‘to, Ronnie.”

“Sumampa ka na sa stretcher, pards,”  suggested the surgery resident.

So I did. I started chest compressions as fast and as hard as I could, as if wanting to make up for lost time. Intern, utility worker, and relatives pushed stretcher (now twice as heavy) back to the ward, where emergency medications could be given in an attempt to rev my patient’s heart back to life.

“CODE! CODE! CODE!”

In the ward, a classmate took over and continued chest compressions.

I walked away.

My senior intern eventually found me in the hallway leading to the ward entrance. I was teary-eyed from guilt. I castigated myself for being undecisive, panicking, and making the wrong decision at the most critical moment.

“OK ka lang, Ronnie?” she said. “Ganyan talaga sa simula.”

I wiped my eyes and forced a smile.

“Thank you ha.”

I fixed my eyeglasses, and walked back to the call room where paperwork was waiting.

I know how it feels to be monitoring patients day in and day out. It is repetitive work with seemingly no other purpose than to induce fatigue among medical students. One of the best things about graduating was realizing that I didn’t have to bring my BP apparatus anymore every time I went on duty.

But when you become a resident, you realize how accurate and timely referrals could spell the difference between life and death. When we fail to recognize signs and symptoms on time, it is the patient who pays for the delay.

You are still a student. You should always have a low threshold for patient complaints. Never dismiss them as “Wala lang.” Neither should you adopt an “Ayos lang ‘yan” attitude when patients or relatives notice that something does not feel quite right. Whenever something feels amiss, seriously consider the possibility that you are missing something. If the patient later on turns out to be OK, there would be no additional harm done.

Look back at the events of that afternoon. What went wrong?

I hope you learn from this, as I did from my mistakes.

I took a picture of us, and then he said, “Dok, nananaba po kayo ah.” I laughed and waved goodbye, certain that we would see each other again at another time.

What he did not know was that I had just come from another hospital, to meet my mentor in neuroradiology whom I had not seen in a year. Shaking my right hand, my boss and teacher said in greeting, “Mukhang hiyang na hiyang ka sa residency ah.”

Needless to say, the patient and the senior physician were referring to the 30 pounds I have gained since I started working as a resident doctor. My cheeks, which used to be sunken, have now become puffy, beginning to conceal the cheekbones that used to be overly prominent. It seems to me that such weight gain is considered an unimaginable feat when one is doing neurosurgery residency in a government hospital.

If I wanted to, I could say in defense, “Stressful kasi, kaya kain ako nang kain.” But the truth is, I think that friends and acquaintances can only make such remarks about physical appearance in good light,when they see that the same person seems content with what he is doing, despite the hard work that every day entails. So I don’t ask myself, “Do I look that fat?” Instead, I end up wondering, “Do I look that happy?”

Apparently, I do.

I have just passed the halfway mark of my neurosurgery residency training. To me, it means less scut work, but an ever increasing responsibility to make sensible and timely decisions pivotal in the management of patients. There is also pressure to master the surgical skills that would ultimately lead to safe surgery for every patient. The remaining two-and-a half years would be just as difficult as the first, if not harder.

I have been thinking (which is always a good thing to do whenever you are halfway through anything in life), and looking back at all the duty days that I have had to endure, all the patients that I have had to serve, all the important family occasions that I have missed, all the surgeries that I have had to cut and close, and all the a**holes I have had to put up with in the name of honest-to-goodness patient care, I would never take back my decision to apply for residency in a government hospital.

A week ago, a co-resident and I were discussing a UP College of Medicine graduate’s decision not to pursue his neurosurgery residency application in Philippine General Hospital. As an intern, he initially expressed his desire to be part of our team, but a year after graduation, he told me that he had decided to pursue research instead. I knew him to be a good and smart person, no doubt a loss to us; nonetheless I wished him luck, knowing that he would do well.

“What’s up with them?” asked my co-resident, also a UP graduate.

“No. What’s up with us?”

That is the question you ask when you find yourself tired, hungry, sleepless, and wearing the same clothes inside and out for the last 48 hours. Why choose to suffer when it seems that the better life lies elsewhere, where the lights and air-con are always on, where the patient list is manageable, where you never run out of time for self-study, and where you can allocate entire days for the other important things in life?

The temptation to quit is a traitor. It does not announce itself boldly during the peak of your work load, often you are too preoccupied to ponder on your lack of a life. Instead, it sneaks in during that silent minute in between surgeries, as you slump on the floor and wait for the next patient to be brought in; it stares at you from a corner as you wait for the elevator doors to open, you holding both stretcher bed and oxygen tank and it’s only an hour past midnight; it whispers in your ear, to wake you up from a nap on the first Sunday afternoon that you get to spend at home in a long time; it holds open your apartment door, as you don your white coat, grab your trodat and keys, and rush to your morning rounds.

Only the patients whom you serve will keep you moving forward. Not pride. Not your family. Not even your ambition.

From our UPCM class of 159 graduates, 67 eventually pursued residency in PGH. It is a good number, at a time when doing residency abroad was a viable and certainly more lucrative option. Whether one decides to stay or leave though, the only important thing is that you are content with what you do. Anything less will always be a waste of your time.

I have realized that when every day is seen as a burden, it inevitably affects the way we treat our patients. We end up cranky and abrasive. Worse, we turn to apathy. We are not just being unfair to our selves, but more so to them, whom we have sworn to take care of with utmost responsibility and integrity.

So choose to be happy.

It was a memory she had been trying to supress: she going home late because the mall where she worked as a cashier had a midnight sale; her heart beating fast and loud as she walked alone through the dark alley leading to their village entrance; a burly man with sweaty hands pulling her into a corner, punching her in the belly, and forcing her into submission;  she partly regaining consciousness a few minutes later, only to hear him whisper in her ear with his breath smelling of alcohol, huwag kang magsusumbong, sisirain ko ang buhay ng pamilya mo; she half-naked, tentatively sitting on the ground after making sure he was gone, wiping her tears, fixing her clothes, gathering her things scattered all over, removing the grass and grit from her arms and legs, not knowing which one she should do first, trembling, faltering, resisting the urge to call for help, becoming increasingly harder to stay still. As the rays of the sun began to slip through the crevices of the surrounding walls, Ofelia stood up and continued her way home.

She was 24 years old and single. Could you blame her if she took pills in an attempt to abort her unborn baby? She did not want to give birth to his child, who would become a constant reminder of her helplessness and how she had been violated.

“Bakit hindi mo ipinakulong ‘yung nang-rape sa iyo?”

“Hindi na po, Dok. Ayos na po ito. Mas OK nang tahimik na ang buhay ko.”

She was not the patient I came to see in the ward. My patient was her son Eric, who survived the abortion attempt, but was later born with an abnormally large head. Now six months old, his head circumference was 53 cm; normally, it should have only been around 41 cm. The cranial CT scan showed hydranencephaly, a condition in which both left and right lobes of the brain fail to develop, and the space inside the skull is filled instead with cerebrospinal fluid. If you shone a pen light on Eric’s scalp inside a dark room, the entire head would transilluminate like a crystal ball. The Pediatric service referred him to Neurosurgery for possible insertion of a ventriculoperitoneal (VP) shunt that would divert excess water from his brain into his abdomen.

Inserting a VP shunt is easy. It would take less than an hour to complete the procedure. However, caring for a baby with a shunt requires lifelong diligence. Complications, should they arise, can be devastating to both patient and parents.

I was especially cautious in discussing with Ofelia the possibility of doing surgery on her son. In Eric’s case, the only purpose in inserting a shunt would be to prevent further enlargement of his head.

“Hindi na lalaki ang ulo niya, pero kahit lagyan natin siya ng shunt ‘Nay, malamang hindi pa rin siya makakapagsalita, makakatayo, o makakapaglakad nang sarili ha?” (He did not have enough normal brain to mediate these functions.)

“Ganoon po ba, Dok?”

I was looking at her as I spoke, but she fixed her gaze on her intubated son instead. I could see tears welling up in her eyes.

“Opo, ‘Nay. At pagkatapos noon, kailangan mo siya alagaan nang mabuti para hindi magkaroon ng problema ‘yung shunt na ikakabit natin.”

In all likelihood, even after a successful operation, he would remain bedridden, able to cry or coo, but fully dependent on his mother for everything else. To make matters worse, Eric had pneumonia and needed a ventilator to keep his lungs adequately oxygenated. He needed to be free of any infection, be it in the lungs, urine, or in the blood, before undergoing surgery. Because of his very large head and his systemic problems, he was at a high risk for developing a shunt-related infection.

The average lifespan of children with hydranencephaly is a little under 5 years, with many dying before their first birthday from respiratory complications. If I put in a shunt and the shunt, by some misfortune, did infect, I would condemn him to spending his short life admitted in the hospital, intubated with tubes inserted in all places, every waking hour interrupted by monitoring nurses and medical students, every vein punctured for countless blood extractions and antibiotic infusions. It would cost a lot of money, too. I have seen this happen. When it does, the surgeon ends up regretting his operation, wondering if the child would have lived longer untouched.

Explaining the benefits and risks of surgery with Ofelia, I admitted to myself: I was afraid of operating on her son.

Still, I had to ask.

“Papayag po ba kayong lagyan ko ng shunt ang anak ninyo?”

She asked for more time to decide.

So I waited.

“No consent for surgery at this time,” I wrote on the chart.

It took two months to wean Eric from the ventilator and several cycles of expensive antibiotics to treat his repeated bouts of hospital-acquired infections. When the Pediatric Neurology service finally gave him an acceptable risk evaluation for the contemplated surgery, I talked to Ofelia once more.

“Sige po, Dok. Payag na po ako,” she said.

“Naiintindihan mo ang napag-usapan natin ‘Nay ha? Kapag nag-opera tayo, kailangan tuluy-tuloy ang antibiotics, at dapat, aalagaang mabuti ang sugat para hindi maimpeksyon o lumabas ‘yung shunt sa balat. Kung hindi, masasayang lang ang operasyon natin.”

“Opo, Dok. Hindi ko po matitiis na hayaan ko lang na lumaki ang ulo ng anak ko.”

I needed certainty.

“Pramis?”

“Opo, Dok. Pramis po.”

Filled with doubt but with utmost care, I put a shunt on Ofelia’s son. I reassured myself thinking that if she had been able to take good care of him 24/7 during the last 10 weeks, she should be able to take good care of him just as well after our surgery.

After spending three months in the hospital, the Pediatric and Neurosurgery services were able to send Eric home, with a working shunt and breathing on his own. Playing, too.

Did Ofelia blame herself for her son’s congenital malformation? Was her decision to push through with surgery despite the attendant risks an act of redemption, to free herself of guilt from having attempted abortion? But who has a right to demand atonement from someone who had been a helpless victim of transgression?

These things I had wondered from day one, but I never got to ask Ofelia–she who had had to bear suffering much more than most of us would ever come across in our lifetime. It’s a shame her son would never be able to fully understand the strength Ofelia has shown under such tormenting circumstances, as other people, even I, cower in fear and in doubt.

This is courage and this is love. Forgiveness becomes irrelevant.

Although he was awake after the surgery, the diffuse brain injury kept him confused and unable to follow instructions. Initially, it was his elder sister who took care of buying his medications and facilitating laboratory tests. He was no different from a child who needed to be fed, bathed, and dressed.

After a week however, I began to see the sister less frequently during bedside rounds. I noticed that he was no longer being given his medications regularly too. When I asked the nurses about this, I was told, quite simply, “Ay naku Sir, palaging wala ang bantay niyan.” At the end of two weeks, no family member or friend attended to his needs at all. You would see Eric spitting, urinating, or defecating in bed. One time, he even smeared fecal matter all over his body, a sight that was both gruesome and pitiful. It was the nurses and nursing aides who took over the responsibility of feeding him and changing his diaper on time, among other things.

To complicate matters, he began to have fever and chills, signs that his operative site might have developed an infection. We needed to start new antibiotics, run additional laboratory exams, and have his cranial CT scan repeated. When his sister finally showed up one morning, I talked to her about Eric’s medical problems and explained the plans of the neurosurgery service.

“Bakit niyo po palaging iniiwan ang pasyente ninyo? Hindi po pupuwede ang ganoon, Ma’am. Kapatid ni’yo po iyan, hindi po pupuwedeng walang mag-aalaga sa kanya dito.”

“Kasi Dok, naghahanap po ako ng pera panggastos namin dito sa ospital. Naubos na kasi ang hawak naming pera sa operasyon.”

“Kailangan ni’yo pong gawan ng paraan iyon. Hindi po responsibilidad ng mga nurses at nursing aides na alagaan ang pasyente ninyo. Akala ko sampu kayong magkakapatid?”

“Eh wala naman pong mag-aasikaso sa kanya, may mga sariling pamilya na po ang mga iyon.”

“May three thousand pa po ba kayo para sa CT scan? Kailangan kasi nating ulitin ang CT scan ng kapatid mo para malaman natin kung may namumuong nana sa loob ng utak niya.”

“Pambili nga ng gamot wala, pampa-CT scan pa!”

Infuriated by her retort, I said, “Eh ano po ang gusto ninyong mangyari sa pasyente ninyo?”

“Basta gusto ko lang gumaling ang kapatid ko.”

There was no point in arguing further.

As government physicians, it has become a necessary skill to keep finding ways to help our charity patients: pilfer spare antibiotic vials and operating room needs, request that the hospital waive the fees for laboratory exams, and refer family members to charitable organizations for financial assistance. However, these are just temporizing measures and would never fully cover the health expenses of any patient. For families to depend entirely on their physician for the care of their patient is, frankly, unfair and unacceptable. We could only do so much. There are many other patients to take care of, who have better chances of having good outcomes only because they have supportive families.

In the days that followed, no new watcher came to stay at bedside and no medication became available. Our service decided to pay for his imaging study and we referred him to the Infectious Disease Section for antibiotic assistance. I was frustrated and nearing the end of my rope.  As a last resort, through the hospital’s social welfare service, I asked the nurses to contact other relatives who might have more concern for Eric.

That was when Ofelia, his mother, came.

To her, I repeated my question.

“Nanay, ano po ang gusto ninyong mangyari sa pasyente ninyo?”

“Gusto ko po siyang gumaling, Dok.”

Her voice was dry and her tone was flat, perhaps still aghast at the state her son was in.

“Kung ganoon po ‘Nay, bakit ni’yo po siya pinapabayaan? Dalawang linggo na pong walang nag-aasikaso sa anak ninyo dito sa ospital.”

“Pasensya ka na, Dok. Hindi ko alam na ganoon ang nangyayari. Ang akala ko, inaalagaan siya dito.”

Ofelia looked at her son who stared back with blank eyes. He could answer simple questions but he could not carry a conversation. He moved only when necessary, staying in bed most of time–far from the functional welder he used to be. Right now, he kept his body curled under his blanket. He still had chills and fever.

“Isang linggo lang po ang antibiotics na ibibigay ng ospital sa inyo, ‘Nay. Pagkatapos po noon, kayo na po ang bahala. Apat na linggo pong gamutan ang kailangan natin. Kung paisa-isa lang po ang naibibigay nating gamot, sayang lang po lalo. Kung wala rin lang tayong maibibigay na gamot dito sa ospital, iuwi ninyo na lang po ang pasyente ninyo.”

“Huwag ninyo naman po sabihin ‘yan, Dok. Kaya nga po kami nandito, para gumaling ang anak ko.”

In that brief second, I felt ashamed for offering Ofelia the option of bringing her son home.

“Bigyan ni’yo pa po kami ng kaunting panahon, Dok. Gagawan ko po ng paraan, kaya nga po ako lumuwas na dito.”

“Lumapit po kayo sa Mayor o Congressman ninyo ‘Nay. Lahat ng kamag-anak ninyo, hiraman ninyo na po ng pera. Kung hindi po kayo gagawa ng paraan, lalo pong hindi gagaling ang pasyente ninyo.”

“Naiintindihan ko po, Dok. Mabait po ‘yang anak ko na ‘yan. Magaling pong welder ‘yan. Nagkataon lang talaga na naaksidente siya.”

It was a good thing Ofelia did not give up when I did. That was the turning point for Eric. From then on, sister and mother took turns watching over their patient while the other sought financial assistance from local government officials. Ofelia was also able to avail of a free cranial CT scan from the charity service of a nearby private hospital. With permission from the Infectious Disease Section, I discharged Eric on oral antibiotics to be taken for a month, and Ofelia promised to comply.

Five weeks later, I received a text message from the Infectious Disease Section fellow who handled Eric’s case. She was elated to report that she saw Eric fully recovered at the outpatient clinic. His latest cranial CT scan showed no sign of brain swelling or infection. I asked her to direct Eric to our ward so that I could see him in person.

He wore a green cap to cover his scalp incisions. I was pleased to see him in tidy clothes.

“Naaalala mo pa ba ang nangyari sa iyo?”

“Hindi na po, Dok.”

So I told him, and said, “Pasalamat ka sa Nanay mo.”

Nang  tumuntong ako ng elementary at high school, palaging Math ang pinakamataas kong grado. Pagdating sa mga inter-school competition, taun-taon ay nakakakuha ako ng medalya sa Math Challenge ng MTAP (Mathematics Teachers Association of the Philippines). Ang pagiging Rank 1 sa buong Metro Manila ang isa sa pinakamasasarap na tagumpay ko noong high school. Umabot din ako sa national finals ng PMO (Philippine Math Olympiad). Kaya naman noong ga-graduate na ako, akala ng lahat ng tao, kukuha ako ng engineering. Eh naging doktor ako.

Hindi mahirap mahalin ang Math. Basta’t naiintindihan mo ang isang formula at kung paano ito nabuo, magagawa mo na itong paikut-ikutin para sagutan ang isa, sampu, o isandaang tanong. Almusal ko ang Pythagorean theorem, barkada ko ang prime numbers, at nagbibilang ako ng perfect squares para makatulog.

Sa totoo lang, tamad kasi talaga akong mag-memorize. Inis na inis ako noon dahil kahit ilang oras kong aralin ang Biology, alam kong hindi ko naman kayang kabisaduhin ang lahat ng terminolohiyang nasa libro ko. ‘Yun ang mahirap, dahil may mga tanong na kapag hindi ko alam ang sagot, hindi ko talaga alam. At kapag nanghula ako at tumama, alam kong suwerte lang ako kaya tumama ang hula.

Hindi ganoon sa Math. Pagdating sa problem solving, sa halip na mainis, naaaliw ako kapag ang tanong ay kakaiba sa inaral ko. ‘Yung kailangan kong pag-isipan kung paano ko hahanapin ang sagot, sa halip na simpleng “plug the values and solve the equation.” Tuwang-tuwa akong mag-solve ng xyz, mag-prove ng equation, magbilang ng ulo ng manok at paa ng baboy, maghati ng lupa para sa mga pinamanahang anak, mag-factor ng (4x to the 4th) plus 1, magpagawa ng bahay sa tatlong bata at apat na matanda, punuin ang isang drum ng tubig habang bukas ang dalawang gripo at ang drain, at magmaneho ng kotseng hinahabol ng motorsiklo.

Mas mahalaga sa tamang sagot ang paraan kung papaano ko ito nakuha. Nandoon ang challenge. Natuto akong dumiskarte. Maaaring sa simula ay hindi ko alam ang sagot. Pero kapag tumama ako sa huli, alam kong dahil ‘yun sa pagsisikap kong magpaikut-ikot ng mga numero sa ulo ko.

Sa kabila ng lahat, hindi ko kailanman nakita ang sarili kong nagtatrabaho sa harap ng isang computer sa loob ng isang opisina. O uma-aattend ng mga business meeting at teleconference araw-araw, linggo-linggo. O nag-iikot sa field site upang mag-inspeksyon ng kung ano mang kailangang iinspeksyon. Ang gusto ko ay humarap sa pasyente upang manggamot.

Marami-rami rin ang nagsabi sa akin noon na hindi ako bagay sa Medicine — na masasayang ang galing ko sa Math kung ako ay magdodoktor. Pero sa huli, ako pa rin ang nasunod. Nang malaman kong nakapasa ako sa INTARMED, hindi ko na pinakawalan ang pagkakataon.

Ako ang naging kabaligtaran ng mga medical student na naririnig mong humihirit na kaya sila nagdodoktor eh dahil ayaw nila ng Math.

Ang pagkahilig ko sa Math ang magtatawid sa akin sa med school. Habang iginagapang ko ang pag-aaral ng Anatomy at Pathology, naging mas madali aralin ang Biochemistry at Pharmacology.

Pero higit pa sa pag-compute ng ATP at dosage ng antibiotic ang naituro sa akin ng Math.

Dahil sa Math, natutuhan ko ang kahalagahan ng pagtingin sa isang problema mula sa iba’t ibang anggulo. Hindi sapat na alam ko ang tamang sagot, ang diagnosis. Dapat ay naiintindihan ko kung ano ang pinagmumulan ng karamdaman at kung papaano ito nagdudulot ng mga sintomas na nararamdaman ng pasyente, upang maibigay ang tamang lunas. Hindi puwedeng de kahon. Tulad ng given at variable ng isang mathematical problem, ang solusyon ay makukuha ko lamang kung pag-uugnay-ugnayin ang mga importanteng impormasyon galing sa clinical history at physical examination ng isang pasyente.

At kung hindi ko agad makuha ang tamang sagot, itinuro sa akin ng Math na minsan, ang tanging kailangan gawin ay umupo nang maayos, magpahingang saglit, at alisin ang lahat ng kalat sa isipan. Konting paglalaro pa ng x, y, at z, maya-maya ay makukuha ko rin ang solusyon.

Kung hindi ako naging batang mathematician, malamang, hindi ako doktor ngayon.