The Graduation That Never (Haven’t Yet?) Happened

Disclaimer: This post does not in any way, shape, or form, represent the school or my classmates’ view or position, and it is solely the writer’s perspective.

In order to give this post some context, we’d have to go back to circa 2012-2013, when things were well and dandy. We were all looking forward to May/June 2015, because that’s when we were all going to graduate, and there would be the much awaited convocation, many of us would finally be able to say “yesssss we did it!!!!”, the first cohort would have graduated and brought pride to their families and teachers and everyone who worked so hard to make this school a top-notch educational ground. We’d be wearing the striking orange-blue robes and receiving our medical diplomas that stated the affiliation with Johns Hopkins University School of Medicine. We’d party like we never did before, we’d congratulate each other, we’d laugh and cry at the same time. It’d be a glorious, memorable day in PUGSOM’s history, and it’d be awesome.

Alas, when May/June 2015 came, all that did not happen. There was no convocation, no party, no flowers or garlands. All there was, was angst, ambiguity, agony (and maybe acrimony). We probably did laugh and cry at the same time, but for different reasons. Who would’ve thought that the affiliation would come apart so quickly, so soon? Who would’ve thought that it doesn’t just end there, and there’s more mess to follow?! Sure, one could say that this is just another bump, things will be okay and we will get the accreditation in time. We all hope that’s true, but until that happens we can’t quite be at peace, can we.

These are hard times, and we’re still not out of the tunnel yet. There are nights when I lie awake thinking about this, wondering what went wrong and why certain things happened the way it did. Unfortunately since the new leadership took over, we were never really told the complete story. At least that’s how it felt. There’s a cultural element here which I can understand to a certain extent. The general sentiment is: well it is what it is, so quit asking why it happened and just focus on how to move on. We as a nation tend to be optimistic and look at things on the bright side. Yet, while it is mostly a good thing, sometimes it can be unhealthy (and I think we’re closer to the unhealthy spectrum of gratefulness). We were always told to appreciate what we’ve got, don’t be bitter, don’t ask why we can’t have more, or why things aren’t better. But here’s the thing. Yes of course we should be grateful. By all means, appreciate everything you have and give your thanks, but what’s wrong with reflecting on what went wrong and how we can be better?! Why is it such a bad thing? Why can’t we be courageous enough to admit that we may have screwed up and then find a way to improve? Since when is it a taboo to talk about mistakes?

Because we weren’t told what exactly happened, we were left wondering. Was it something we didn’t do enough? Was it really the insufficient weeks and the lack of certain rotations that weren’t included? Were we seen as unprepared for the housemanship? Did the school fight hard enough to try to convince them our curriculum is a great one? Did they put up a fight at all, or did they concede too soon? Have they fought tooth and nail but to no avail? Or was there some other factors that played into it, factors we’re not privy to? There’s a huge void here, and the lack of communication makes us feel left out. This dead space between us students and the school weighs down on us. The thing about dead space is, it’s never a good thing, be it in physiology or in communication. It allows distrust to grow, it gives room for speculations.

***

I realize, at this juncture, that I’d never get the answers I sought. That’s fine. I’m letting it go. This post has been sitting around for a long time, I wasn’t sure posting it for public’s eye is a good idea. But then again, I’m not fabricating anything, these are just my thoughts, nothing more. More importantly, this is written for myself, and for my fellow classmates, to keep on fighting. There are still a few more hurdles before the finishing line, and we will get there. As Dr. Ray puts it, we’re being put in the crucibles, and all these obstacles are nothing but the heat that would prove our true mettle, and we shall come out more refined and purified. All in good time. 🙂

Some pics to share below. One of our classmates, Nezar, couldn’t make it to the photoshoot, and he’s deeply missed. We took these ‘pre-graduation’ photos knowing that our graduation will not be anytime soon, but that these will keep us going until the real thing. Would also like to take a moment to thank all of those who’ve taught us and cared deeply about us. Sending love to everyone.

Pre-graduation Photos

Pre-graduation Photos

Pre-graduation Photos

Pre-graduation Photos

Pre-graduation Photos

Pre-graduation Photos

“Sometimes the best thing you can do is not think, not wonder, not imagine, not obsess. Just breathe, and have faith that everything will work out for the best.” – anon. 

Always thankful,
J.

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New Year, New Beginning

It’s been a while since anything was posted here. 2014 wasn’t a good year for Malaysia. 3 plane crashes, a lot more problems I’m sure, and then of course, what affects us the most is the falling out between AMC and Hopkins. Many of my friends have shown concern by writing me and asking about this; a couple of people from the media have done the same. I’d like to use this opportunity to thank everyone for their concerns about our well-being. Here are some thoughts.

But before I go any further, note the disclaimer: please understand that this is just a blog written by students, and has nothing to do with the school. Anything written here should not be taken too seriously either. If you’d like more information about the school, it’s best to contact the school’s communications/publicity team. Do understand that we are in no position to give out any information (not that we have any to begin with), especially since we are all JPA scholars.

The first few questions most people ask is this: Oh does that mean the school has closed down? What’s going to happen to you guys? Does that mean you’ll be ‘absorbed’ into the other counterpart school, the PU-RCSI?  Well I can tell you that the school is still operating as usual till now, and we were given assurance that we won’t be sent to PU-RCSI to complete our degree. As for what will happen to us, I guess the short answer is to keep doing what we’re doing, attend classes/clerkships as usual, and hope that the school will figure things out. There are a few issues us students care about, namely: 1) Now that the school will not be using Hopkins’ curriculum anymore, which curriculum are we going to use? This probably doesn’t affect the 3rd and 4th years as much, but to the 2nd years and incoming students, this is a valid concern. 2) Will we be getting the same standard of education that the school has promised us? I have no qualms that the current faculty is doing their best to work things out for us, but does that translate to equal standards, or do we have to compromise? There is no straightforward solution to these questions, and it’s more complicated than it seems, but I personally think students should not be shortchanged no matter what happens. 3) What about the teaching hospital that was promised to us since Day 1? No news about it till now. I hope it will happen eventually, sooner rather than later.

As the title stated above, it’s a new year, so hopefully there will be a new beginning. I pray and hope things will get better for the school, for my fellow colleagues, and I hope we (the first class) will get to graduate this year as planned. There is not a day that passes by that we don’t miss our Hopkins faculty. But just like how kids from broken marriages manage to get through the difficult days, we will too. As the saying goes, what doesn’t kill us makes us stronger.

Signing off,
J.

Things I wish I knew before entering third year

1. Decision

Congratulations! You are done with your step 1, so what’s next? After a few weeks you will get back your result. What should you do then? If you are enthusiastic to apply for residency, you should start preparing for your third year. It will be a marathon and you need to be physically and mentally prepared for the challenge. Before you make your decision, get the latest charting outcome for IMG about where you are now in term of applying to specific residency. Then talk to your faculty member and get a realistic picture about your chances. This is extremely important because we all know that IMG in general is very difficult to get into residency. But if you never try, you will never know.

2. Financial

So the next thing to figure out is the financial part. Applying to residencies is expensive, even for med student in US. But here is the rough estimation:

  • Return flight ticket $1200 x2
  • Accommodation $500-800/ month
  • Meals: $400-600/ month
  • Health insurance: $ 280/month
  • Malpractice insurance: if needed
  • Registration fees for Hopkins elective: 1,300 USD/2 months
  • USMLE Step 2 CS: $ 1248
  • ERAS application to 150 programmes: $ 3300-3500

Bear in mind that you should have at least 2 to 3 months US clinical experience, the more the better. It is not a hidden rule, any google search will bring you to the discussion forum. Though AMG seldom do away rotation, we are IMG and it is very very very different when it comes to clinical experience. Health insurance is required when you do elective in US. For JH, you should purchase their health insurance as they have strict criteria on health insurance policy from other company. You might wonder about sponsorship, but they will be unable to confirm it until end of third year, so it is best if you include everything in your budget estimation. So for a 3 months elective in US, exam fees etc, they will cost you at least about RM 30-40K. If you get a lot of interview (IV), you might need to travel more between states, which mean even more money.

3. Year 3-

Choosing your first rotation After making up your mind to pursue this path, this will be where the marathon starts. Choose your group. I think you can decide which group you want to join for the rotation and each group has different schedules. Even though you are not sure about which one you like. For example I know I might like OB a lot, so I should complete during the first part of your 3rd year! Because during March or April you need to start applying for elective in JH, many electives require specific core clerkship as prerequisite requirement to apply. The registrar will find it difficult to consider that elective in your application if you have not completed the core rotation. Having said that, you might still benefit from your internal medicine core rotation during the last few months of your 3rd year as you will be preparing for step 2 CK around that time.

4. Year 3-

Prepare for clerkships Core clerkship is important. You need to get good grades. 2 major things: Clerkship director global rating and NBME. I recommend this book: Success on the Wards: 250 Rules for Clerkship Success. It can be borrowed from library. It has a green cover. I read it carefully before starting my year 3 and took images of the page that I find useful. This is important as you will be having US attendings that have certain expectations on you. Although the setting in HKL makes those expectations hard to meet, I would say the expectation of clerkship directors would be similar to what they expect of in US med students. This book gives you a clear idea how a routine day is like, how to write notes, how to get relevant history, case presentation as such. You can find out how the global rating was done in the clerkship handbook. Read and embed in mind what you want to achieve at the end of the clerkship. 2nd thing is NBME. The crazy exam that you all will have at the end of each rotation. The result percentile that we use in school is the same result percentile that compare with US student. We do not produce our own percentile based on our class percentile. This means that not only you need to perform well on the bedside, but you must score well to get the percentile that is eligible for honors. All these NBME is good preparation for your CK as well.

5. Step 2 CK

You will sit for your CK during the end of year, probably June, July or August. Before year 3 starts, survey on what are the step 2 CK review books. I recommend you to buy it and start using it now. Add notes along the way, CONCISELY! Buy UWorld as well (school will sponsor for 3 months, but if you can afford, why not), start doing questions along the clerkship, writing down notes in your review book. This will help your NBME and eventually your CK review. By the end of year 3, you might forget many things in first few rotations and the book can help. You can reset the Qbank once after you finish all. If you want to do it again, just mark all the questions and redo the marked questions when the exam is near. But some might strongly against doing that and purchase the qbank for 2 months when ck is near. You might find the qbank less helpful if you purchase too early. So it depends on you.

There are a few review books out there: Master the Boards by Kaplan, Step up to step 2 CK, First Aid etc. For every clerkship there will be a textbook recommended. However I still highly recommend you to have a review book so that you can have a concise review for your step 2 ck which will be at the end of your 3rd year. You will have to add in notes into that book during your third year across different clerkships into the same book. Unlike step 1, there is no one good book for ck. But you need to have certain level of details in your review book for example check out step up atrial fibrillation section (page 12), look at their management, that is the level of details you need to know. You can always add in notes after you do your uworld. First aid has plenty of space for you to do that but I found certain section is missed out in that book. I do hear good things about first aid to Wards. Check it out. Step up to medicine is a more textbook or comprehensive version of step 2 ck but it did not cover obgyn, peds and psy. Master the board, at first I thought is for dummies because it looks simple and brief, but many imgs scores well based on that book because it makes the basic concepts really clear. And they makes good diagram, tables, ecg etc. In short, is better you chose a section and compare those books side by side, see which one you like. Choose one, stick with it, add in notes along your clerkship from textbook and qbank, I cant guarantee you can score well for step 2 ck (i am still struggling!) but at least you will be more prepared and higher chance for you grab all the honours if you buy qbank and perform well in wards

6. Step 2 CS

Again, if you have decided to apply to residency (even though you might not know which one you are applying), you should register for step 2 CS early, perhaps on December. You need to apply online, pay, send in forms to Philadelphia, which takes about 3-4 weeks for them to process and get your scheduling permit. You need to get a scheduling permit first before you can schedule the exam date. The slots fill up pretty fast especially during summer time. You need to bear in mind to check on the scoring report date. It should be before the ERAS open date application. You should get your score back before the application opens. Thus schedule it before mid of July is advisable. Since you are paying the exam out of pocket and your elective most likely will start on July, and the only CS center near Baltimore is in Philadephia, book your slot early.

If for some reason you are unable to do so, there is a trick to get the slot. Download Check For Change apps in Mozila, open the scheduling page, highlight the particular date that you want, choose to reload in every 10 seconds. Turn on your volume the loudest and just do your work/ sleep. The app helps to refresh the page fast enough so that It ring the alarm if anyone drop out on that particular day.

7. Elective

We start applying elective on March/April to JH. Great, you get to choose to do 2 months elective in JH. But you might want to start applying to other hospitals so that you have more clinical experience in US. How to start to look for a hospital? A simple search on the internet will guide you. But decide a region, a state> Look whether they take NON-LCME accredited medical school outside of US (You are VISITING STUDENT/INTERNATIONAL STUDENT) > application fees, tuition fees, sponsorship from faculty, health insurance, malpractice insurance (there are good list on the internet which include all these)> get documents ready> apply. The current hospital policy for visiting student is that you need to apply through VSAS, which our school is not listed in, thus we are unable to apply through that. I did call up many hospitals to ask about direct application to registrar department but it did not work out well. There are very few that willing to accept, buzz me if you need the list.

***WARNING! This is not a recipe of success to residency, as you all know it is VERY DIFFICULT to get into US residency.

PUGSOM is a joint effort of many awesome folks in Perdana University and Johns Hopkins Medical school of Medicine. Their dedication in our special journey is enormous. I can never able to describe how much our faculty member had done for us. We see our lecturers caring for patient, the attitude, the quality of care they provide to patient, which have certainly embedded deep in our hearts and minds.

At the end of the day, regardless what happen in the future, you will come out as a good, responsible, and accountable doctor that genuinely cares for your patient, no matter which part of the world you are at.

PUGSOM class of 2015 wishes our juniors all the best in all the USMLE exams as well as residency journey. We do not know how far we can go, but if you have any questions/ problems, we are more than happy to help.

Keep calm, keep working hard and keep walking.

Thanks for reading. Thanks Wei Quan for editing.

Best regards,
Yuan Xin

Part IV: Stardust

Last take, from yours truly. Word of caution, it’s a little long, but only because there are pictures. 😉 

Two weeks from now, you probably won’t remember what you had for lunch last Friday, or the breaking news you heard on the radio just this afternoon, but there are things – incidents, people, places – that sear themselves onto your mind and soul such that you will always carry it with you, be made a part of you, so much so that you may not have even noticed it at all.

December 6, 2013 till December 11, 2013. Those marked the days we spent in the Philippines for Typhoon Haiyan (Yolanda) Medical Mission organized by Operation Smile Philippines. There were 8 of us, 4 faculty members and 4 students, who represented PUGSOM to be part of this relief mission trip. It was an honor to be allowed such opportunity, I’m sure my friends would attest to that, but it was also emotionally conflicting at the same time. Let me explain. This journey that we were about to embark on, was almost analogous to visiting an ailing aunt in the country that you most wanted to go, like, oh I don’t know, the city of l’amour, or the ancient city of Rome. For how could you be excited when your aunt is dying, even if it means having the chance to visit your most coveted destination? It’s not quite that of course, but almost, you get the gist I hope. This relief mission was such an exciting adventure to look forward to; finally we got to do something good, to help and do something important (maybe, or at least we thought so), but I almost felt a pang of guilt for feeling remotely psyched about it. After all, so many people have lost their homes, their source of living, and most of all, their loved ones. It’s a lot of heartbreak in a place at the same time- in a scale that is quite possibly unfathomable by those of us living comfortable lives in our typhoon-free country. And so I tried my best to not let the enthusiasm show too much, lest it was deemed inappropriate. But underneath that Dr. Seuss’ tee shirt was a heart beating steadily (albeit nervously), for a known purpose and reason bigger than its own existence.

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Two commercial flights, a breakfast at the Pancake House, a lunch of fried chicken with rice, and a military plane ride later, we got to our destination- Ormoc, Leyte. The first thought that came to mind as soon as we stepped down from the plane, was how clear and blue the sky was, how serene that place was, and how completely opposite it must have been just a month ago when the typhoon struck. We were brought by the military personnel in three military trucks and an ambulance to a house where the coordinating team for the relieving efforts were stationed. On the way there, I noticed the broken yet open-for-business shacks at the roadside selling drinks and snacks. Kids were running behind our trails, waving to us in excitement. Their cheers and laughter infectious, I couldn’t help but smile back at them. From the station, we made our way to the district hospital where our team would be relieving the Canadian Red Cross who had been there for a few weeks then and would be heading back the next day. While the team met with the director of the hospital, we students had the chance to check out the hospital grounds, only to find half of it destroyed. Patients lying on the stretchers in twos or threes, abandoned wards with fallen roofs, rays of sunlight spilling in from above onto the broken beds and sodden mattresses. Outside in front of the hospital where a number of tent-wards were located, we reconvened with the team after getting our bearings around the hospital. Having an idea of what to expect the next day, we were then brought to the house where we would be staying for the next few days.

1461148_555922687827139_1392468809_nWe had a total of 4 days of mission work, 3 out of which I was out in the Barangay’s (meaning ‘village’ in Tagalog). Each Barangay was about an average of 30 minutes’ drive inland; in each Barangay the tents and ‘stations’ were set up in a basketball court or some community area. When we got there the crowds were already waiting for us patiently like how kids would wait for Santa Claus to give out presents during Christmas. In a way, we were really like Santa to them, except we were giving out medicines and multivitamins instead of candies, soft toys, board games and what-have-you’s. And like in any community activities, there was entertainment- in our setting there were magic shows and games for the kids. Though I couldn’t really see it or join in the fun as I was at the station seeing patients with either Dr. Joyce or Dr. Dan, the cheers were as loud as boom box on my shoulders even the deaf could hear it. The child in me was tempted to ditch work and go play with them, but the more conscientious and logical self knew I have responsibilities and meaningful work to be done. It nevertheless made my heart smile knowing that the kids were having a great time. Back at the station, it’s amazing how my limited Tagalog and Visaya helped me so much. With phrases like “open your mouth”, “take out your tongue”, “deep breaths”, “pain… where?”, numbers, and crucial words such as cough, fever, cold, weak, vomit, diarrhea, etc. I managed to get some communication going. Until they started speaking sentences or words that I didn’t recognize. Then I would stare at them with a blank face, and them me, followed by smiles that imply “yeahhhh I think I’ve lost you”. But of course, I didn’t have to worry much because each time this happened someone would inevitably come to my rescue, bless their helpful souls.

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In those visits to the Barangays, I learned that a portion of the villagers who came to seek medical attention did not have any active complaints or illnesses. Rather, they came for medication supplies for the rainy days, or for some form of routine health check- since most of them would not have access to health care otherwise. But of course! It made perfect sense to me. How else would they get medicines and BP check or multivitamins for their kids? They live miles up the hill or inland, and it would take hours to get to the nearest town, and that’s if they could afford to miss a day’s work. My heart goes out for them, my only regret was not to be able to carry out a decent conversation with the local people and hear from them their personal stories.

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My only day (and night) at the hospital was spent taking care of a 3-month old baby girl with pneumonia complicated with pneumothoraces- yes the same one that my friends would’ve/might’ve mentioned. Baby P was on a ventilator when I got there, but not long after that the electricity went out and we had to manually ventilate her with the baby-size ambulatory bag. That had to be one of the most challenging tasks I have done in the 4 days I was there. My hands were shaking as I squeezed the bag, each squeeze done with much care and calculated strength, for fear of squeezing too hard and causing another pneumothorax. My sympathetic nervous system revved up, palms sweating profusely, heart rate increased and BP spiked every time the oxygen saturation on the monitor took a dip and the beep changed into a lower tone. It may sound exaggerated now, maybe even comical, but that was how I felt at that time, at least initially. Never had I bagged a person before, let alone a tiny little human who has a lifetime ahead of her to explore. And so, to say that her life depended on the ventilation we provided is no exaggeration, any mistake could’ve cost us more than anyone could afford. Thankfully, baby P survived the night, and made it all the way to Manila for her continuation of care. After 3 ambulance rides and a flight later, she got there safely with Drs. Nicole and Fiona, together with Nurse Aoife and her parents. Everyone who had contact with Baby P took care of her with so much dedication, it was their contribution that made this a reality, and it was my honor to have witnessed it and be a part of it.

1463536_555930064493068_1362515565_nAnother memorable experience was being in the OT. Dr. Jojo, Dr. Gerto, Dr. Manny and Dr. Fiona as well as Janice who were in the OT with me might have noticed the excitement and elation in my eyes to be allowed to scrub in with them (and if they didn’t, it was because I contained myself- successfully, and prevented self from being too wild and crazy), as it was something I experienced only twice during my surgical clerkship. So you could imagine how much I appreciated this opportunity and tried to take in every moment of every second. And to be allowed to suture on an actual living, breathing human, and not just any part of the body but the face?! No amount of description, exclamation mark or emoticon could express the emotion I felt, and above all, the immense gratitude that I had for such an opportunity.

When we set out for this relief mission early on, I was just a girl with a hopeful and open heart and complete willingness to do anything to give and help, but what I didn’t expect was that I returned with so much more than I had given. To have seen the destruction that the typhoon has brought the Philippines, especially so in Tacloban; to witness the Filipino people stand back up and find their way to rebuild their lives and cities; to be in contact with those who stand tall with resilience in the face of adversity – I have so much respect for them. What’s more, I met this group of amazing people who made up the relief team, and whom I have the pleasure and fortune to befriend. They taught me a lot, took care of me when I was feeling under the weather, and were simply so much fun to be around with. To sum it all up, apart from the overflowing gratitude that I have for everyone who made this mission trip possible, my feelings and thoughts on Mother Nature is nothing short of awe. At the end of the day, we all are mere stardust in this universe. So puny, so easy to wipe out. But that does not mean we should give in, does it? I know, at least for the people of the Philippines who survived the tragedy, they feel the same. As they put it, they may be “roofless, homeless, but never hopeless”. Alas, the relief mission had to end, and we had to return to our lives. But the work in the Philippines continues, and I send out my best wishes and prayers to them, hopefully the forces of universe (or the internet, whichever works) will get it through to them. As for me, for as long as I live my puny existence, I will make it count by seeking out ways to help and serve.

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Footnote: Photos are mostly from Dr. Nicole, but also some from other friends from the mission. Big thanks to them for sharing. 

Part III: First, But Not Last

Take Three: Wei Jie’s take of the relief mission in Ormoc. Enjoy!

Participating in a medical mission is one of my goals when I first enter medical school. I was very fortunate to be part of Humanitarian Medical Mission Typhoon Yolanda in the Philippines. After missing out last year, I thought that the chance would slipped from me again but after a dramatic turn of events I was onboard the Cebu Pacific airline on the 6th of December with three of my colleagues Mior, Min Ying and Joan led by three of our faculties Drs. Modupe, Brian and Geneva to Manila. I was excited and nervous not knowing what to expect, as we were told by our Vice Dean Dr. Nicole that, it will be harsh! After meeting up with Dr. Nicole who makes this trip possible we took another flight to Cebu where we met up with the rest of the team. Then we board the C130 an army plane, which I believe is one of the coolest ever flight.

“An aircraft without pretty or handsome air stewardesses or air -steward, no safety briefing, no comfortable seat, and most importantly no one nags you to buckle up your safety belt whenever there is air turbulence.” Everyone including myself were looking forward for the once in a life time flight. Ironically, I had my best nap of all the three flights, as I lay on the cargos which are mainly bags of rice.

The first thing that I saw once I arrived in Ormoc, a small city of the island Leyte where Typhoon Yolanda made its landfall, is how all the branches and leaves of the coconut trees are all uniformly blown to a particular direction making it a very scenic yet eerie atmosphere. We were then escorted VIP-style to the Ormoc city hospital by a convoy of army mostly armed by a heavy machine gun. When we arrived at the Ormoc city hospital, temporary tents were being set up, by international organization and one of it was our very own Mercy Malaysia relief team, it was really heartwarming to see Malaysians lending their hands to people in need. The hospital itself however was severely damaged by the typhoon. Half of the hospital were either roofless or collapsed and was uninhabitable. Meanwhile, inside the hospital, the only word that I could use was “chaos” and it was packed full of people. This reminded me on some of the disaster movies that I had watched where patients are lying on every inch of space in the corridor and families crowding around them, the only difference is that, this is reality and it’s happening right in front of my very own eyes.

The first day itself I was pulled into action with Dr. Modupe as she noticed a postpartum patient with severely edematous legs bilaterally in the Canadian Red Cross tent. Concerning about her overall condition, she called Dr. Brian for consultation and he confirmed Dr. Modupe’s concern, she most likely was suffering from postpartum cardiomyopathy, and needed furosemide for diuresis in order to relieve the edema as well as the strain on the heart. I was nervous when I was first pulled in by Dr. Modupe, knowing well that I would definitely see an Obstetrics case, this is because it’s been almost 2 and a half month since my O&G rotation and most of my O&G knowledge has already evaporated from my hippocampus. When I was asked to measure the blood pressure, the only sound I could hear was the sound of vehicles passing through the hospital, after 3 tries I passed the blood pressure cuff to the another fellow nurse Nikki who is also part of our team.  At that time I was very disappointed, embarrassed and feeling very dejected that if I couldn’t even take blood pressure what else can I do to help? I told my feeling to Dr. Modupe and she gave me assurance that it was not my fault, and even Nikki and Dr. Brian couldn’t get a definite BP, only then I put that event to the back of my head.

The next day, I was assigned to Dr. Modupe to help out in the labor room. There I met the O&G specialist Dr. Roman and Nurse Nimfa. It was the first time I took care a patient from their first stage of labor to the moment they deliver their baby. Although I was slightly disappointed to not personally deliver a baby, but I was lucky to see Dr Modupe in action finally and I believe it was her first few deliveries after leaving Home! So I was very happy for her as well.

Besides that, I also took two night shifts for the last two days to take care of a 4 months old baby who had pneumonia. It was the first time I took night shift, and also the first test on how my brain functions at these ghostly hours, it turned out quite well though. I also had the privilege to have a private lesson from one of Mercy Malaysia volunteer also from HKL Dr. Melvin, an anesthetist who also took part in taking care of this baby. He taught us some of the basic concept behind ventilator machine. On the first night the baby was on ventilator, so we took vital signs hourly and monitor the baby closely, however the next day we were required to take turns to bag the baby as the ventilator was not reliable and couldn’t keep the O2 saturation up.

On the day when the baby was due to transfer to Manila hospital, as we would be leaving Philippines, I got a little emotional. This baby could finally be taken care of in a better equipped hospital. Also, the fact that it took such a monumental effort and a team of dedicated people to keep the baby alive till the very day of transfer was itself a highlight of this mission.

Aside from the experience in the hospital, I also had the opportunity to take part in the community service in the Barangays (village in tagalog). Again we were escorted by the army for the entire journey. We were also told that most of the patients are malingering as it is difficult for them to visit the clinic due to the distance. In my first trip, I got a shock of my life when I saw so many patients walking around with a systolic BP of 200mmHg when I was manning the BP station. Besides that, I also see pediatric cases which were out of my comfort zone as I haven’t been through pediatric rotation yet, but with guidance from Dr. Dan a pediatric specialist, I was taught the dosage of medication for this group of patients.  It was also the first time I prescribed medication to patients; I was worried at first thus asking Dr. Dan about every medication that I prescribed just to double check

Through this mission I truly appreciate the meaning of TEAMWORK. How each and everyone in the team regardless of background, we worked together with a common goal in mind, to save and help people. Finally the journey through the city of Tacloban the hardest hit area was an eye-opener. The city was literally flattened, not a single building escape major damage, huge trees being uprooted were common sight, and the worst of all, ships were pushed far inland by strong waves. It was then I realized that how insignificant we are compared to the forces of Mother Nature.

Overall, it was an invaluable experience and I truly respect everyone in the team who make the mission a successful one. This will be my first mission but definitely not the last mission; it will only be a springboard for me to do more for the society and not to be confined just in the hospital settings only.

Part II: A Willing Heart

Take Two: A post from Min Ying, her reflections on the relief mission. Happy reading!

A year ago, I listened to presentation by Amirah and Malini about their experiences during the Philippines mission. One of their slides was a photo of Dr. Patrick patiently squeezing a normal saline IV fluid bag drop by drop beside the patient. At that moment, I felt proud of them and hoped that someday in the future I would have the chance to join medical mission, and I did.

In my mind, medical mission is challenging given that we have limited resources but such high demands. In addition, none of us know when will be the second strike of typhoon. My mom who was particularly worried about my safety even asked, “who can tell if the typhoon will not recur in a few days, weeks, or months after its first attack”, when I mentioned about my intention to participate in the mission.

Before reaching our destination in Ormoc district hospital, we were so excited to be on the C130 air force plane. Despite the loud noise from the huge engine, I was still able to sleep peacefully and soundly in the plane partly due to the “reversal of the circadian clock” effect after 5 days night shift in HKL.

The military plane brought us in one piece to our destination- Ormoc. At our visit to the hospital on our first day, I realized that the hospital was badly damaged by the typhoon and reconstruction process was still going on. As we walked in the hospital, there are patients on the bed along the corridor. It was quite crowded and the patients looked helpless. Since we were not the first team to arrive here, the condition appeared in front of my eyes now is quite under control and I believed the situation was so much worse before.

Our team was divided into two groups. One group went to serve the community and another group went to the hospital. On the first day, I went to the hospital and tagged with Dr Nicole. That morning, we saw a 9 yo girl with second degree burn with her left hand writhing because of pain. Her house was burnt down due to the curtain that caught fire from the mosquito repellent incense. I can’t imagine the multiple traumas that she had to undergo after escaping Typhoon Yolanda.

In the afternoon, I had the chance to observe a laparotomy for a 12 yo boy who had abdominal blunt trauma a few days ago. After the surgery, he had respiratory acidosis and needed the help of a ventilator to breathe. Unfortunately, no ventilator was available for him. What we had was an oxygen tank and ambu bag, which meant the obvious – we need to bag him to keep him alive. I was thankful that I was given the chance to bag that patient for hours and that it was the happiest moment that I had in the hospital. At that moment I felt that my presence meant something, that I was actually useful to the team. Although that was not my first time to ambu bag a patient since I did it before during coding in HKL, I found this particular case a bit challenging as the patient was partially breathing by his own. I was taught by Dr Nicole and Dr Melvin (an anesthesiologist from HKL who was also there in a mission with Mercy Malaysia), to bag in the rhythm synchronize with his breathing pattern. I tried to do as they taught, but it was hard initially. My eyes fixed at the oxygen saturation on the monitor, I was nervous when the reading decreased to less than 96% and my reflex was to bag at a faster rate. Later, I was reminded by Dr Nicole that it was impossible to bring up the oxygen saturation by just bagging faster because oxygenation and ventilation is two different things. I learnt it theoretically in medical school but I re-learnt it practically in the “ICU”.

After a few hours of continuous bagging, I was asked whether I felt tired as they volunteered to take over the ambu-bagging job, and I answered “no, I am fine”, and that was my honest answer since the feeling of satisfaction by doing something for the patient overshadowed the feeling of tiredness.

I also had the chance to observed 3 deliveries in the delivery room as the other team members took turn to bag the patient. That was the first time I saw in person an infant`s head coming out from a women`s vagina. I thought of my mom at that moment. It was pretty exciting to watch but I guessed we can never understand how much pain a mother had to go through during the delivery if we ourselves never experienced it before. As I have not yet undergone my ob gyn clerkship, what I can do for the patient was help to spread her legs apart and gave her mental support.

Another experience in the Ormoc district hospital was the oncall night with Dr Dan, Dr Melvin, Nikki and Weijie. We were taking care of the 2 patients in the “ICU”. One of them was a 3 mo old baby who had pneumonia and another patient was a thyrotoxicosis patient. We took the vital signs every hour overnight. Now we understand how the nurses feel when they need to fight with the feeling of sleepiness when taking care of the patient during night shift. Close observation of the patient vital sign overnight is not easy but as I imagined the patients being my mother or little brother, a sleepless night was not a big deal anymore.

Going to the community was even more exciting for me as I felt that I saw more patients and reached out to those who had difficulty accessing health care previously. But the language barrier occurred and I found it difficult to interview patient without a translator. Learning some Tagalog such as sakit (painful), would be helpful. Most of the patient that I saw presented with HTN. For instance, one of the patient’s SBP reached 280mmHg! Most probably they were having a lot of stress after the Haiyan typhoon and another possible cause is high salt diet. Therefore, I believe that besides medical mission’s aim to treat the medically ill patients, managing the etiology of their illnesses is also important. Many patient complained of coughing presented with clear lung sounds bilaterally. Some of the patients did not look at us – their eyes were busy screening the medications that we displayed on the table. According to Dr Joc and Dr Richard (they were the doctors that I tagged with during the community service), most of the patients in the remote area have difficulty accessing basic health care. Hence, this is the chance that they can get some medication to keep for use in the future. From then on, I think I should change my mindset regarding malingering. For the patient in the remote area, it was not a right or wrong thing to do; they did it because of their anticipation for their illness in the future.

Besides “working”, we went to several places eg: Tacloban, Bay Bay and Leyte while dispensing the medication to the clinic nearby. The sunset in Bay Bay was impressive. However, when we move around in Tacloban, the collapsed building and smell of dead bodies made me feel the attack of Typhoon Yolanda was still very fresh. Can’t imagine how it was a month ago.

Everything that I have undergone in Philippines is far better than I expected. I enjoyed the boodle fight and felt touched by the kindness of the people over there. Although I did not feel that I did a lot, I did see and learnt a lot.

The doctors who took care of the patient in the “ICU” regardless of time of the day, inspired me to study harder but at the same time maintain a good health. They reminded me that both medical knowledge and good health are important. For how can a doctor manage patient in a low resources setting without a strong medical knowledge and how can a knowledgeable doctor take care of the patient if he or she fainted in the middle of the night? Nothing is impossible with a willing heart. I believe, in the future, besides ambu bagging, I can do much more for the patient.

Part I: Bangon Ormoc!

“Mior, have you decided which specialty you are planning to go to?” Dr. Modupe suddenly asked me.

“I am interested to become an anesthesiologist. This occurred right after I did surgical clerkship.”

Dr. Modupe explained how important the anesthesiologist in the eyes of an OB/GYN specialist.

“You know what. Most of the times, I can’t save my patient without anesthesiologist.

The conversation above took place while we were on the plane, waiting for the plane to fly to our destination, Manila. We were two out of eight members from PUGSOM and John Hopkins Hospital (JHH), who volunteered and were selected to participate in a medical mission for Typhoon Haiyan in the Philippines. The team consisted of Dr. Modupe, an OB/GYN specialist, Dr. Nicole, an pediatric intensivist, Dr. Brian, an ICU pulmonologist, Dr. Geneva, a psychiatric resident from JHH and four third-year medical students which includes me.

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To be honest, I received my acceptance e-mail for the mission within less than two weeks from the date of departure, and I did not prepare myself for the mission until the night before departure. However, meeting with the entire team members somewhat relieved my anxiety. They all felt exactly the same way I did. Each of us was totally clueless on what to expect for the next five days in Philippines. 

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We departed from KLIA at midnight, and reached Manila early in the morning. Our next flight from Manila to Cebu was scheduled at 8.00 a.m. After arriving at Cebu International Airport, a white bus picked us up and we were welcomed by a group of people who would be our best buddies for the next few days. At that point of time, it never crossed my mind that I would fly in an airforce C130 plane to our destination, Ormoc City.

Upon arrival, I took chance to mingle with the rest of the teams. I was introduced by Dr. Modupe to two anesthesiologists, Dr. Fiona and Dr. Manny who would be helping the team mainly in the hospital, in the operation room. I told them how anesthesiology interests me during my surgical clerkship, and they were pretty excited to hear about that. We got to know each other briefly before we had our first dinner. After dinner, Dr. Manny suddenly asked me to try balut, a boiled egg with embryo inside, but I figured out that was too much for me. I didn’t dare to chew the embryo! But putting my lack of adventurous tastebuds aside, I witnessed what the typhoon had done to the Ormoc. It was unbelievably terrible. Most of the buildings were roofless with their window glasses were broken. Some of the houses were severely damaged. And all of the people lived without electricity.

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On Day 1 of the mission, I went with the team to the field, delivering healthcare services and distributing medicine and vitamin supplements to the affected local community in a barangay, meaning ‘village’ in Tagalog. We went to the barangay and set up our tents there until afternoon. At the end of the day, I felt accomplished as I was able to communicate with the local despite the language barrier. Thanks to a 10-minute informal Tagalog language class and assistance from the doctors and nurses, I managed to clerk a number of patients and even provide instructions of medications to the patients!

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That night, I volunteered to be in the hospital, taking care of another group of patients. A group of very sick patients that needed critical care. In fact, Dr. Nicole and Dr. Brian, with their expertise, have set up an intensive care unit (ICU) room in the hospital. However, the ICU operated without any mechanical ventilators, which means, they required people to help bagging the intubated patients!

There were three patients in the ICU at that time, two middle-age women, and a 10-year old boy.  Doctors, nurses and I rotated to bag each patient. As it turned out, it was not a calm, quiet night. The 10-year-old boy suddenly coded due to severe respiratory distress. Dr. Nicole got me to wake the other doctors up for assistance. I ran out and called for help. It was nerve-wracking to witness the code team operated. CPR was performed. Medications were prepared and administered, one after another. At one point, I was asked to perform chest compression on the boy, replacing the other doctors. So far, none of the patients whom I did chest compression came back alive, and I really did hope that this boy did not follow their fate.

Unfortunately, he did not make it. Dr. Nicole went out of the room to break the news to the parents. The patient’s mother rushed into the room to her dear son, crying and mourning for his death. Dr. Nicole consoled her, but to no avail. It was the saddest moment of my time in this trip. Despite burying with emotions, we had to move on with our tasks. There were other patients that relied on us in order to live. And that is what makes a doctor’s job a challenging one.

In the morning, Dr. Nicole told me to go back to the house, freshen up and get ready for the next mission. But I did not. All of my energies were entirely consumed for the whole day and night. I ended up sleeping for three hours, as both hospital and field teams left me in the house alone. After that, I managed to get into the hospital and report to Dr. Nicole. I decided to help in the operation room, so I met Dr. Fiona and Dr. Manny there. I straight away volunteered myself to be their partners and they happily welcomed my presence!

I asked them if they could teach me all the basic anesthesiology, and so they did. I assisted them preparing local anesthetics, administering succinylcholine and bagging the patients. It was too good to be true, but what was more – I was also given the chance to intubate a patient! I could not believe it when Dr. Fiona told me to intubate the patient! When I was about to put the tube through the vocal cord, she firmly told me:

Don’t you ever blink your eyes to that vocal cord.

She was serious though. After I inserted the tube into the airway, she checked the larynx.

You did it.

Although the process of revealing the vocal cord was guided by Dr. Fiona, I was still thankful for the rare opportunity.

It was definitely not as easy as it seems to be.

After intubating the patient, both Dr. Fiona and Dr. Manny left the room, all of the sudden. I was the only one in the room, bagging and observing the patient. At one point, I noticed all the vital signs went haywire, not as what Dr. Fiona explained to me earlier. I became panic. I began to feel my cold sweat on my face, inside the air-conditioned room. Several minutes alone in the room seemed terribly long for me.  I had no idea what to do, other than to keep on bagging the patient. Luckily, they came back and I hastily reported what happened. Both of them did not do anything to the patient. Instead, they laughed out loud and mocked me for the unnecessary anxiety.

Look at your patient. Don’t rely on the monitors, machines etc. Remember that they are there to guide you, not to confuse you!

I was reminded too on how important for an anesthesiologist to stay calm in the operation room. They emphasized that it is a good practice for me to remain calm at times of crisis and emergency and think what we can do for the patient. For just a single situation, I learned so much from them. Although my silly scene became the hot topic for the entire team for the rest of the day, I was really lucky for such unique experience.

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On the same day, I watched Dr. Modupe performing a Cesarean section operation and one high-complication delivery of placenta abruptio. It was nice to see your own teacher actually practiced in front of you.

Even better was, they entertained our question during surgery or procedures, which was scarcely observed among the doctors in the hospital I was posted for my practical training.

Indeed, Day 2 was the best day of my time in Philippines.

I tagged with Dr. Richard who is a locally-trained urologic surgeon on Day 3 to the barangay as part of the field team.

ImageHe was my best buddy of the day.

He asked me to listen to each of the patient’s lung and presented to him each sound accordingly. Most of the patients came with complaint of prolonged ubo (cough) but their lung sound were always normal upon examination. After listening to many normal lungs for the whole day, I noticed that it became handy to distinguish between the normal and pathologic breath sound.

You have to appreciate the normal physiology first, before you can fully understand the pathology.

I spent the whole night sitting with Dr. Manny, Dr. Fiona and Dr. Richard, enjoying the night scene and eating the local delicacies. It was late past midnight, but I perfectly knew there will be no other time that I could spend with them talking about career tips, life experiences and jokes!

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On the next morning, we headed to Tacloban, the most affected city by Haiyan typhoon. It was horrible and depressing scene for all of us. You could even smell the stink of the dead bodies. All of the buildings were heavily damaged. I was not surprised when I saw a ship lodged next to a house.

Our last night in Philippines was ended with an appreciation dinner for the team who had done a wonderful job for the community. It was truly fun for the past few days, and now, it’s time to get back home. Saying farewell is always hard for me, and for unknown reason, it was even harder this time. They had treated me well not as passionate mentors, but as best friends.

Thanks Philippines for all the wonderful new friends, memorable experiences, useful advises, inspirations and fun. I am grateful to be part of the team to help those in needs.

Bangon Ormoc, Bangon Tacloban and Bangon Philippines!

You can do it!