A Canadian Studying Medicine in Indonesia

Hi. I'm Waqqas from Calgary, Canada. I maintained this blog during my studies from 2011 to 2019 in the International Medicine program at Universitas Gadjah Mada of Yogyakarta, Indonesia. *pause* How did I end up there? Read my first blog post (and others) by clicking Archive at the top.

[inmed]

Signing Off

This is the end of the road for all I’d like to share about my journey.

It is mid 2020 and I’m a year into my Master of Public Health degree at the University of Malaya. I don’t know where I’ll go or what I’ll do after this. Although it may be exciting at first - like just jumping into a cold lake - soon it becomes exhausting and frustrating as you start to get tired of treading water and your feet keep searching for solid ground. I need solid ground now. I need something that I can rely on for my future. Living without knowing what’s next all these years has taken a toll on me.

Hopefully my next step will clear the fog and show me my trajectory. I can finally take a breath of relief and not live with constant anxiety.

The journey of a medical doctor is long... specially one who has studied internationally. You’re a foreign puzzle piece that doesn’t quite fit anywhere and despite being unique, you feel unwanted.

Clouds are gathering over Petaling Jaya, it’s 4 PM on a Friday, and I’m going to head out to meet an old friend and reminisce about our former lives in Yogyakarta. Ah... the past... some people hate to associate with their past and love to pretend it didn’t exist. But, I disagree with them... the past is our best teacher. We are who we are because of what we went through. Sure, we must always look to the future, but we cannot do that effectively without standing on the shoulders of our past.

So, don’t just forget the past. We all make mistakes. Learn from them rather than pretend they never happened. Improve yourself. Make amends. Try again. Try harder. Be forgiving - both with yourself and others. Smile. Life is but an afternoon drizzle. Don’t be scared to dance in the rain.

Good bye.

[inmed]

Advice I wish I was given at the beginning of clerkships (koas)

Clerkships (”koas”) are over and I’ve walked out of it a fair distance to be able to turn around and reflect on the whole two years.

I went into koas with very little knowledge of it. During the theory years (”S1 years”), we got very little exposure to life in the hospital. We did get some brief glimpses thanks to field trips to puskesmas, etc. but these don’t really give you a full sense of what it feels like being in koas.

Many fellow medical students are hereditary doctors where they have pre-existing knowledge in the form of having heard anecdotes from parents and older siblings who are doctors during their whole lives up until now. Many students knew they were going to be doctors from a young age and had been preparing mentally with a long-term low-dose intake of medical and hospital knowledge for years. Many are Jogja citizens who had been in and out of these very same hospitals visiting their sick relatives, inadvertently observing the ins and outs and workings of the hospitals here.

Others had been involved in certain activities such as research, events, etc. during theory years that brought them into contact with clinical doctors, nurses, patients, and the hospital.

I was not among these. I come from a family where scarcely anybody is in medicine. Also I’m a foreigner so I have no reason to go to the hospital unless I’m sick myself (and I’m a pretty healthy guy - bar an appendectomy and otitis media infection). I was friends with lots of seniors. But I was friends with them for the sake of friendship and not for leeching off of them to progress my education/career. Whenever I felt like I was asking too much, I stopped myself because I felt awkward. They did talk about koas life among each other, but the conversation only made sense to those already in koas. I was often like a blind man at a tennis game: hearing the conversation, turning my head from left to right, but not understanding what’s going on. I was also dating a senior who was in koas when I was still in my theory years. But she was the type to almost never discuss her koas life with me other than what was absolutely necessary such as what time she’ll be done that day. Perhaps she underestimated my ability to understand just because I was her junior. She rarely shared with me her daily koas triumphs and trials. We rarely discussed medicine, although we both would have benefited from doing so. Lastly, my final year research paper in the theory years did not require me to go to the hospital. And I was never in any committees, groups, events, or such that required me to go to the hospital. To cut it short, I had basically zero knowledge going into koas.

Two years ago, just before kaos started, we got a series of talks from doctors and seniors. Their advice was always vague: “make the best of it. don’t worry. don’t be scared to ask. don’t forget to have fun.” Maybe it’s a bit helpful, but I won’t waste your time being that vague. I want to tell you very specifically things I wish I had been told during these talks:

1. Always eat. Food is energy and koas is going to drain it. You will often be in situations where you feel stuck: you aren’t doing anything useful but you can’t go home, you can’t leave, and you can’t eat. Get rid of this mentality. You can always eat and you must not feel too ashamed to do so. Once I realized the importance of eating, I would often excuse myself to go to the toilet and then sneak into the cafeteria to fill my belly. I would often bring snacks in my pockets and backpack. I would always, always, always have bottles of water with me. As long as you’re avoiding hunger, eating healthy, and staying hydrated, you will be energized and motivated in koas.

2. Sleep. Don’t be scared to take shameless naps everywhere. You can sleep during lectures, presentations, etc. easily. You can sleep while waiting for doctors. Even a 15 minute nap can freshen you up. I know some expert sleepers who sleep so much during koas that they simply don’t sleep much outside of it: having social lives, playing games, studying, etc. I got a blindfold (is that what you call it?) and noise-canceling earphones to help me sleep.

3. Don’t fight with koas mates trying to get easier cases, etc. It happens all the time: there’ll be a situation where you have to split work: cases, patients, topics, whatever. There are always prejudices about which topics or cases are “easier” and which are harder. Often, these assumptions are wrong. A simple sounding disease may have a lot of literature about it, requiring more reading, and it may be so well known that the instructor will expect deeper research from you when presenting. Be smart and play the compassionate card: tell them you’ll let them have the easy cases “this time” (but do it every time). You will avoid an uncomfortable confrontation and they may return the favor later by being nice to you in other ways. Also by taking on challenging sounding (but not actually challenging) or obscure cases, you’ll be educating yourself on something potentially new and interesting, you’ll gain the admiration of the instructors and peers, and you’ll probably get away with making mistakes.

4. Check the nurse station for vitals. You don’t need to spend two years of koas taking vitals over and over. That’s stupid. Instead of wasting time on vitals, practice with your stethoscope. Patients don’t know if that’s part of vitals or not, and you can never get enough auscultation practice. You may even find a murmur and impress your instructors. 

5. You’ll often be working with and around residents (variably depending on which hospital and which department). Most residents respond better to koas who have “street smarts” and enough basic knowledge to be confident. They also respond well to koas who can help lighten their load. Don’t waste their time by asking them basic questions you can get the answers to online. Most residents don’t care how respectfully you speak, how low you duck your neck when greeting people, how soft your voice is, how many buttons on your white coat are fastened, how you refuse to rest or eat, or how many assignments and books you carry around. You don’t even have to be super intelligent to win their respect. Remember, nobody knows your GPA. If you do a bit of homework before starting a new koas department, you can look fairly knowledgeable. It isn’t hard and takes just a day’s investment to go over all the competencies/diseases listed in the koas book. After this, you can get the confidence to actually be useful. I remember in the Surgery and Pediatrics departments, the residents were often relieved that I had followed up our patients more thoroughly and was able to help the residents answer questions during rounds. As long as you’re being responsible, the residents will be happy to give you permission to “go eat”, which often just means to go home and nap for an hour, and then socialize with friends for another two hours over dinner. Don’t be scared to simply ask the residents if you can leave. As long as you aren’t sacrificing your duties and appear responsible, the residents will be willing to take any one of your countless fake excuses: work on group assignments, go to KKN meetings, etc. etc. 

6. Dare to have basketball-sized gonads. The midwife asked me, “have you delivered a baby yourself before?”   “Of course! Often!”, I lied blatantly, telling her to relax and let me do this in peace myself. In reality, I had only ever seen midwives and doctors deliver babies. I remember I had tried really hard to capture every movement and every step in my mind so I can do it with confidence when the time came. Another time, I simply asked to assist in a surgery and the doctor got a bit taken aback at my confidence, but then agreed. It was great sticking my hands into an abdomen for once (something which is considered a big no-no for koas for some reason). 

7. At every new hospital you go to, invest a bit of time doing a survey in and around the hospital for: best food, best toilets, and best showers. I have taken hot showers in unoccupied VIP rooms, taken glorious poops on brand new toilets on newly renovated floors, and eaten at clean little restos just a couple hundred meters from the hospital. When I started koas, GoFood wasn’t widely available but now it is. So, near the end of my koas, I extensively used GoFood to eat delicious food all the time. At one time, I used to have my maid pack cut fruit and snacks in tupperware for me to take daily.

8. Don’t take anything to heart. Always remember one thing: koas is temporary. It’s basically like a rapidly flipping magazine. The days go by like pages and old chapters don’t matter. So, don’t get into conflicts and if you do, forget them and move on immediately. Your main goal must always be to get through koas with harmony. It will be over before you know it. It will go fast because it is divided into departments and you will always move to a new department right when you’re getting comfortable. You will be going in and out of “luar kota” (rural hospitals) and all this will keep you busy enough to forget that time is passing. People’s opinions are just that: their opinions. You can choose to take something to learn from them, but don’t ever let people’s words cause you permanent injury (to your ego or confidence). You will make mistakes. You will be told off. But just laugh, apologize when appropriate, and keep going. At the same time, keep your opinions to yourself unless they benefit you somehow. Keep your ego in check. It isn’t worth picking fights with your groupmates, nurses, etc. These people are temporary and you won’t see them again after koas is over. But for now, you need them. You need them for shifts, and alerting and reminding you of assignments and meetings.

9. I learned the most and got the most out of the hospital in Klaten: the surgery department is overflowing with patients and I had an endless supply of interesting cases in the ward. The other place I learned a lot was the ER in Klaten. It is understaffed and brimming with patients. I was very often allowed a great deal of autonomy just because the doctors and nurses were too busy with other patients. The places I learned the least were classrooms in Sardjito. Perhaps the material was useful but because it was in a classroom setting, the memories melted away. What stuck with me are memories of real patients that I saw, talked to, touched, and followed up from start to finish. I remember their diseases and remember studying about them as a result of meeting those patients. You will see an irrational distribution of trust in the hospital: in the OR (operating room), they don’t trust a koas to sit the right way on a toilet. However in the ER or during Obsgyn, I was often allowed to do minor surgery all by myself, install IV lines, etc.  So, don’t waste your time in places where (thanks to stupid ingrained stereotypes) they don’t trust you. As much as I enjoyed watching surgeries in the OR, I got much more hands on experience in the ER, VK (birthing room), and even poly-clinic. Also, I shouldn’t have to tell you this, but you’re in koas to gain general physician competencies. So, as cool as the specialized stuff looks, focus on getting your GP competencies first.

10. Request to combine refkas, tutorials, mini-CX, etc. It isn’t always easy to find, schedule, wait for, and travel to these things. So, don’t worry about working a bit harder to finish two assignments for the same day. The time saved by combining them into the same meeting will easily outweigh any extra time you spent finishing your assignments quicker. One of the worst things that can happen in koas is you not finishing your refkas, tutorial, or mini-CX by the end of the department. So, of course, the earlier the better anyways.

11. Live closer to the hospital. This is a mistake I made: I chose to live too far from the hospital. Shortening your commute is going to benefit you on a daily basis. Even if you have to pay more and live in a smaller place, choose to be closer. I live right near RSA (hospital) so when I was assigned there, it was heaven. I could leave home 5 minutes before I had to be there and return home in the middle of the day, just for a quick shower or lunch or just to poop in peace. Sadly, being far from Sardjito means that my commute is 15-30 minutes. It isn’t near enough to go back to to wait for a doctor to become available.

12. Three white coats. I chose to get three with different materials. It was a great decision. When I knew I was going to be in a hot room all day, I wore the one with the lighter material (and I’d highly recommend this one, because I found myself wearing it more than the other two). Having three meant that I could laundry them lazily whenever I got the chance. I know some koas who only bought one and were forced to wear a dirty white coat because they had no chance to wash it. 

13. Don’t bring textbooks. You won’t read them and they’re just going to weigh you down. My backpack was always filled with snacks, convenience items, and water. I never brought a textbook and even the ones at home, I never opened them. Instead, I got most of my knowledge from PubMed, Mims app, Patient.info, and of course my UptoDate.com membership. My backpack also served as a great pillow (thanks to the padded back) on many occasions. 

14. Sketchers shoes. The ultimate best investment for koas. I bought these at the beginning of koas and used them throughout. They went through a lot as I wore them daily, and they’re still mostly okay. They’re super light, easy to wash and dry, easy to put on take off, well ventilated, and heaven for your feet. You will spend a lot of time standing and walking in koas, and sore feet will make your whole body ache. I used the official Sketchers ankle socks. Excellent investment.

15. Plan for the future. Keep an UKMPPD journal/file where you write down stuff from each department to help you for this exam at the end of koas. Think about your career in the future. Do you need to network with certain specialists so you can get research assistance work later or letters of recommendation? Do you want to take part in events and conferences so you can get experience and build your CV? Start a LinkedIn profile and start networking right off the bat from the beginning of koas. Don’t underestimate your peers: they may be koas or residents today but tomorrow (and by tomorrow I mean just a few years) they will be the leading doctors of Indonesia. They may even be your bosses or your boss’s bosses.

That’s all the time I have for now. (Got the UKMPPD coming soon and I need to study!) Good luck!

[inmed]

Today is the last day

It is 12 noon. I have arrived home from my Radiology final already. But more than the Radiology final, today is a significant date: it is officially my last day in clerkship (koas). It’s finally done.

Let’s quickly capture my emotions while they’re fresh:

There are a few aspects to this. One is that my personal journey in clerkships has come to an end. And second is the disbanding of my “koas group”, the group of people I’ve (in various combinations of sub-groups) spent the last two years with. Let’s talk about the latter first to get it out of the way. I suspect I don’t have much to say on the matter. (Oh no, I rhymed “matter” with “latter” and now this probably sounds like a ballad). Anyways, my group. They are a mix but not exactly a very good mix. That is to say, they have diverse personalities but probably not as diverse as one would hope for. There are the quiet people, the loud mouths, the hard workers, the stragglers, and let’s not forget, the assholes. But it’s not fair to categorize people like that. I think those are just the common positions that people assume - sort of like a self-configuring flock of migratory geese - when put into such groups. As for my own experience: I went into this group knowing full well that I will have to tolerate them and they will have to tolerate me for a full two years. That meant that I had to keep a lot of my opinions to myself, try to mitigate conflict, and take everything they say with a fistful of salt. I (correctly) assumed that a lot of conflict in groups like these stems from one person feeling that another isn’t pulling their fair weight. Although, due to language barriers, having a busy life, and different culture, I did often slip and mess stuff up sometimes (usually bureaucracy/paperwork, which Indonesians love to be enslaved by so much). But other than that, I always tried to be generous about my time and energy in night-shifts and taking on responsibility for portions of work. I never complained to them that I did an hour more or that the topic assigned to me is too hard compared to the others. This was a good decision. Feelings of jealousy and anger are much more taxing than doing an extra night shift or taking a harder subject to make a PowerPoint on. Not constantly comparing my plight to others put me generally at ease throughout these two years. I cannot say the same about some of my groupmates. Right off the bat in my first department (Neurology) two years ago, I saw the seeds of discord already being sown. There were tears and public venting, and many chose to appease whoever was in front of them rather than be diplomatic and nip issues in the bud. I remember feeling that several of these groupmates were immature and irresponsible with their backbiting, self-serving, passive-aggressive ways. My feelings have not changed. I will give you a fresh example. So, since koas is ending, we’ve been burdened with lots of paperwork that we individually have to do. So I’ve been delayed with one of these documents, and I have been making slow but steady progress on it. Not doing it won’t harm anybody but me. Anyways, one of my groupmates obnoxiously asked me if I had done it yet. Shocked that she’d show concern for me, not a millisecond passed that the reality sunk in: she just wants to feel superior and slap me with a chastigation. I replied that I’m dealing with it as we speak. “Make sure you finish it or else you won’t be allowed to do UKMPPD” (the Indonesian medical competency exam) she said. I acknowledged. Then, out of the blue, a couple of hours later, she typed out the exact same question into my group’s Line group and tagged me by name. A decent human being would private message another when the conversation is between just two people. Publicly posting it in a group is looking for an audience. And of course, the question was not intended for me as she had already asked me verbally just a couple hours before! She just wanted to make me look bad to the group. And sadly, 99% Indonesians can’t see through things like that. Of course, I could’ve returned the fire and publicly demanded an explanation of why she’s trying to belittle me in front of the groupmates asking me the same question she already got the answer to just earlier. Instead, I chose to let her inflate her ego (again) at my expense. I’ve lost count. “Whatever. All this will be over soon and none of this will matter,” I thought. Besides, Indonesians generally have no problem with slander but are terrified of conflict, so engaging her would’ve drawn the typical, “hey hey hey, calm down, she’s right” sort of crap anyways. I want to end this part on a good note with a clear disclaimer though: several of my groupmates have been great and I felt lucky to have them on many occasions, specially when I was exposed to stories of other groups from my friends. There were many times I said, “I owe you one” to them. And there were a few times that they too overlooked my flaws. Will I stay in touch with these groupmates? I doubt it. Our lives will diverge and I never really gelled with them on a social/personal level beyond the perfunctory. It isn’t over yet though. I still have to traverse through the rocky path to UKMPPD with them (i.e. take evening preparatory classes with them). So I’ll be seeing them for the next couple months and then again for graduation (if we all graduate together). Actually, I just remembered: three of my initial groupmates changed some grades (after receiving lower marks) and got in major trouble back in our first department. They were reprimanded stiffly and kicked out for a semester. So, they’ve been absorbed into other groups since they’ve been back, due to scheduling issues I’m guessing. Anyways, I won’t be seeing them very much anyways since they’ll finish next year.

Okay, now I’m free to tell you how I personally feel about finishing clerkships. Before me is a vast, dark abyss. On the other side of this chasm is a glowing residency in the US beckoning me. I have to take a few steps back, run as hard as I can, and then leap. But time is running out. The longer I wait, the wider this chasm gets. It feels out of reach but I know that it isn’t impossible yet. As Jim Carrey’s character said in Dumb & Dumber, “So you're telling me there's a chance, “ when faced with near-impossible odds. That’s basically all I’ve got. I have no choice but to take the leap. If I fail, I will think of a plan-B. But for now, there is no plan-B. There never has been. I selected UGM from a list (WHO FAIMER) of recognized universities for working as a doctor in the USA. My plan since day-1 has been to get my MD from UGM and then write the USMLE to get into a US residency program. That’s the beast cracking its knuckles to beat me to a pulp after all this. So, one of my main emotions right now is: unrelenting fear. “How will I do it?”, “What if I fail?”, “Will anybody help me?”, “What if it’s too hard?”, “When should I have started this?”, “Is it too late already?”, “What else do I need and how will I get it all?”, and other thoughts are bothering me constantly.

The other emotion I’m feeling is relief. I’m done this 7-year journey of med-school and it’s a good feeling. I’ve achieved something in my life. I haven’t exactly summitted yet, but it’s still something. No more koas departments! No more night shift. No more refkas, tutorial, minicx, and exams! (I know you’re saying, “wait for residency!”)

On the flip side, I’m also sad. I enjoyed the clinical rotations a lot more than the theory years at campus. I love doing stuff with my hands, talking to people, and seeing quick results of my work. The pride you feel after looking at the fine suturing job you did on a mangled foot, or repairing an episiotomy to make it like new (well, not exactly like new), cannot be compared to anything you do in your theory years. Sure you study hard for a pre-test and then get a 10/10. Great. Does that make anyone smile internally until it spills out onto their faces? I doubt it. Everybody cheats on those pre-tests anyways, walking in with the questions and answers memorized. Yeah, I never chased a high GPA and I never took pride in having to do that sort of crap myself in order to survive med-school here. But I can tell you that I felt awesome delivering babies, assisting surgeries, pretending to be a real doctor in the ER, winning hard-earned trust in the OR, and following up on my patients. And I am definitely going to miss that. I hope I can get into a residency soon and revive all these happy feelings somewhere else.

I’m feeling stupid. I should’ve studied harder. (Oh look, the same retroactive advice I give myself at the end of every academic year since grade 2!) I should have though! I got distracted by various things including my personal life issues, business demands, relationship issues, social life, being lazy/tired, and the whole system of inefficiency developed by UGM to keep students busy slapping stamps, filling forms, and Whatsapping teaching doctors. Had all these things been better managed, I’m sure I’d have the energy and time to actually enrich myself with books or at least videos on the stuff I was seeing at the hospital. Sadly, I rarely ever laid my finger on any book in the last two years and I was using Google more than anything to get that last minute answer to pressing knowledge gaps. My mind still goes blank when I glance at an ECG (ugh, I should know this by now!) and I don’t have even half the drugs memorized as I’m probably expected to by now.

And on the flip-side, I’m also feeling smart and confident. I delivered babies all by myself, damn it! Without supervision! I sutured up patients in the ER. Also without supervision. I did rounds with confidence in Internet Medicine. My white coats aren’t so white any more. I’m experienced now. I’ve seen it all and done it all. I’ve been there, and also been there and there too, and I know exactly how this and this feels. I’ve been in clerkship long enough (two years) to start saying, “during my time” when referring to things while giving advice to my juniors.

What other emotions am I feeling? Tired due to insomnia. Yes, I had coffee last night. An Americano from Ethikopia next door. It tasted better as I drank it. Not because of getting desensitized to the bitter flavor but due to the sugar at the bottom of the cup. Anyways, I will try to take an hour nap to recuperate some strength. And then I have to go for evening lessons at PADI (no, not the diving thing) for UKMPPD prep.

Until next time, Adios!

[inmed]

Radiology

It’s hot and I can feel various folds on my body are already damp. The time is 1:51 PM and the appointment with the Radiological Oncology Consultant was about an hour and a half ago. The koas student sitting next to me is resting his elbow on the armrest of the wooden bench, his neck tucked in, his eyes shut, and he’s occasionally taking deep breaths and nodding, hanging somewhere between sleeping and dozing. We are waiting in the dusty, eerie Radiotherapy and Nuclear Medicine building, next to the Forensics building. This is where we’re supposed to meet our teacher to continue our discussion with her.

The last time we met her, a couple of days ago, it was on the 6th floor of the ICC (International Cancer Center) building at the back of the hospital. I wondered then why they put such a flashy-looking building near the rear of the hospital where it would be obscured from view. Maybe that’s the only place in the congested RSUP Dr Sardjito complex with some empty space left? I scuttled from umbrage to umbrage, shielding my face from the blistering sun with my book, while stealing looks at the dozens and dozens of people hanging around the entrance and lobby of the building. As I got close enough to the building and started to see the faces of the patients, I entertained a thought that perhaps, like the lepers in Ben-Hur, the cancer patients were banished here to keep them away from the “healthy” society. The patients there didn’t appear angry or sad. They generously smiled at each other, perhaps more so than is usual in Yogyakarta, because they knew full-well why they were all there, and perhaps because they felt they weren’t alone suffering such a fate. Perhaps they’re looking for reciprocation of a reassuring smile? Unlike other departments where patients animatedly discuss their diseases, I felt that here, patients were too busy with their internal monologues, practicing what to say to the doctor, as they patiently waited. Or perhaps, they were too weak to talk? No, like many “cancer patients”, they looked healthy and free from any complaints. The greatest pain they were experiencing is probably the anxiety about the malignant tumor growing within their bodies.

“There’s so many!”, I thought, as the realization about countless number of people there hit me. Many came with their spouses or accompanied by a child (well, not children, but mostly older teenagers or people who would have 50+ year old parents). Some patients sat alone. I felt a bit of sadness when I saw the solitary patients, as loneliness always strikes a delicate chord with me. These are people undergoing a terrible disease which will probably kill them very soon, and they’re left alone to face the doctor (well, “face the news”, would be more accurate) alone. I had stood behind the doctor and watched her go through patient after patient, spending about five minutes per patient. One 50-something-year-old patient had masses growing within her chest. She had already gotten a mastectomy and that that’d be that, but the cancer came back. The doctor was candid, but remained unsmiling, explaining only the most necessary to the patients in bite-sized packets of patient education. One of the younger patients was concerned about his dry mouth. She started replying while still writing in the medical record, “it’s a side-effect of the chemotherapy”. She ended with her fingertips clasped and pointing towards the patient in a posture of power. The patient looked reassured but a part of him was still unconvinced or perhaps he simply didn’t understand. Either way, the doctor couldn’t have made it easier to digest. He threw a quick gaze at his partner and then slumped in his seat, allowing the doctor to finish scribbling and motion him to leave. My mind drifted as I stared out of the floor-to-ceiling glass of the doctor’s office and towards the buildings of UGM and beyond. “Life is delicate,” I thought. Our time here is limited. We will all surely die. The only question is “when” and never “if”. Every human who has ever lived has died. I felt my throat being tight and dry from the anxiety of thinking about mortality. Then, I remembered a quote which went something like, “I don’t feel sad that I wasn’t able to experience the billions of years before my birth, so why should I feel sad about missing out on the billions of years after my death?” In fact, as humans, we can’t be physically everywhere, so in fact we only experience a very narrow segment of events happening right now. Then there’s our fickle memory that forgets past events. Not being present is no different than not being alive, for all those people and objects we can’t interact with. So, we’re just dust, waiting for the next wind to blow us away, leaving little to no trace. We’re so insignificant, no more than a biological beaker of chemicals, active for the duration of the reaction and then, a slow decay without any fanfare. But, somehow, this beaker is able to look up at the stars, wonder, and fathom its own existence. Sobering!

Ok, let’s enter the time-machine, and go back to the present: it is now 2:09 PM, still hot, and the guy next to me... well, his head is still bobbing on Plutonian seas. Coming up here (I’m on the second story), I was told that one of the patients wanting to register for radiotherapy was given a date in December. It is currently June! There are clearly a lot of things we can improve today rather than chanting the age-old mantra of “cure cancer! cure cancer! find a cure!” 

Radiology, so far, has been just a bunch of BIKOs. These are basically lectures in a small classroom. Sometimes we break into smaller groups, get some homework, and do some discussions, but these tend to be very one-directional, not much unlike the BIKOs. So, that just means, all we do are BIKOs. Radiology isn’t heavy, so there’s free time here and there, and the residents seem to be quite relaxed (and not the stressed-out, pressure-cooker-dwelling residents of Internal Medicine, looking for a punching-bag in the shape of a koas student -- maybe I exaggerate, but sometimes it felt that way, okay :-D ). When I get a chance, I think I’ll go sit at one of the terminals (computers) and just browse dozens of radiographs: X-rays, CT scans, USGs, etc. I believe, as part of the scheduled activities of the Radiology department, I will get a chance to actually go see the scans happening at some point. Otherwise, I’m happy to just try and interpret the radiographs. In my heart, I know that within a few years, all this interpretation will be done by artificial intelligence (computers) and we won’t need Radiology specialists. But still, it’s fun to see this part of medicine. It makes more sense too as I’ve gone through all the other departments and am familiar with a lot of the diseases. (Did I mention Radiology is my last department? No? Ok, I’m mentioning it now then!)

Since it is my last department, as you can imagine, it’s quite emotional for me to reach this point. I’m not talking about sappy, crying sort of emotions. What I mean is that I’m finally stepping back and looking at the whole picture. 7 years I have been here! 7 years! That’s around 1/4 of my entire life. And it’s the most recent 1/4 too, so it is more significant. Was it worth it? It’s too early to answer that question. One thing’s for sure though, it has been a huge sacrifice of more than just money and time.

2018 and 2019 will be the most significant years of my life. This is when I hop out the nest and flap my wings for the first time. I’ll keep you updated.

[inmed]

Internal Medicine: Yawn

Before I got into my clinical rotations, I used to think I’d enjoy the logical and analytical Internal Medicine the most and probably despise messy, butcher’s shop departments like Obsgyn and Surgery. I was wrong. I just went through Internal Medicine - a whole 10 weeks of it - immediately after 10-weeks of Surgery. Now that I’ve cleared them both I can easily juxtaposition and judge. I thought that Internal Medicine would have a lot more speculation, discussion, and analysis. But unfortunately, the overwhelming amount of cases all fall within a few buckets so usually you already know the problem within 60 seconds of meeting the patient. Congestive heart failure, type-2 diabetes, pneumonia, oh god, I am so bored of these same diseases! Internal Medicine is broken into sub-sections like Cardiology and Pulmonology. The cardiology week was spent in the ICCU (intensive cardiac care unit). There was a good variation of diseases (not just myocardial infarctions) including LBBB/RBBB, AV-blocks, etc. Still, it was very boring as we were required to read dozens of ECGs every day. And, to me, ECGs is like reading tea-leaves. It isn’t totally ECG’s fault. It’s the way ECG is taught  is also a huge issue. Doctors that understand ECG just assume students to somehow understand it too with a basic textbook-style definition. In the end, they shower the students with ECG features and what disease they point towards and expect the students to just tack-on all this information into our memories. It was painfully boring looking at those scraps of ECG paper, and also painful realizing that no matter how hard I concentrate, I won’t be able to memorize all this crap. I hate memorizing stuff anyways. I ended up downloading an app on my phone that is loaded with a bunch of commonly found ECG findings and this helped a bit. Sadly, real ECGs are rarely “textbook ECGs” and even stump the experts (cardio residents) sometimes. Pulmonology was basically infections of the lung, COPD, and Asthma. This wasn’t that exciting as I’d already studied these extensively before. Oh, there were TB cases but TB isn’t as exciting as it sounds on paper due to the very long therapy when the patient is devoid of symptoms.

I want to write more but it will have to wait. I’m tired and tomorrow is day 1 of Pediatrics.

[inmed]

7-Year Goals

We all have a white picket fence dream for our future. We all want to be comfortable, healthy, and happy - surrounded by friends, things we like, and people we love. Most people don’t want to be filthy rich, but they want something that’s better than what they have now. They want to be in a position to give a better life to their kids than they had. And none of this comes cheap. Amateurs to “real life” (e.g. teenagers) love to say things like, “money isn’t important in life”. But guess what, everything costs money. You want to spend more time with your kids? Money. If you don’t have money, you’d be working double-shifts and your kids will be asleep by the time you get home. You want friends? Money. Social life costs money and leisure time costs money too. You want the best for your old parents? Money. Hospital bills aren’t gonna pay themselves, and trust me, nothing kills a person more to see their (dependent) loved ones refuse vital medical treatment because the person can’t afford it. I see this daily and it really tears me up inside. The doctor will say a surgery is necessary. The “man of the house” will then ask, “it sounds expensive. How much are we talking about, doc?” The doctor would reply and then, a long, stressful silence will descend upon the room. Usually this silence will be broken by the patient - usually a feeble old grandmother. She will say, “No, it’s ok. It’s too expensive. The pain is not so bad. I think I will just rest at home.”  A scream will emanate from within me: “OH MY GOD NO! YOU NEED THIS SIMPLE $200 TREATMENT OR ELSE YOU WILL DIE A PAINFUL DEATH!” But, it’s not my place or my responsibility. So, I just watch in silence and swear to myself that I will work very hard to make sure my family never has forego a life-saving treatment because of shortage of money.

This is why I decided to study medicine. And that’s the fire within that’ll fuel my motivation and get me through this.

So, as you can imagine, my main goal is to have enough that I can give a comfortable life to those I love. I have parents who worked hard their whole lives and didn’t save much for themselves, always choosing instead to invest in their kids. I’m the oldest of four brothers. Although I’m sure they’ll be independent (and one is already independent with a wife and kid), I want to always be there for them and their kids. I want to be the uncle who takes them on summer holidays to Europe and safaris in Africa for Christmas. Okay, this is getting to be a huge skyscraper of text rather than a nice list I had in mind. So let’s switch to list mode now with more specific goals...

- Buy my parents a new house, boat, trailer, and an SUV to pull all of that (except the house of course). - Send my parents on a 3-month world cruise. - Take all my nephews and nieces on yearly week-long vacations. This is as much a gift for my nephews and nieces as their parents. - Put my (eventual) kids through private schooling along with whatever extracurricular classes they want including international exchange. And basically, make sure that finances are never a factor in picking where they study. - Take 2 months off per year to either start a new business, do some charity work, write a book, invent something, study something new, get a unique part-time job, or just travel to a new place in a new way. - Take my eventual wife on several surprise week-long vacations per year. - Own a large piece of land where I can build an open-air aviary, do gardening with unique plants and trees, and have lots of lemurs (one of my favorite animals) just hanging out, and horses running wild (my favorite animal). - Own my own two-seater gyrocopter. - I don’t care to own luxury or sports cars. I like cars but I think they’re a huge waste of money (i.e. the amount of time spent per 24 hours in a car vs. amount paid to buy and maintain it). But I’d like to own an autonomous car, so I’d probably want a Tesla. Will we even own cars in the near future? I don’t think so (just see my previous blog post about my predictions for the future). We’ll just use autonomous Ubers. Okay fine, I won’t own a car then. Good. Saves me money for a better gyrocopter. - Oh and I want an awesome rec room complete with computers, game consoles, and arcade machines from my childhood (I was born in the mid 80s so as a kid in the 90s, I’d go to arcades which had old coin-op game machines from the 80s). I also want the large swathes of time required to play these games. The rec room must also have an elaborate train set and a massive TCR track. I feel like a kid in a candy store just thinking about all this. I’m not done yet though. I also want a large aquarium with sharks and a radio controlled submarine. I really feel like I’m sitting on Santa’s lap here. I also want a model of the entire city of Springfield (from the Simpsons) and a full scale replica of Darth Vader ominously standing there watching over everything. I also want an antique TV that only plays old shows I grew up watching: The Addams Family (1960s series), Batman (also 1960s series), Lost in Space (yep, also 60s), and cartoons such as the Flintstones, Jetsons, Popeye, Loony Toons, and anything off the old Cartoon Network. I want posters of every Wes Anderson movie on the walls and both a foosball and air hockey table, and also a Space Cadet themed pinball machine. Great, now you know how big of a nerd I am. - Moving on... - I’m too excited about my rec room and am utterly unable to think of anything else. - End of list.

As you can see, my goals aren’t to amass a fortune. Most of them are to take care of people I love and to get the most out of life. Unfortunately, everything in this life costs money. And unfortunately like most people in the world, I wasn’t born heir to a huge fortune. So, I have to start with a good job. Ok, gonna go study a bit now that I have sufficiently motivated myself. :-D

[inmed]

Immediate Goals for the Next Two Years

I’m in the last year of my clinical rotations of med-school now. This is the final stretch. To be honest, clinical rotations don’t feel like hurdles. Instead, they feel more like a book that you’re reading: it gets boring sometimes, it gets interesting sometimes, but as long as you keep turning the page, you’ll keep moving on. It isn’t hard, it’s just tedious at times.

I’ll be honest, I still have no idea where I will be or what I’ll be doing in about two years from now. I have some ideas on what I’d like to be doing and where I’d like to be. But life has a way of throwing curve balls and you don’t always get what you exactly wanted. You may not even want what you wanted, and you may actually like what you ended up with. Life is messy but we can make the best of it if we’re flexible enough, adaptable enough, and remain hopeful, optimistic, and smiling.

Okay, enough abstract talk. Let’s discuss where I’d actually like to be in two years from now. (Heh, I can’t wait to read this in 2019): Hopefully, in a residency program that I like in a country where specialists are paid well, in a city that isn’t too big or too small to be annoying. More specifically: let’s say Anesthesiology department anywhere in the USA that isn’t a city of over 2 million people.

So how will I get there? Phew... it isn’t going to be easy, but this is how: after I finish my clinical rotations, I have to write the Indonesian national medical competency exam (the UKMPPD). Once I clear that, I get scheduled to receive my degree - usually within a couple of months after the exam results come out in my favor. It takes four months to study for the UKMPPD exam and a month or so to wait for the result. If stars align in my favor and I pass on the first try, I’m still going to have to wait about 6 months from when I finish my clinical rotations (29 June 2018) before I can get my degree. Once I pass the UKMPPD, I need to immediately begin studying for licensing exams in the country where I wish to do my residency. In this scenario, that’s the USMLE exams for the USA. They say it takes 6 to 8 months to study for the first exam and then a month or so to study for the next two. So we’re looking at a whole year. Then, after writing the first exam, if I do well, I can enter the residency match. Stars align once again, and I’ll get a residency match in a program that I like, in a city that I like. To be honest, just getting a match (in any program, in any city) is already a huge blessing. So, if I reach that point, I’d already be very happy.

Stars don’t always align, specially for me. I’ve been pretty unlucky in my life, and I know this better than anyone. So, I can’t put all my hopes and dreams in one basket and then watch them all crumble. I need a plan-B. Hell, I need plans C through J too. Ok, so basically, any alternate plans simply involve me trying the exams for other countries in parallel to the USMLE. My criteria is simple: English speaking countries with residency programs that are open to international graduates, and where residents are paid (well). These boil down to: Canada, UK, Ireland, Australia, and New Zealand. I haven’t properly looked into them but from what I know so far, Australia and New Zealand will simply accept the exam results from UK. And Canada is in the process of revamping their exams, so I’ll probably wait until they’re ready with that (2019 I think). So, plan-B is looking to be the UK at this point. A job is better than no job, so even though the salary is lower in the UK, cost of living higher, and ... eww, British people :-D - I’d still accept just to put food on the table and to keep my career from stagnating immediately after med school.

Beyond these options is the painful prospect of having to repeat the failed exams the following year and trying to get a residency match. This is really tough, as you can imagine. I’m already almost 31 years old. I can’t be going too long without an income at this age.

So, what happens if I fail at all of that? Do I get the McDonald’s job application ready? Do I buy a shovel to find work as a gravedigger? Okay, seriously though, it’s a real possibility. Let’s say I did fail all the exams, now what? The other options are looking into a scholarship for a Masters program that can cover living expenses. That’d buy me time to try the exams yet again. So, maybe the smart thing to do is look for and apply to such Masters programs (and scholarships) when I’m nearing the end of my clinical rotations. It’d give me a plan-B waiting in case I fail the exams. I wouldn’t mind doing a Masters in Public Health or Hospital Management. Not my first choice, but it’s better than scraping greasy grime off pans in McD’s.  There’s also research, but I have no idea how to even get into that.

It’s already November. Just 8 months until I finish clinicals. Time’s a ticking. Hopefully in two years, I can look back the way a person looks back after successfully leaping across the Grand Canyon. (Do people do that? I don’t know. I’ve never been to the Grand Canyon.)

[inmed]

My Predictions for the Future (Year 2117)

I talk about these from time to time, so a few friends have asked me to finally publish my complete list of predictions for the future. So what do I mean by “future”? Let’s just say... a 100 years from now. As I’m writing this in 2017, that would make my predictions for the year 2117.

1.       AI and robots will take on a lot of tasks that traditionally humans did without much help, including computer programming, farming, research, construction, surgery, design, and even producing music.

2.       AI will be able to sit and discuss things with a human with the same level of intelligence and creativity as a very smart, very funny, very creative person. AI would easily pass the Turing test.

3.       Brain-machine interfaces will render many devices obsolete. We will Google by thinking.

4.       AI will not “take over” and destroy us. Instead, AI will extend our own intelligence – augmented brain power, in other words. We will be able to think of funnier jokes, store memories, speak languages, and be more creative by having AI and computational power available to us just by thinking about it. Eventually we will be able to store our entire brain in the cloud, attain immortality, and let go of our flesh and blood body.

5.       Our culture will evolve in complexity and add new layers of abstraction as a result of augmented brain power. The way we think and what we exchange with other humans will totally change.

6.       Jobs will become an obsolete concept.

7.       A new power source (probably fusion) will permanently satisfy the world’s energy demands and make electricity incredibly cheap. Coal, nuclear, wind, and solar will all become obsolete.

8.       Battery technology, wireless energy transmission technology, and optimizations in electronics themselves will mean that we wouldn’t need to think about charging our devices the way we do now. One charge would last for years or it would just charge itself.

9.   Combustion engines will no longer be used.

10.   Pollution and greenhouses gas levels will be reversed to pre-Industrial era.

11.   Screens (TVs, mobile phone screens, laptop screens, cinemas) will become obsolete.

12.   We will have the ability to simulate senses. We’d be able to listen to music or watch a movie in our heads rather than via our ears and eyes. The movies of the future will be experiences and feelings rather than watching a screen.

13.   All diseases will be cured.

14.   Aging will be slowed, and human health-span and life-span will increase to around 300.

15.   Every baby born would have been genetically engineered in some way (using CRISPR). Congenital defects will cease to exist.

16.   Every car, plane, drone, and ship will be autonomous. The idea of owning cars will be as strange as owning a plane is today: only reserved for billionaires and hobbyists.

17.   There will be no more poverty. Costs will be reduced thanks to automation and optimizations by AI, easier/cheaper to grow foods, genetic engineering, and blockchain. Philanthropy will help speed up adoption of emerging technologies in poor countries.

18.   All food will be genetically engineered. Much of the food would be synthesized and grown in lab farms and oceans (such as salt-water rice).

19.   Everything will be 3D-printable including food, electronics, houses, and clothes. Exotic materials and nanotechnology will allow structures like houses to be built within hours.

20.   We will begin terra-forming Mars. There will already be a permanent colony on the Moon, Mars, and Venus composed of scientists.

21.   People will regularly commute to the other side of the world, which will take less than an hour.

22.   Anybody would be able to see any part of Earth at any time. (like a live Google Maps satellite view with the ability to replay).

23.   Physicists would have developed a Grand Unification Theory and would also be able to answer questions about how and why the Big Bang happened, dark energy, and the nature of time.

24.   We would have achieved faster-than-light (FTL) travel or at least FTL communication.

25.   The world will use a single currency.

26.   Music and art will be created on-the-fly just for you. So, the song you’re listening to would have never been heard before and will never be heard again.

27.   Globalization will make commodity and services prices the same all over the world.

[inmed]

How to remove a toenail and other gross stuff

The trick is to go in from one the edge of the toenail, pushing the flat forceps all the way in. And then, with a nice firm grip, roll the forceps, and remove the nail. It’s like opening a can of anchovies.

Before this, I had only seen toenail extraction as part of torture depicted in movies. But I’m glad I learned to do it as part of the surgery department here at RSUP dr Soeradji Tirtonegoro Hospital. It’s actually easier than it sounds. I thought it’d be a huge bloody mess with fragments of nail stuck to meat everywhere, but it wasn’t.

I’ve seen loads of other shocking stuff here. In my last blog entry, I wrote about maggots in the leg of a live person. I thought that was the grossest thing I’d see. But unfortunately I was proven wrong several times after that. A few minutes after the toenail extraction, I was asked by the consultant specialist (my teacher) to drain abscess. It was pretty easy also, but not less gross. I held my breath as I pushed the scalpel into the inguinal lump. I made the incision just wide enough to slide my forceps in. Then, I opened the forceps and stretched open the incision. The yellow soup within poured out. I used some dressing held in forceps to dig into the opening to give it a nice scrub. And then shoved in some more dressing smeared with antibacterial cream to be left in for a couple of days. Done.

I mentioned my last blog entry about the maggots. I have an update about that, by the way. So, a couple of days after that, I met the friendly plastic surgeon again. He looked grim. He asked me, “do you remember that patient with the infected ulcer?” I knew what he was talking about, but since we get many diabetic ulcer patients every day and because I didn’t want to seem like that one patient was a particularly big deal to me (it was), I feigned with, “Which...?” And the doctor continued with, “the one with the larvae”. I immediately replied, “ohhh! yeah yeah yeah, doc, I remember.” He continued, looking bitter, “she died yesterday”. I was a bit surprised. I was expecting something like, “she needs an amputation” or maybe some questions he wanted to ask me about it. “Why did she die?” I asked, realizing I should’ve asked, “How” instead, to not sound so shocked. The doctor explained, “her family say she had trouble breathing so they brought her into the ER. By the time she reached the hospital, she was dead”. I nodded. I could see in the doctor’s eyes that he suspected malice, or at least criminal negligence, but I thought it best to leave it at that.

This week has been a bit easy. I’ve been in the Urology department. The first two departments were most heavy: General Surgery and Orthopedics. They get a lot of patients so the follow-up is insane. I remember I was spending 3 to 5 hours a day just doing follow-ups. At the end of the day, tired from presentations, the operating room, policlinic, and the heat, I’d visit the sauna-like ward to start my follow-up. Checking the time, I’d see that it’s already 6pm. “Should I do follow-up after dinner or before it?”, I’d think. If I eat first, that means I’ll get hungry later at night. If I decide to eat later, most places will be closed because my follow-up takes so long. I put aside these thoughts and start my follow-up. It involves opening every single medical record for all the patients on that floor. The worst part that takes up the most amount of time is deciphering the hieroglyphics and chicken scratches that are scribbled senselessly by the doctors. If you don’t already know what is written, it’s very hard to read it. If you’re already expecting this patient to have a certain disease and already know the common medications given to patients of said disease, then it’s not so bad. So if you’re expecting “Ceftriaxone” and you read something like, “Cjlasxona” then you can just assume “Ceftriaxone”. But if you’re a medical student like me who doesn’t have the experience yet, when you see “C#!zsasdcz” you have no idea if it is “Cetirizine”, “Cefixime”, “Ceftriaxone”, or something else altogether! Computers use up a massive amount of processing power to try to recognize and understand handwriting. I can see why because in that hot sauna of a ward, after a long day, I can feel my hypoglycemic brain overheating as I try to make out the handwriting. Then, against the law, we fill in the medical record (we call this “templating”) so that the next morning, the residents just sign next to it to save their time. It takes forever, specially because for many of the patients, I have to physically go and talk to them and even inspect them. Then, exhausted, I’d remember there are three more floors. Finally, the suffering would end. I look at my phone’s clock: 10:35 pm. All the (already very limited) places to eat are all closed. I drag my tired legs to the student’s residence (climbing three flights of stairs to my room). I look around for snacks and there’s nothing. I make a mental note to buy something next opportunity I get the next day. I should shower but the thought of the trickling ice-cold water and the dirty bathrooms convinces me to just fall onto the rock-hard plastic-encased mattress and just fall asleep. I set my alarms for 4:30 am, 4:35 am, 4:40 am, and 4:50 am. The next morning, I wake up at 5 am, rush to shower - hating myself for not showering the night before because the water has had all night to get even colder. Then, I rush to the ward again and get ready to walk around to all the wards to check each patient with the residents. And when they’re done, the consultant surgeon will arrive and we’d see all the patients again, but this time, we’d all get quizzed and made to feel really stupid: “did you even bother to check this patient?”, “you can’t even read the X-ray properly?”, “so, you have no idea what ____ is?”  “you should have learned this years ago in campus”, “study this again, you don’t know it”. 

It is Saturday today. On Monday, I enter my last week of surgery here: Digestive department. I expect it to be easier except that there’s an exam encompassing the whole six weeks. Then, when this week finishes, I get to continue for another couple of weeks in the home/central hospital (Sardjito) back in Yogyakarta. After Surgery, I have Internal Medicine and then Pediatrics, some of the heaviest departments. After these two big boys, I finish my clinical rotations with Radiology. And then, I’m supposed to begin studying for the Indonesian medical licensing exams.

What will I do after all that? Let’s leave that for another blog entry.

(a photo of me waiting for some `sate kambing` dinner from a roadside vendor)

[inmed]

Surgery Department

It’s been a long time, I know, since last I updated this blog. But I have not forgotten you, dear readers! I’m in the GoCar, on the way to Klaten to start another day at RSUP dr Soeradji hospital. I’m in the plastic surgery week in the surgery department. There aren’t many patients (compared to orthopedic, physical rehab, or general surgery) but still I managed to experience and learn some new things.

Yesterday, an octogenarian patient was wheeled in by her granddaughter and grandson. Her right leg was bandaged from her toes to her thigh. There were eight or nine flies buzzing around the patient and looking down at her toes, I noticed they were blackened due to neglect. The bandage going up her leg was tightly bound and was also dirty with large areas of dried blood on several parts. I already knew what we (the specialist and I) had to do: this was another diabetic ulcer patient requiring a change of bandages. So, I turned around towards the instrument table and put on a fresh pair of gloves and opened a new packet of instruments. The doctor indicated I help him unravel the outer compression bandage first, so I knelt down next to him. He held the leg up by the ankle while I continued to twirl the bandage in a spiraling fashion to unwrap it, revealing the white dressing underneath. Green and yellow fluid had oozed through the dressing and made parts of this bandage moist and gooey. I had been holding my breath in anticipation of the nasty aroma (diabetic ulcers stink!) but my lungs were demanding oxygen and I was only half way done unraveling the bandage. I inhaled slowly through my nose and got goosebumps at how nasty the smell was. I kept going while trying not to show anything on my face. The room was hot and me being hunched over in a half-squat was taking a toll on my muscles. I adjusted my stance slightly and continued. I reached the knee and there was more green and yellow goo. Then, as the pale orange bandage I was unwrapping off the leg made another pass, a few large-sized maggots fell out. I tried to control my reaction but a little “oh!” did escape. I glanced up at the stone-faced granddaughter and continued the last bit of unwrapping. Now, the leg was covered with the white dressing (“kasa”, as they call it here) – well, white being its original color. Now many of those 5 cm squares of dressing were red, green, yellow, or gray. Being wet with goo and then drying up, they had naturally stuck together and hardened to form a sort of cast. I passed the doctor a small pair of scissors and took my turn holding up the leg. He began to cut this hardened cast up from the ankle towards the knee. If the smell was a sound, it would be absolutely deafening. It was truly an attack on the senses. As the doctor cut, flies attacked the gooey meat visible underneath. As this hardened cast was pulled away from her leg, many parts began to actively bleed. Blood dripped onto the white tiled floor of the small and hot examination room. Infection and maggots were enjoying the lack of skin on her leg. We tried to dab the large skinless wounds with NaCl to try to clean it up a bit. Then, without wasting time, we quickly and silently reapplied the white dressing and then wrapped it up with a new pale-orange bandage. As the patient was leaving – slumped into her wheelchair and crying due to the pain, I turned towards the doctor and waited for his reaction to all this. He looked grim despite being the happiest (and nicest) person I had seen in this hospital. “I told her to change the bandages daily. How long ago do you think they last changed the bandages?” – and by “her”, he was referring to the granddaughter. I replied, “Judging by the size of those maggots, I’d say a week.” He nodded in agreement and said, “Yes. Those larvae were very large. It is definitely more than three or four days.”

We threw paper towels onto the bloody, gooey mess on the floor and kicked them aside. The next patient walked in and was asked to lay on the examination bed by the doctor. Talking to me in English, the doctor told me that this patient had taken injections of silicone and oils into his penis for the purpose of penis enlargement. Obviously, it hadn’t worked and not just that, the skin of the penis had eroded and died off as well. The doctor said that he had grafted skin onto the penis but the result was… let’s just say, less than desirable. I looked at the one-and-a-half-inch stump, covered in Dalmatian like spots upon a base of dark brown and patches of skinless meat, and nodded in agreement. “The dark spots are rejected skin graft”, the doctor informed me. “Where was this skin graft taken from?” I wondered in my head but never got a chance to ask. If you could see my face at that point, it would clearly be saying, “What were you thinking, man? What did you expect from some back-alley healer? Of course this was going to happen otherwise that healer would’ve been rich and famous, and probably hired by the hospital!” He’s lucky the thing didn’t fall off altogether. It’s pretty bad since the patient was still young: probably recently married without any kids yet. Although accompanied by his wife, he looked pretty dispirited. I let the doctor change the bandages on this one.

Next!

[inmed]

KKN in Srowolan

KKN is this mandatory community service that is part of the curriculum of UGM and other universities in Indonesia. They put together groups of students from different faculties and then send them to an undeveloped village. The students get to come up with and do “programs” to improve the village. 

So does it actually help and work? Let me tell you about my experience.

I wanted to go out of Java for my KKN so I applied early into a team of students making a proposal to go to Haruku Island in Ambon. Due to a computer error which was totally UGM’s fault, I was barred from going there and instead, randomly assigned to a new team being sent to Sleman. Later I was told that they do not want foreigners going too far. I suspect they used their website error as a way to block me from registering to go out of Java.

I’ve learned not to cry over spilled milk. Jogja is a sea of spilled milk. So, it’s better to just bite the bullet and go with the flow. Forget Ambon. Let’s go to Sleman!

I live in Sleman. It’s a district in the tiny province of Yogyakarta. Sleman starts in what is the city of Yogyakarta and then spans way up towards Merapi. In Sleman, there’s a sub-district called Pakem. It starts at the northern edge of the city and then stretches north to encompass lots of villages. Basically, Pakem is a really rural part of Sleman. The part of Sleman I live in (Mlati) is very much the city. It is indistinguishable from the rest of the city of Yogyakarta. But Pakem is mostly rice paddies, fields of other crops, and woods. In Pakem, there’s a sub-sub-district called Purwobinangun and then within that there’s a small village of some 400 people called Srowolan. I was sent to Srowolan for my KKN.

There are two landmarks in Srowolan. One is an “outbound” activity center called Banyusumilir. And the other is an abandoned marketplace called Pasar Perjuangan. I arrived on my motorbike with the help of GPS coordinates. The roads were dark and rocky, and winding between graveyards, the odd building, and what were probably rice paddies by day. Finally I saw a makeshift streetlamp and then a small empty field appeared between some sleepy village houses. This field was the parking lot of Pasar Perjuangan - the dead marketplace. 

I alighted and found myself walking into a sizable house. This is where I was to stay with 24 others for a period of 2 months. I estimated the single-story house to have been built about 30 years ago and abandoned about 5 years ago. The pictures framed on the walls told a story of a Christian family with their children graduating from university in the 90s and 2000s. One photo had a tombstone-like birthdate and death-date. The year of death was 2006. A short but heavy set man peered out the color photo with relaxed, small, beady eyes from behind a pair of steel-framed glasses. I explored the house. It was in the same of a rectangle. On one end there was a very large living room. A hallway left the living room towards the kitchen and toilets at the other end. Four bedrooms opened up onto this hallway. There were 25 of us, 13 guys and 12 girls. We decided the guys would sleep on mattresses and airbeds on the floor of the living room and two guys would sleep in one of the bedrooms. The girls would occupy all rooms except the one with the boys. Halal enough! So, where’d this house come from? It was basically unoccupied so the villagers lent it out to us. I believe we put money together to pay the owner, but I’m not sure. The leader of our KKN handled it so I didn’t pay too much attention. Ah yes, forgot to mention that we elected a leader during “bakti kampus”. What’s “bakti kampus”? It’s this weird ceremonial cleaning of UGM by the students who are about to go for KKN. You show up, pretend to clean (I moved dried leaves around), sign attendance, and then go home. Since we got together for bakti kampus, we decided to elect a leader. He became the leader of the four “sub-units” - as the 25 of us were divided into four groups, one group per village. Luckily, my village was Srowolan, the very same village where this house was located. The other three groups had to travel about 5 minutes by motorbike to reach their villages.

For KKN, each of us was supposed to come up with five “programs” and then carry them out during the two months. The main theme was rejuvination of the dead marketplace. The easiest and first thing that came to mind was to simply promote it using signs and such, and soon it will be alive again. Right? Wrong. We found out, in meetings with the villagers, that the marketplace has been dead for over 40 years, nobody really believes it can be alive again, and nobody really cares if it was alive again. So, we all adjusted our programs and instead focused more on other programs related to health, education, agriculture, etc. As I’m a medical student, one of my five programs was assigned to me by the local puskesmas (clinic): to collect some medical, health, and living conditions data by visiting some homes in the village. The other four: social media promotion (I uploaded pics to Google Maps), giving health education (I held a Q&A forum), making a promotional video for the village, and building an announcement board. I built the announcement board using plywood and other stuff I found in the hardware store nearby. I had to pay for it myself, sadly, but there was simply no funding. The promotional video is taking way too much time and effort and it’s almost the end of KKN. So I’m just going to put the half-baked video on Youtube and call it a day.

So, what did I really do for the last two months? Ok, disclaimer: I started KKN with a lot of enthusiasm. I wanted to finish up all the programs as quickly as possible and then relax the rest. But it didn’t play out that way because life moves really slow in the village. There are meetings and more meetings, and in the end, you need to have a logbook detailing daily activities. So, I gave up and decided to be lazy until the end. Every opportunity I got, I went home - about 30 minutes by motorbike. I often slept at home and often took unexcused days off. We were allowed to take five days off - with excuse. I took two this way and about 15 just unexcused. Even when I was there, not much was usually happening. I’d arrive at 9:30 AM and people would be lazily waking up and getting in line to bathe. This would continue until around 1 PM. And then, everybody would get busy trying to look for food, laundry, and other stuff. Then, the UNO cards would come out. Laptops with PES (soccer game) or The Sims. And, I’d be sitting there wondering, “why did I even bother coming today?” 

Not all days were like this though. Some days there was a flurry of activity and I’d help out when I could (to be nice and to get “helping hours” - we need a certain number of those) or join in for some fun.

There’s a lot more I can say about KKN. But I think I’ve said as much as I’d like for now.

[inmed]

Obsgyn Hell in Pati

Would you fly in an airplane if you were told the pilots have been forced to work 32 hour non-stop shifts? No. You wouldn’t. Even a child can tell you that we need 8 hours of sleep in every 24 hour period. Common sense: skipping sleep immediately becomes evident as the senses dull, memory gets hazy, mood gets irritable, and decision-making ability goes down the hole. Do these symptoms sound familiar? Yeah, the same thing happens to people drunk on alcohol. A sleep-deprived pilot is no better than a drunk pilot. And nobody will be at ease in an airplane knowing the guy in the cockpit is drunk or sleep-deprived.

If we wouldn’t trust a sleep-deprived pilot, why do we trust sleep-deprived doctors? We can’t blame the passengers and we can’t blame the patients. They probably have no clue and they blindly place their trust in the hands of the professionals.

Sadly, the people who made the decisions to have doctors work 32-hour shifts are doctors themselves: the experts of human physiology! These are the very same professionals who prescribe rest more than any other medicine! Isn’t that ironic and amazingly stupid?

Well, whoever that decided that koas have to pull 32-hour shifts must have the IQ of a ping-pong ball who has failed at understanding the most basic physiological aspect of humans other than the need to breathe: the need to sleep. Not only should this person be stripped of their medical license, they should also be jailed for putting patient’s lives at risk. If I was the chief of an airline company and I demanded that my pilots shall work 32-hour shifts without sleep, and people found out: I would deserve to be jailed. Why should this practice be accepted in the hospital?

Okay, now that I’ve made my four paragraph preamble to set the mood for what’s to come, let me start my diary-like blog entry:

Obsgyn is my first big station. I had Forensic before this. Forensic was basically a load of paperwork and waiting 24/7 for the inevitable: a dead body in the hospital requiring an autopsy ASAP so the family can bury it in the morning. So even though there were just around 10 autopsies during the four week period, the constant stress was irritating: sleeping with the ringtone volume on max. There’s not much else to say about Forensics: it was stinky, we didn’t do much other than get strained wrists from writing endless reports. 

Ok, back to Obsgyn. It is 10 weeks long. That’s two and a half times as long as a small department (such as ENT, Neurology, Forensics, etc.) The first couple of weeks we were in Sardjito. The following three weeks were spent in RSUD Sleman, my favorite hospital so far. Those three weeks were alright despite the 32-hour shifts thanks to the many opportunities to sleep in the comfortable koas room or just quietly escape the hospital. Still, 32 hours are 32 hours and it is absolutely exhausting.  I would say “daily” but a day only has 24 hours. Our 32 hour shifts were “daily” in the sense that when one ended (at around 2pm), we’d go home and then be back the very next morning at 6am for the next 32-hour shift. There is no such thing as “weekends” or “holidays”. Let me give you a run-down of what one shift looks like:

5 am: wake up. shower. call a GoCar by 5:30. 6 am: arrive at RSUD Sleman. Go up to the 3rd floor where the Obsgyn stuff is. Start going through all the patient’s medical records in both the ward and the “VK” (birthing room) and noting down the “SOAP” along with some other important info in my notebook. 7 am: the doctor arrives for a “visit”. Basically a walk through the ward and VK to see all his patients for up to a couple minutes each. We scuttle behind him and try to mumble out the patient’s information that we jotted down earlier. The doctor ignores most of this and asks us simple questions about the patient: “when was the last time hemoglobin was checked? how much is it?” - and usually we wouldn’t know the answer. 8 am: the doctor sits at the nurse station to write stuff in the medical records and the koas stand there waiting for questions. These questions tend to be more about theory and are quite difficult. 9 am: the doctor goes to the poly-clinic. Two of the koas who started their shift the day before follow him. I remain in the ward with one other koas. 10 am: we chat with the nurses and midwives about random things. 11 am: we walk down to the cafeteria and eat something. I buy some bottles of water. 12 noon: we try to nap in the koas room. there are two beds and it’s airconditioned.  1 pm: unable to sleep, I walk into the VK. I notice two women in labor. I sit down at the mini nurse station there and start chatting with the midwives. 1:30 pm: the midwives order me to do “DJJ” (fetal heart rate monitor) on all the patients. Now there’s four suddenly. 2 pm: Finished with the DJJ, I sit back down only for the resident doctor to walk in and ask me to set up the USG and wheel the patient in. 3 pm: My koas partner wakes up and walks into the VK. We sit together with the midwives, talking. 4 pm: One patient seems to be going into the active phase. The midwife orders me to do more DJJ. We start wondering who will assist with the delivery. 5 pm: Another patient is brought in. Suddenly the VK is full. 6 pm: Hungry. The cafeteria is way past closed. What to eat? I start flipping through the GoFood options when suddenly I hear loud noises from behind one of the separator curtains in the VK. I peer in and see that the midwife is already in position to help the patient deliver the baby. She looks at me and asks if I’m going to join or not. Of course I say yes and put gloves and apron on. I feel useless because the midwife is capable of doing everything herself and I’m just standing there watching. 7 pm: The baby is out and I take my gloves off. The gloves never really touched the baby. Instead, I was left to pull the placenta out. Boring. It’s all boring. And I’m quite hungry by now. Back to GoFood options. We walk to the ward’s large nurse station and sit down there, chatting with the midwives. It gets boring quickly. 8 pm: Food is on the way still. And we walk back to the VK. The midwife there tells us that a woman had already delivered while we were absent. We act surprised at how quick it was. A new patient is wheeled in. “God damn it, why do women have to give birth so much?” is written all over my face. I get told to do DJJ and take blood pressure. The GoFood has arrived at the lobby. I run down to get it. 9 pm: We finish eating in the koas room. I waste time on my laptop and my partner sleeps again. I wish I was good at falling asleep, but I’m not. 11 pm: I put my laptop away. I walk to the VK. 12 midnight: another woman starts giving birth. 1 am: the same lady is still giving birth. We all keep glancing at the clock because we know that the baby is stuck. The resident is woken up. I’m drowsy and want to sleep but of course, I can’t. I’m watching the midwives and the resident doctor try to encourage the woman. They start discussing the medications given to the woman. 2 am: the resident finally gives up and decides he will operate for SC (cesarean section). I’m ordered to follow the resident. 3 am: the operation finally begins. I get to help out a bit by holding the suction and passing some instruments to the doctor. I don’t feel sleepy but the core of my bones feel sore. 4 am: the operation ends. the resident is annoyed it took so long. there was bleeding. Small chat with the resident ensues and we walk back to the VK. 5 am: I lay down on the bed in the koas room. Exhausted. 6 am: My alarm rings and I walk over to the ward to go through the medical records again. 7 am: the doctor arrives for a “visit”. I’m wearing the same clothes as I did the last time (yesterday) when he came. He’s wearing fresh new clothes, hair still wet from his shower. 8 am: the doctor asks questions. 9 am: the two of us follow the doctor to the poly-clinic where we do anamnesis and watch how the doctor handles each patient. What was a sort of dull headache becomes a full fledged one: I’m trying to figure out if it’s due to low blood sugar levels or dehydration or because I only got like an hour of sleep. 12 Noon: the patients finally finish. The nurse makes small talk for a bit. We then walk upstairs towards the koas room. The midwives there make more small talk. 1 pm: My GoCar arrives. I feel lucky that the poly-clinic ended earlier than I hoped. 10 minutes later I arrive at home. I finally shower, shave, brush, and then eat (my maid’s cooking). 2 pm: My head touches the pillow and I fall asleep. 9 pm: I wake up. Most restaurants are closed. I can’t go out at this point. I guess I have to call GoFood again to order something from somewhere that’s open late. 10 pm: I eat and then wonder what to do. I can’t sleep again because I just woke up.  I try to work on the PowerPoint to present for my Refkas (case reflection) tomorrow. 2 am: I fall asleep anyways. 5 am: Wake up. And the whole process repeats again.

So, this happened for a total of three weeks in RSUD Sleman. Then, about two weeks ago, I was sent here to RSUD Pati for a total of four weeks. The shift is the same length but the content of the shift is different. Here in Pati, we can’t just relax that much. We’re expected to do a lot more deliveries (by mostly ourselves), suturing episiotomies and ruptures, filling in medical records, doing loads of little tasks such as taking blood, installing IVs, installing IV pumps, and of course studying. After Pati, RSUD Sleman looks like a holiday. 

It is midnight now. Tomorrow morning I have to be at the hospital for another day in hell. So I’m going to leave it there.

Hopefully I get time again to discuss Pati. It’s an interesting place with interesting hospital and I have a lot to say about it.

[inmed]

Anesthesiologists do more than just anesthesia

Before I entered the Anesthesiology department, I didn’t know anything about it. I mean, I had the preconceptions that everybody else usually has: anesthesiologists give sleeping gas to patients undergoing surgery and then themselves sleep during the surgeries. I had heard throughout my life that they’re the laziest doctors who get paid a lot to do the least amount of work.

Okay, that’s not actually true of course. Well, they do sometimes fall sleep during surgeries :-D but it’s rare and it depends on the type of surgery. I will explain...

Let’s define anesthesiology first. I will try to use the fewest words: anesthesiology is the branch of medicine that deals with keeping a patient alive in critical situations. What is “critical situations”? It’s when if there is no intervention by a doctor, the patient has a high chance of dying. Surgery and being under general anesthesia are critical situations. General anesthesia is the act of putting a patient in a very deep sleep where if it is too deep, it can be permanent (the patient dies). So, when general anesthesia is given during surgeries, anesthesiologists are always present. They make sure the patient gets enough of the right sort of anesthetic meds (I’m over-simplifying here to keep it simple) to not feel any pain but also not die.  But wait - let’s not stray too far here. I told you about the definition of anesthesiology, right? Well, as you would’ve noted, it’s a pretty broad definition. I mean, “critical situations” can be anything, like a broken leg in the ER or a patient taking his last breaths in the ICU. Well guess what, anesthesiologists work in the ER and the ICU also. In some places, these doctors are sometimes called “intensivists” because they work in “intensive care” units (ICUs) or “EMs” (emergency medicine) specialists. But in Indonesia and many other countries where they don’t have intensivists and EMs, the work of keeping patients alive in critical situations is done by anesthesiologists.

So, what exactly do anesthesiologists do? Until now I keep saying, “keep patients alive” but I’ll try to be more specific (for the unimaginative among us). They’re always watching the monitor for the patient’s vital signs: blood pressure, oximeter reading, heart-rate, breathing, and ECG -- usually in that order. They’re also constantly making sure the fluids are balanced and there is no danger of shock or acidosis/alkalosis. As you can imagine, this requires a good anesthesiologist to have sound understanding of the cardio-vasculo-respiratory system along with the kidneys and GIT. 

Maybe many people don’t realize it but the anesthesiologist is one of the doctors who visits them the night before their surgery. We call this visit the “pre-op”. During the pre-op, we ask a lot of questions that then help us decide what sort of anesthesia the patient should be given and how risky the surgery is. We come up with an “ASA score” based on the result of the pre-op and the lab results (which we have to pore over during the pre-op). If it’s “ASA 1″, it means it’s a low risk surgery and if it’s a higher ASA such as ASA 3, then we may have to consider postponing the surgery if it isn’t absolutely necessary. During the pre-op we find out history of operations, past and current illnesses, and even things like false teeth. Why are false teeth important to know about? Find out in the next paragraph...

One very important thing that anesthesiologists do that I forgot to specifically mention is: airway management. During coma (e.g. coma induced by general anesthesia), the patients may not be able to breathe themselves (properly). So, we have to make sure that we use an airway device such as an endotracheal tube (ET) and a ventilator to help the patient breathe. During the pre-op, we need to find out which is the safest and best airway device to use during the operation. We do this by assessing the Mallampati score - which is basically to see how small their throat is - among other things. Mallampati 1 means you can see their uvula and a pretty poor Mallampati of 4 means that you can’t see any part of their throat from inside their mouth. We measure the opening of their mouth and the distance from their jaw to their neck and then from that point on the neck to their adam’s apple. The scale we use to measure isn’t centimeters or inches. Instead, we use the patient’s fingers. It’s easy and fast. So, if you haven’t figured out why we ask about false teeth by now, let me explain: when we’re inserting an airway device in the patient’s mouth, there’s a (high) chance that we’ll be accidentally hitting the teeth with it - and there’s a risk the tooth may come off and fall into the throat. There are other reasons also: if a patient has no teeth, then their mouth would be smaller and thus, more difficult to insert airway devices in their mouth.

The anesthesiologist’s job (in the operating room) starts with the pre-op (in the ward) the night before, as I’ve described. Then, the next morning, the anesthesiologist is the first one in the operating room. Wait. Instead of talking about “the anesthesiologist” in the third person, I’ll just talk in first person as if I’m in the anesthesiologist. Okay, so, the next morning, I am the first person in the room (and no longer speaking in the third person -- Sorry). I check the patient manifest (as I like to call it). I see the age and the weight of the patient next to their name and type of surgery. I check my notebook and I’ve already done all the calculations (with the help of the Anesthesiologist Android app) for the medications and fluids for this patient. Great. I smile alone in the bright operating room as I notice that those meds are stocked on the little anesthesiology cart parked near the head of the operating table. All of them are in glass ampule bottles. Careful not to cut my finger, I remember to turn the dot printed on the ampule towards myself, place my forefinger on the opposite side, grasp the top of the ampule with my thumb, hold firmly, and break the ampule’s neck over my forefinger while simultaneously applying an upward force using my thumb. I hear a “pop”. I pause. No blood. (the pain always comes later, so I check for blood first). Okay, no blood. No awkwardly broken glass. My latex gloves aren’t ruptured either. Awesome! I then expertly turn the ampule upside down, insert a needled syringe in with the other hand, and pull the liquid drug into my syringe faster than you can say “anesthesia”. I do this 4 to 8 times, loading syringes like ammunition in guns before a battle. Then, I check the equipment required for the airway. If it’s supposed to be ET intubation for example, I get the correctly sized laryngoscope and blade (making sure to check them), throw my stethoscope over my neck, grab a couple of ET tubes, connect the suction tube, find an OPA/MAYO, a stylet (pfft... nobody uses those anyways), and check the oxygen. While I’m thinking, “what else, what else... what did I forget?” the doors open and the patient is brought in. There’s an awkward transferring of the patient from their guerney to the operating table. I grab the bottle of infusion fluid (usually ringer lactate) and hang it. I make sure the patient’s arms are out sideways and bound, sort of like Jesus on the cross. Either there’s a 3-way stop-cock or just a bulging ball thingy on the IV cannula. With the 3-way stop cock, I have to screw off the needle off the syringe, screw the syringe on the stop-cock, turn the stop-cock to open it, and then push the drug into the patient. It’s easier with the bulging ball thingy: I just stab it with the needle of the syringe and push the drug. Then unstab and I’m done. Drugs are pushed into the patient before the patient even realizes that anything is happening. The patient is usually very quiet and looking scared - sometimes even praying. The operating room staff often talk to each other, pretending the patient is an object or isn’t even there. It’s weird but that’s just the operating room culture here. The patient might feel everybody is really relaxed and waiting for something. And they’d be right. They’re all waiting for the anesthesiologist to give the go-ahead. And the anesthesiologist looks like he’s waiting too. His eyes dart from the monitor to the clock, and then to his notebook, and then to the patient’s face and then quickly towards the anesthesiologist’s cart - remembering suddenly: “Omg, I forgot the syringe used to inflate the cuff on the ET!”   Eventually the drugs do their magic and the patient seems to fall asleep. If there was a moment when the 80s action music would be queued, it would be now. The anesthesiologist’s heart-rate goes up, pupils dilate. 

All eyes in the room are now clearly fixed on the anesthesiologist, except the patient’s of course - they’re closed. Very gently but quickly, I graze the patient’s eyelashes. The patient doesn’t flinch. This is it. I perform the triple maneuver - with just enough strength not to look strained (or break the patient’s neck) - and then, using the mask connected to the oxygen, I oxygenate the patient, preparing them for what I’m about to do to them. 

The surgeons stand there, fingers criss-crossed in front of them, waiting for the anesthesiologist’s next move. It’s the most interesting part and nobody in the room wants to miss it. Time ticks and tocks. The anesthesiologist knows what he’s doing. The lungs have something called the FRC (functional residual capacity). This is like extra space that we can saturate with oxygen, like an auxiliary tank of fuel, so we can get up to 5 minutes to insert tubes without the need to give the patient any air. So, despite the oximeter showing 100% oxygen saturation, I keep holding the patient’s jaw with my middle, ring, and pinky finger with the mask affixed on the face with my first finger and thumb. My other hand squeezes the rubber bag to manually deliver breaths to the patient. The squeezes look random, but they aren’t. One eye is on the patient and his rising-falling chest, and the other bounces like a ping-pong ball between the monitor and the clock. This is probably how famous figure-skaters feel: they know the world is watching but they have to focus so hard not to mess up that they can’t even spare a moment’s gaze or thought on their audience. Another milestone hits. Without taking a single step away from above the patient’s head, I pull the oxygen mask off. A mental countdown clock starts as the oxygen in the FRC starts diffusing into the lungs. With hands as stable as a horse, I snap the laryngoscope together, yank the patient’s head back, shove the metal blade in their throat, bend over forwards and down slightly, and with the other hand, insert the ET tube into the correct hole (the breathing hole, not the swallowing one). A stethoscope is then used by an assistant on the lungs and the stomach. It is like a referee being given a chance to decide something very critical. He nods and gives a thumbs-up. I sigh with relief and continue bagging while using tape to stabilize the tube which is now going from the ventilator to the patient’s lungs (almost). The tension in the room eases. More drugs are pushed into the patient. The surgeons are given the okay and they begin their butchering and gossiping.

The anesthesiologist may look relaxed during the surgery but he’s constantly listening to the monitor: “beep... beep... beep... beep...” and the second there’s a “boop” instead of a “beep”, the anesthesiologist whips his head to look at the monitor so fast, you can almost hear the swoosh and crack of a bullwhip. And yes, the beeps from the monitor actually mean something. The frequency of the beeps is the heart-rate (everybody knows that) and more importantly, the pitch is the oxygen saturation. Every five minutes, the anesthesiologist has to update everything including vitals and medications onto a chart. There’s a load of paperwork involved, so it isn’t unusual for there to be a desk provided for the anesthesiologist’s use in the operating room. At the end, the patient is brought back out of their induced coma, the airway device removed in a responsible manner, and the patient prepared for transfer to the recovery room. I accompany the patient until the recovery room and make sure he’s stable and (sort of) awake. Now I can walk back to the operating room and do it all over again for the next patient.

At the end of the day, when I’m exhausted, I remember I have “jaga malam” (night shift). Luckily, before that, I have time to shower and eat. Oh wait, no I don’t. I have to do pre-op. After the pre-op, I rush to the ICU; a sad reminder that anesthesiologists are also intensivists here.

[inmed]

Jaga Malam in Saraf

“Jaga Malam” (night-shift) in “Saraf” (neurology) department at Sardjito is the only jaga malam I have done so far so I can’t say how similar or different it is from other stase (departments) and other hospitals.

Three students handle one shift at a time (from 3pm to 6am on weekdays and other timings on weekends). The task is simple: go to each patient and check their vitals: heart-rate, respiratory rate, temperature, O2 saturation, and blood-pressure. 

A normal jaga malam shift goes like this: At 3pm, the three of us arrive at the bangsal (the Anggrek II ward). Two remain in the ward while one goes to the Stroke Unit. Personally, I enjoy being in the Stroke Unit a lot more than being in the bangsal. The Stroke Unit is air-conditioned, seems to have better ventilation, has fewer patients, doesn’t have patient’s families laying all over the place, is well-lit, requires less walking, has convenient ICU log sheets, and has patients that often have monitors attached. The bangsal is a warm, sauna-like environment with all sorts of funky smells emanating from the communal toilet, the bubbling consommé of bacteria in each oxygen filter, and the people littered about in the stuffy rooms. Anyways, continuing on from 3pm: the two of us at the bangsal then head to the nurse station. There’s a resident doctor there (also doing jaga malam) who we greet and introduce ourselves to. The resident tells us the frequency of visits we have to do to each patient. For example, the resident may say, “Mr Joko is a critical patient who just had surgery. Check him every hour” or, “Nobody is critical. Just check all patients once every 4 or 5 hours.” There are usually around 20 patients in the bangsal but there could easily be more, not to mention the possibility of other patients spread out over various bangsals (e.g. I had one patient once in IMC about a 10 minute walk away). Since there are two of us, one becomes the scribe taking notes and the other takes measurements (wearing latex gloves and holding a small basket-tray with the instruments). We walk into a room (there are 12 rooms in Anggrek II), we identify the patient (each room has anywhere from 1 to 8 patients), and we go right up to them and say, “permisi... periksa ya” which just means, “excuse me, check up, ok?” I quickly strap the blood-pressure cuff and hit the “On” button. Thankfully it is automatic. It takes a couple minutes before showing the result. During this time, I stick the thermometer in the other arm’s armpit (or use the highly inaccurate infrared forehead thermometer on non-febrile patients) and attach the oximeter on that arm’s finger for a few seconds until the heart-rate and O2 saturation shows up. While I’ve been doing this, my partner (the scribe) has been counting respirations. If you’re efficient, you can check each patient within two minutes. If the resident doctor has requested the calculation of fluid balance (”balance cairan”), then these two minutes can take longer. But usually we only have to do BC (balance cairan) for a couple of patients only.  At the end, the scribe transcribes all the patient’s vital sign info into a book that is kept at the nurse’s station.

In the Stroke Unit, things aren’t too different. The exception is that you never have to do BC (the nurses do it) and also that you have to be a bit independent since you’re alone. I got pretty good at attaching the blood-pressure cuff with one hand. You take the vitals and then immediately write them onto the ICU log sheet which is clipped onto a lectern at the foot of each bed. It’s quick and easy. It becomes even quicker and easier when your patient has a monitor attached. You just hit the NBP (”new blood pressure”) button on the monitor and it automatically inflates the cuff (which remains attached to the patient) and takes the blood pressure. Ah technology :-). Well, actually, one little (obvious) trick that I learned is that you can make your own automatic BP monitor using a spare automatic sphygmomanometer (that’s “blood pressure measurement device” for you laypeople): just leave the spare cuffed onto a critical patient’s arm (e.g. a patient you have to check every half an hour) and then all you have to do is hit “On” and then “Off” every time you want to get a BP measurement. This will save the tediousness of strapping on and taking off the sphygmo.

The smart and dirty way to do jaga malam is to create large gaps in which you can sleep or go back home for a while to change/shower/nap or whatever. If you don’t have very critical patients that require hourly checks, create a large gap by doing (for example) your 6pm round at 5pm, and your 4am round at 5am. Skip the midnight round if possible since the patients are gonna be asleep anyways (yes, if non-critical patients are asleep, then you won’t be penalized for sacrificing checking them to allow them some undisturbed sleep). 

Morning comes, you get signatures from the resident doctor, and you’re done.

That’s it for now. There’s plenty more I can say about jaga malam in neurology but I’ll leave it for another time. I’ve covered the essentials, I think. 

[inmed]

Graduation Woes

If I whine and complain, my friends will remind me that this is to be expected and that I shouldn’t fight it and just accept the reality that I’m in.

I know I’ve said this before but I need to reiterate: Indonesians have a sickeningly unabated obsession with red tape and paperwork. There is so much red tape binding these people that I believe that it actually hinders the progress of this country. Still, the Indonesians seem to not mind and just go along with it. Any other sane person would beat their skull in rather than try and fill all the holes in the logic that’s required to justify all the bureaucracy. 

So, you think I’m just a whiny “bule” (foreigner) who can’t accept Indonesian culture? Let me counter that and I promise you will change your mind. Today, I had to fill a form given to me by UGM. It’s part of the mountain of paperwork that needs to be traversed after completing all the requirements for graduation and actually being allowed to take part in the graduation ceremony. Ok, get this: the form asked me for the name of the university. *face-palm*.  The letter-head said “Universitas Gadjah Mada” and then below fields asking me for my name and student-ID, there were some fields: “Study program:”, “Faculty:”, and then SHOCKINGLY, “University:”!

If I got a quarter for every time UGM asked me for my name, I wouldn’t need this degree because I’d have enough to retire. 

I went to fill this form at an office I’ve never been to before. Apparently, this form acts as a release letter from this office. I guess if you’ve borrowed something from this office, they’re supposed to keep you from graduating. They asked me for my student ID. I showed it to them. They said, “we need a photocopy of it”. I left the office and had to search for a photocopy shop. That’s another thing: UGM probably spends hundreds of thousands on maintaining these useless offices and staff, and collects millions in student fees, but then never has photocopying machines in these offices.  Anyways, they made me fill out this stupid form, requiring my name and student ID number-- even though the copy of my student ID has this information already! Then, as a cherry on the cake, they asked me to write my name and my student ID number in a book. They never actually checked to see if I borrowed anything. They gave me the release immediately. They charged Rp 3000, a very tiny insult to injury.

I’ve been given letters from one staffer of UGM and told to give them to another staffer in the same building - many dozens of times. This is absolutely absurd yet it’s considered “normal” here. I’m not a beast-of-burden or a pack-mule that you can use to transport your paperwork around the office. There is zero respect for a medical student’s time when it comes to this. I’m a medical student and I don’t have several office-fuls of administration staff. So why am I expected to do all the administration work?! What’s really eye-opening is that these systems were probably put in place by highly educated people with loads of degrees listed after their names and both a “dr” and a “Dr” in front. The logic-defying limbo that their brain would’ve had to do to justify some of this bureaucracy deserves its own special on Cirque-du-Soleil.

When we start, they give us a credit-card-sized plastic student ID card. Then, they never, EVER require it during your study. However, for each final exam (and there’s six to ten for each student every year), the student is given a little temporary-looking ID card: basically a piece of paper with a passport-sized photo glued onto it. You NEED this to get into the final exam. You can flash that plastic FK UGM student ID you got in the beginning and they’ll just be like, “nope.”  They have a list of students that are to be examined before each exam and any photo identification should be enough, but it isn’t. You need that stupid exam ID card: and god forbid you ran out of passport-sized photos to glue onto it or lost it. Well, if you did, you can just *ba-dum-tish* just fill out a stupid form; quickly run back to the exam hall and hand this hand-filled form to the invigilator and walk into the exam, having defeated every purpose.

All of what I’ve mentioned is barely the tip of the iceberg of paperwork that you have to face if you want to study at UGM. The procedure I had to go through for registering for koas was so ridiculous, I don’t even know how to put it into words. (There’s multiple websites with multiple logins, you have to pay Rp 0. to a bank account, and you have to print out, paste materai (like a postage-stamp), scan, and reupload several forms, and oh my god: a buttload of forms asking the same information).

Let me end with some optimism:

- I wish that one of these days, some big-wig at UGM has a eureka moment in the bath: “Let’s get rid of all the forms!”

- I wish that they’d ask me for my name just once and never again.

- I wish they’d use some of that $8000/year that I’m paying them to buy a photocopier, instead of casually asking me to go get something copied, as if I’ve got a Xerox machine strapped onto my back.

- I wish the dozens of secretaries and administration staff that they keep on their payroll will actually do all the form-filling, data-entering, signature-getting, materai-pasting, notebook-filling, transporting paperwork around their campus, and photo-pasting -- you know, SECRETARIAL AND ADMINISTRATION work!

- I wish they’d only ask me for information that is absolutely (oh, and I mean ABSOLUTELY) vital and information that they couldn’t have gotten themselves from one of their offices. (e.g. asking me what university I’m studying at or my address, phone number, and father’s education level and job title).

- I wish they’d set up a camera in their office and take a photo once on my first day and only once and never again. Then, whenever they need a photo for whatever reason, they’d print it out rather than bug me. They must NEVER ask me for a an actual photo. Ever.

- I wish they’d stop wasting my and all the other student’s time with all their stupid red-tape so that we can focus our time and energy on actually studying.

[inmed]

The Neurology Department and Stroke

It’s Wednesday. I’m half way through the third week of my four-week Neurology clinical rotation.

Ok, let me jump right into the nitty gritty. What are the cases like in the Neurology department? I’d say about 80% of the patients are post-stroke. When asked, we usually answer “SH” (stroke hemorrhagic) or “SNH” (stroke non-hemorrhagic) when asked what the patient is suffering from. It’s hard to tell the difference just by looking at the patient if they’re SH or SNH. No two stroke patients are exactly alike in terms of their clinical signs, so this makes it even more difficult to differentiate just by looking at the patient. Stroke happens when a part of your brain doesn’t get oxygen and begins to get damaged. So, it all depends on where in the brain the stroke happened and how severe the damage was. A mild stroke (and I’m not talking about TIA) may not manifest in any easily noticeable clinical symptoms. For example, a stroke in the Vernicke’s or Broca’s areas of the brain may manifest as aphasia: with the person either unable to speak (motoric aphasia) or understand (sensory aphasia) or both (global aphasia). It may be severe in some people and mild in others. Again, it depends on how bad the stroke was and the location of the stroke. 

Overwhelmingly, stroke patients have hemiparesis of some sort. That means their arms and legs are weak on one side of the body. Sometimes it’s so severe that their arm hangs limp like an unfilled sleeve while other times we have to very carefully assess the difference in strength in their arms by simultaneously testing their grip strength, for example, or asking them to hold out their arms and watching for which one drops first. Usually, in-patients are debilitated to a point that they’re bedridden, so the majority of the patients tend to have pretty severe disabilities.

You’re probably wondering what the treatment for stroke is. Well, if you are, then you’d be sad to learn that there is no real cure for stroke. We can’t just tell a patient, “don’t worry, you’d be able to use your arms and legs again,” as much as we’d like to. So, like I said earlier, stroke is when a part of your brain doesn’t get oxygen and starts to get injured. When treating stroke, it’s important to know what sort of stroke it is: SNH or SH. In SNH, basically a blood clot forms in a blood vessel in the brain (thrombotic SNH) or forms elsewhere and then a chunk of it breaks off and then goes into the brain and then gets stuck (embolic SNH). Basically, in either case, this crap clogs an artery in the brain and blocks nutrient-rich blood from reaching one or more parts of the brain. So, the treatment involves giving meds that will go and break up that clog and also prevent further clogs. (Anti-thrombotic, anti-embolic, anticoagulants basically). Additionally, the body naturally kicks the heart into high-gear and increases blood pressure immediately after a stroke - presumably to try and get blood into those stroke-hit (infarcted) areas. This hypertension lasts for a few days and then the blood pressure returns to whatever the blood pressure was before. Example! So if a patient was already 150/90 before a stroke, he’d return right back to 150/90 in about a week. But immediately after the stroke, he might have a heart-rate of 130 and a blood-pressure of 190/100. (I should talk about the MAP at this point... but... nah... too lazy to explain boring stuff...)

Now let’s talk about SH. In SH, for some reason (usually hypertension), the wall of an artery in the brain rips opens. I don’t wanna get into the details of how this actually happens but just imagine a hose made of balloon material and there’s a rip. So, basically, this is bad. You don’t want an artery squirting blood all over your brain - whether it be in the brain itself (intracerebral) or in the layers around it (subarachnoid hemorrhage, for example). SH isn’t as common as SNH but you can expect to find loads of SH cases every day in the hospital. Anyways, so the treatment for SNH (anticoagulants) would be a fatal mistake in SH where you’re actually trying to stop the bleeding. Also, remember I said that after a stroke, the heart goes crazy and increases blood pressure? Well, apparently the heart is stupid because it can’t tell the difference between SH and SNH and even in SH it increases the blood pressure all the same. This is bad. The whole reason a patient got SH is probably because of high blood pressure and now your idiot heart is increasing it even more because there’s a stroke. So, treatment of SH involves reducing the blood pressure and more importantly: removing pressure off the brain. I should mention in case you don’t know: the damage in SH is caused by the build-up of pressure from all that blood squirting and spurting into your brain. So, we give mannitol to try and diuresis that fluid out the brain. 

We keep patients for 10 days after their stroke. During this time we give them drugs according to what type of stroke they have. We can tell the difference between SH and SNH thanks to CT scans, which are done for every stroke patient right off the bat. Every koas is required to read and interpret these CT scans. It’s actually pretty easy. Even patients can look at a CT scan and guess correctly at the abnormality. Anyways, the radiology department writes a pretty detailed description of the findings that they attach with each CT scan, so you don’t have to panic buying CT interpretation books before your Neurology koas.

Okay, enough about stroke. Some of the other cases we get are diabetic neuropathy, lower-back pain, epilepsy, loss of consciousness, and others - Oh! and how can I forget: vertigo! We get plenty of that. And, it shouldn’t be taken lightly. Vertigo is basically “pusing terputar” (spinning dizziness) in patient’s eyes but it could be a stroke around the cerebellum. If it’s a hemorrhage in that area, it can enlarge and push up against the (what’s right in front of the cerebellum? that’s right it’s the...) brainstem! And pressure on the brainstem can be a REALLY bad deal: a patient can die within minutes.

Let’s wrap this up. Neurology is mostly strokes. I’m a bit bored of them by now and whenever I see an unusual case, I get excited (like that GBS patient yesterday). Policlinic is incredibly boring. 90% of patients are there for control only. Often patients just say, “my meds ran out. please prescribe more” and the doctor starts scribbling. Boring.

[inmed]

Luar Kota in Koas: RSUD Sleman

This is the end of my second week in koas (neurology department). The first week was spent in Sardjito and now this second and then third week will be spent in RSUD Sleman before heading back to Sardjito for another week.

We didn’t get to pick our “luar kota” (out-of-Sardjito two-week long assignment) in this department (some other departments allow us to pick our own luar-kotas). I got lucky and got put in a group of six assigned to RSUD Sleman, which is a hospital about 15 minutes north of where I live (I live in Jombor. Please don’t stalk me).

We arrived at RSUD Sleman and headed to the administration office. There, we waited for a lady to show up. She told us that one of the doctors will be giving us a little orientation talk. Finally he showed up and we had our talk. Then, another doctor led us to the ward (Alamanda III). It has about twenty beds and is dedicated to serving third-class neurology in-patients. We introduced ourselves to the nurses. Alamanda III was to be our “home base” for the upcoming two weeks so we really paid attention here. Then we were shown to several other wards around the hospital quickly: each one with its own nurse’s station.

We were told that there are no resident doctors in RSUD Sleman. That means we’d be responsible for all the Neurology in-patients -- not to the point where we make decisions about treatment, the way residents in Sardjito do, but at least to the point of knowing all about the patients and their condition and checking up on them daily. 

There are three Neurology specialists at RSUD Sleman. Each of them visit their patients in the ward daily. Their visits are unpredictable and they’re somewhere between 8 am and 4 pm, tending to be around 9 am. Each of us koas students has taken responsibility of two to four patients in the ward. So, when the specialist visits, we all walk around the ward with her. She does a bit of teaching, a bit of testing (e.g. asking the koas to perform a neurological exam, for example, or asking verbal questions), and will often just loudly ask about the condition of the patient. The koas responsible for this patient needs to quickly answer. The questions are usually like, “has the blood-pressure dropped?”, “when was the last time he vomited?”, “how many days has he been in the ward?”, “what does his CT scan say?”, “are there any abnormal blood results?”, etc.   The koas responsible for the patient should answer these questions. But sometimes, the koas draws a blank and the nurse comes to the rescue. That’s right, there’s a nurse that follows each specialist visit. She holds all the medical records and is much better at answering the specialist’s questions than the koas. At the end of the visit, the specialist doctor sits down at a desk and scribbles some notes into each medical record.

To prepare for these visits, the koas need to arrive extra early in order to follow-up all their patients. These follow-up sessions involve going up to the patient and asking them if they have any complaints (e.g. pain, dizziness, etc.) and then assessing their condition using various neurological exams. It’s a great way to practice these skills also. We try to go in two’s for these follow-up visits if possible so we can give each other feedback. (I still can’t remember all the names of the reflexes! Ugh!).   This is the Neurology department so quite often the patients are in a coma. This makes for a pretty quiet follow-up where we try to elicit a response to pain and then perform a bunch of reflex examinations while also noting the tone and trophy of the muscles.

Koas aren’t allowed to write in the actual medical record so we simply carry a mock-record. We update it as if it was the actual medical record. We divide the page into four sections, “S”, “O”, “A”, and “P”. I forgot what they stand for but “S” is where you write the chief complaint, “O” is for all your findings (e.g. vitals, neuro exam results, even lab results), “A” is for the diagnosis (or the suspected diagnosis), and “P” is the treatment plan (e.g. the medications).  We use this SOAP-style medical record a lot. We’re gonna be squeaky clean by the time we leave RSUD Sleman, to say the least. (ba-dum--tish!)

Okay, so what about the nurses and patients? Are they friendly? Yes! Very friendly. They’ve probably seen more than their fair share of koas but they don’t let that dampen their genuinely friendly demeanor. The nurses have some sort of hierarchy that I haven’t been able to fully figure out. They’ve got it plastered on the wall like a family tree, complete with photos, so I should give it more than passing glance next time. There seem to be a few “nurse koas” or intern nurses or something or the other. They look incredibly shy, scared, and bored all the time. I’ve seen them being actively supervised and trained by the more senior nurses. 

As for the patients, they’ve been pretty cooperative. I haven’t run into any problems that I’d consider “problems”. I mean, this morning an old lady refused to want to get a CT scan because she was afraid the result was going to be bad (and somehow affect whatever condition her noggin is in). Maybe it’s the blood clot talking, or maybe she’s just really superstitious and logic-defying. Whatever it is, I finally gave up after 15 minutes of trying to convince her that it’s just an X-ray, not much unlike the one she got for her chest a day ago. *sigh*. Still, that’s not a “problem” and the patients have all been pretty nice to me.

The specialists don’t speak any English and begin giggling the moment some English leaks into my Bahasa Indonesia. Don’t believe anything otherwise: the language used in RSUD Sleman is overwhelmingly Javanese. Every conversation starts with “inggih” and then ends with “inggih” with loads of tonally varied “inggih” sprinkled all over. My rusty Bahasa Indonesia doesn’t help when the patient insists on describing their pain using Javanese words that are very specific in their description of the characteristic of the pain (e.g. “electricity-like pain” “sharp pain” vs “throbbing pain” vs “dull pain” etc), for example. Many patients are ancient fossils and they probably predate any attempts by previous Indonesian governments at convincing the population to adopt Bahasa Indonesia. I ask them questions in Bahasa Indonesia and they go off in full-on village-style Javanese. (Hemiparesis and a dental situation that reminds you of the war in Syria doesn’t help either). I usually nod for the whole story and then turn to the person next to me (the patient’s family or koas or a nurse) and beg for a translation. If none is available, I just guess and reconfirm using a combination of true-false and the international caveman language of pointing-and-grunting and following that up with a thumbs-up and a smile.

We get a respectable amount and types of cases at RSUD Sleman. In Sardjito, many patients had two legs and an arm hanging in the grave. Here, the situation isn’t as dire. Most are new stroke patients. We’ve only had one death in the ward this week. Any really complicated or critical patients are simply shipped off to Sardjito. I think RSUD Sleman is a pretty decent hospital for koas in terms of getting plenty of cases that are relevant to our competency.

I’ve got another week to go here. It will pass quickly and I’ll miss this place. And then it’s back to old Sardjito with the stinky “ruang koas” (koas room) and the smell of pneumonia (... which gives durian a run for its money as I’ve learned).

I have a lot of stories to tell and I’d love to update more often if I can find the time.