Palliative Care

Just finished a whole week in the palliative side of medical practice. The posting lasted 4 days, some theory, some practical and exposure to different fields of it. Though it was short, there's just a whole load of things to reflect upon.

The typical ward round and documentation of patients' condition has this format (or close to) SOAP. (S)ubjective - Ask the patient how he feels today. (O)bjective - check his vitals. (A)ssessment - what are the current issues? (P)lan - Can he go home? All seems well and good. You cover the medical side of things, and hey, you talked to the patient and asked about his opinion. On the surface it seems to be a good framework, but going deeper down, all these is so... superficial.

Contrast this to pallative medicine - the team moves around in 2s or 3s. Every patient gets seen for more than just his medical condition. His well-being is asked about, his ideas, concerns, expectations. How he's coping with his illness, his prognosis. Psychosocial issues are probed into. Financial status, home-care, family support, future plans. Spending an hour just to find out about all these is not uncommon - it can even be considered little.

Entering medical school requires you to write an essay on why you want to enter, why they should choose you. The model essay go something like - I want to save the world. I want to treat every patient like they're my parents. I want to spend as much time as needed with them. I want to give them the best care that I can. I want to explore and address every issue they can possibly have. I want to give my all for every patient in the ward.

Idealistic? Yes. But in retrospect, palliative medicine is definitely closer to this idealistic world that has been preached during lectures, during the theoratical part of medical school. It just seems like all these ideal practices have become a specialty named Palliative Medicine rather than one that is incorporated in all fields.

Definition of palliative medicine - The care of patients with advanced/terminal life-threatening illnesses.

Is it right to only focus on the non-medical issues that patients may have only after their illness has progressed to that terminal stage? Are they not entitled to the same amount of care even before their cancer becomes incurable or before their lung diseases have progressed to the untreatable stage?

As usual there comes the debate between idealism and reality. The ideal world is always... well, ideal. But the cost of it in this context is time. Reality doesn't allow for that much time when there's a few more cubicles of patients waiting to be reviewed and another hundred more in the clinics. That's the harsh reality that is present. The question is, if palliative physicians can do it, why can't the others?

Hymn and carols

Merry Christmas

The spirit of Christmas fills the world - restaurants, shopping centres. almost all public areas have a hymn or a carol playing in the background to create the ambience for the festival. Choirs and small groups perform in hospitals, community centres and homes for the enjoyment of the less privileged. The music that fills the air is indeed one that brings people to a joyous mood.

It is easy to sing along to the tune and go with the flow of the Christmas mood. What few think about really, is the actual lyrics of the songs. All hymns and carols did not originate purely from a composer's mind. Every sentence, every word is filled with praise to Jesus; the beauty and glory of God which inspires the songs of praise.

Let's take one of these carols as an example

O Sing, choirs of angels,
Sing in exaltation,
Sing all that hear in heaven God's holy word.
Give to our Father glory in the Highest;
O come, let us adore Him,
O come, let us adore Him,
O come, let us adore Him,
Christ the Lord.

A verse that simply runs through the minds and the lips of carolers as they sing without much thought to anything but the enunciation and the melody. But if one examines the meaning behind these words, how powerful and how meaningful it really is!

O sing, choirs of angels, sing in exaltation! The carols aren't meant purely for our own enjoyment, it is meant to exalt God in heaven above! Exalt his Name, exalt His Word, that all may hear His holy Word. Give Him glory while singing, exalt the King in these songs! Come, let us adore Him, adore Christ the LORD for He is the reason for Christmas. He is the one whom we are praising and worshiping whilst singing these carols.

This Christmas, let us sing these hymns and sing these carols, not because they sound nice, or because others are singing it too. Sing it because this season is Christmas, and commemorates the birth of Christ, our King, our Saviour, our Redeemer...

Merry Christmas everybody

Love

Love - a very simple word with a very complex meaning behind it. Who can fully comprehend the power of love and its impact on people?

There was this 3 month old baby suffering from chronic lung disease, swallowing difficulties and respiratory distress. Everyday, she would be fed through the NG tube; she needed oxygen to support to survive. Everyday, she only sleeps, and occasionally wakes up for minutes before sleeping again, without noting anything around her. Still, her mother would always be there, daily. She would be there by the cot-side just looking at her daughter, ready to attend to her whenever she makes the smallest cry. One day, when the baby was ready to go home, her mum could only grin from ear to ear with a tear of joy in her eye.

This 10 year old girl was diagnosed with type 1 diabetes mellitus. As students, we just went through the motion of asking about her dad about her condition, her signs and symptoms with all the other typical questions. Halfway through the conversation, daddy's eyes notably turned red, his speech started to tremble a little, as he forced out the words: she'll need to take her medicine for the rest of her life...

A 9 year old girl had a rare metabolic disorder. She was not born normal and she would never be normal. While she sat in the bed playing with picture cards, her dad simply sat at the side, looking at her lovingly, smiling whenever his daughter handed him two cards to piece together, picking up the dropped cards without the slightest complain even though this happens non-stop for hours. Her life depended on enzyme replacement therapy every 2 weeks each costing a hefty SGD1500 after subsidy. He told us, "Well, our family simply lives from day to day. Actually, last time the doctor said she would only live up to 5 years old." You could feel within him, that he had mixed feelings of joy and hurt.

This young kid was admitted to the hospital and stayed in the wards for almost a month before he went home. During his stay, he was hyperactive - running around the whole ward, being the big brother to the other kids, finding friends, playing happily. Nobody would guess that he was a victim of child abuse. The day he was discharged, he called out to me (at the bus stop) - my first reflex was to ask, "Wa, going home already ah?" The reply came back rather drearily, "ya..." His eyes were downcast, he evidently preferred to stay in the hospital than at home where he could find ... if i dare say... more love than in the past...

Stories like these aren't uncommon. There are parents who love their children so dearly and rejoice in their recovery. Others are forced to accept the harsh reality that face their children. Still, others do not treasure what they have, and bring sorrow to self and others around them.

Wouldn't it be great if every family is bonded purely by love, love that is modeled upon perfection - patient, kind, does not envy, does not boast, is not proud; does not dishonour others, not self-seeking, not easily angered, keeps no record of wrongs; doesn't delight in evil but rejoices with the truth; love that always protects, always trusts, always hopes, always perseveres; love that never fails...

Love is so powerful in so many ways. The presence or absence of it can make or break a person. It can build relationships or destroy them. It can make a family everything... or nothing...

"And now these three remain: faith, hope and love. But the greatest of these is love" - 1 Corinthians 13:13

Show me how to love like You have loved me

Returning to the throne of grace

"Our church has people with many problems, but we are God's people"

I keep wondering to myself: how many times must we fall from the same mistake before we learn from it? It's always upon looking back after falling where we realise where our mistake lies. We try to learn from it, but for some reason, the lesson doesn't last.

There is just this one thing I need to learn: The pursuit of anything but God almost always translates to misery and dismay. Things don't always turn out how we want them to. At one point, when we expect something and the opposite happens, things just fold in onto us; we're affected greatly, we wonder what or why things went wrong?

This morning, I was half thinking about not going to church~ but I'm so so glad that I went in the end. I realised that in times of failure and brokenness, instead of running and hiding from God, I should seek Him and renew myself in His presence. It was particularly great to see Dr Tan Lai Yong as the speaker today in church - he's always been one figure who's been particularly inspiring to me even though I've heard little about and from him.

God worked within me in wonderful ways at church today. The worship songs appeared to be tailored to my needs. The message was directed to the problem I was experiencing. Although church took the same amount of time today as the past weeks, it felt to me that it was over ... just so fast today.

I just pray that, this encounter I've gone through will once again act as a reminder that God is central; no benefit will come if I prioritize anyone above Him - Him who is greater than all else, Him who I will ultimately bow before at the throne of grace

~~~

Now You are exalted to the highest place

King of the heavens, where one day I'll bow

But for now, I marvel at Your saving grace

And I'm full of praise once again

I'm full of praise once again

And once again I look upon the cross where You died

I'm humbled by Your mercy and I'm broken inside

Once again I thank You, once again I pour out my life

Faith vs. Reality

If you have faith like a mustard seed, and you tell this mountain to move, it will move.

Went to church today with a heavy heart.

We're always told that when we're in church, worshipping, we should be leaving our baggages and burdens behind, focus our hearts and minds on God. But it's just so hard when your mind is simply elsewhere, thinking about other stuff, concerned about other matters. On another note, it's also so easy to tell others to have faith, to depend on God, to make time for Him and trust that He will multiply your time. But really, how many of us can actually practice that in the face of so many troubles? If I myself am unable to practice it, who am I to preach it others?

Just yesterday, during QT, I was meditating upon prayer and faith. The bible tells of many stories of which men of faith have prayed fervently and God is moved by their prayer and grants them their request. Testimonies from brothers and sisters in Christ also speak of the power of prayer with faith. Then I looked back on myself. How much faith do I actually have? It's a constant struggle indeed.

I only had one simple request yesterday... And when I put reality and nothing else into perspective, I knew that request was never gonna happen. But I knew that if I asked in faith, without doubt, what I ask would have been fulfilled as I'm sure my request would be in line with God's desires. Unfortunately, I knew without doubt... that I had doubts. It's so difficult sometimes, just to pray... in faith. Without doubt.

In the end, I didn't dare think too much. Intellectualism in the kingdom of God almost certainly fails each time. I didn't dare think about the outcome. I just prayed. I'm really not sure how much faith I had at that point. I just asked.

Father, may Your hand and Your grace be upon those who need it.

Romance, reality and repulsion

Activaid 2011 was a nice insight of how mission work overseas is really like. It was no longer things like: you should go for missions; the people need your help; why providing aid to neighbouring countries is important; the need in the world. No, the speakers there knew one thing: they want to go on missions, and they have been. No more pep talk on pushing people for missions. The conference was on missions, and how they are realistically. What do you want to achieve? How is it going to be done? What are the short term and long term aims? How is finance going to be settled? Very real questions to very real problems.

The second workshop I attended was termed: Avoiding another 'hit and run accident'. There are instances when people go there with good intentions, do a job halfway and leave. Not only do they not help the people, they left an obstacle: a half built and useless concrete buildi... ruin in the middle of their village. So, yea the talk was how to avoid that or the like

One thing the speaker brought up was the progression of how people who want to go on missions go down the route of romance, reality and finally repulsion.

Romance: Yes, missions are really great! I want to go out and help others, to reach out to those who need my help, to hear the marginalised society and give aid in every way possible. I want to build houses for them to live in, toilets for good sanitation and help them find a stable income to break the poverty cycle!

Reality: Well, I can give this family a meal today, but that helps them for one day. They're hungry again tomorrow. The new system implemented for better sanitation is not being accepted by the villagers due to custom and habit. There aren't enough funds to do what I want to. I cannot stay here forever

Repulsion: Missions are stupid. They're absolutely useless. They waste time and they waste resources. All this effort put in will only come to zilch. I'm never going for missions anymore. I'm going to discourage everyone from doing it.

Sounds harsh, but definitely true in some situations. Not only in missions I would say, but also in the wards, in the calling to do Medicine.

On my side, the 'romance' part started very similarly. The passion for learning, for helping others, to heal them, to cure them, to better their lives. Nothing detered me, not even the doctors' advices which all ranged from: bad choice; 36 hour shifts; *shakes head*

'Reality' has set in. Studying isn't easy. Well to be fair I never loved studying. But still, the field of Medicine is just so big. There's so much to know and probing too much into one area leads to a deficiency in another area. It's just not possible to cover everything however hard one may try. But that's only secondary. Learning is a lifelong thing. Even the consultants are learning. Studying is important, but what about our morals, and this big thing about ethics?

The other day in one of the ward rounds, an MO was asking a consultant regarding medical futility versus the law. The discussion went on to talk about negligence, and quoting the consultant...

"There was this case about a guy who went to the doctor for an acute chest pain. The doctor did an ECG, found it was very fuzzy and could not read much from it and decided that the ECG is normal - he discharged the patient and tore up the ECG because it was of no use. The very same day, the patient died due to an AMI. The doctor got stripped of his license, not because he failed to pick up the AMI, but because he tore up the ECG - he had no prove he did an ECG for the patient. If he did not tear up the ECG, the court would have let him go.

You see, there is a difference between negligence and stupidity. If you do not do an ECG for that patient, you are negligent, your title deserves to be stripped. However, if you did an ECG, and the ECG shows a blatant ST elevation in a few leads but you discharge the patient saying there is a no problem, the court cannot charge you. They will just say, doctor, you can't read ECGs. You need more training. They cannot strip you of your title just because you are stupid. They can only do so if you're negligent"

The entire conversation.... I can't find words to describe my reaction. Shocked wouldn't be too accurate. Enlightened isn't right either. I felt like.... although I wanted to judge that consultant, I couldn't. He was very right because that's how the law is. But at the same time, how can a patient's life be lost simply because a doctor is "stupid" but not "negligent"?

Which brings back the thing about reality. Reality is such that nothing is ideal, nothing always goes as planned. Being skilled for the exams is one thing, being skilled in the important areas of service is another.

The scariest part of reality is, the possibility of it progressing to repulsion. I don't want to reach the point where I find the wards repulsive, find studying useless and worst still, find patients irritating.

Romance, reality, repulsion. Out of these, I'm supposing reality is the most applicable because, well, it's reality. What's most important is, integrating romance into reality and shunning repulsion from day to day. That's the ideal, but it definitely is by no means easy. Not with the environment around being so stressful and demanding in one way or another.

God, be my Guide. Be my everlasting Guide I pray.

I love you - sincerely, Jesus

Today was a great day because of how it ended - a meetup with CF comm 07-08 to celebrate Liz's birthday and a farewell for dear Skyler... A night of laughter and chatter over a buffet: what an amazing way to break the monotony of school :) Best part is, aunty Ros even joined us for dinner and treated us to yoghurt after that hahaha thanks aunty Ros =) =) It seems that the longer we move away from JC, the longer the intervals are for when we are able to meet up as a comm to catch up with one another. Thankfully, little has changed, not our character, not our maturity (lol), not even our valued friendship and hopefully, not our devotion to God either. Being in the company of them definitely is an outlet of stress, thanks CF comm, and take care Skyler!!

Well, the highlight of this post really, is about my trip home given by aunty Ros (many thanks for more than just the car ride :)). Most people are relieved of their stress and worries by pouring it out to the other party. Aunty Ros on the other hand, was able to minister to me just by speaking on and on about seemingly random things. Somehow, these random things were so relevant to the problems and struggles I was currently facing tonight - as if God was using aunty Ros to attend to my needs at such a perfect moment... I've always been amazed about how Godly she is and how God speaks to and through her so clearly every single day...

"... I'm not really a person who knows songs very well, but these words came to my mind one day: I am forever in your life, I'll see you through the seasons... and these words repeated another two times; I began to cry. I asked God, why is it that You are willing to follow me through my whole life? ..."

"... I asked her and found out these words actually came from a song which went: You are forever in my life, You see me through the seasons. But the words that I heard, they came from God, it went I am forever in your life - it was God speaking to me..."

"... then I realised, God is telling me one very simple thing. He keeps telling me, I love you, I love you, I love you..."

My past two posts were just part of my many many thoughts running through my mind in the past few days or maybe weeks. Well, human nature tends to get me analyzing here and there... I attempt to find solutions, explanations or whatever else for the things I face. Sometimes it works, most of the time it leads to more thoughts, more troubles - mostly self inflicted. Going to church, praying more - all seemed to be the right thing to do when doubts arise, but ultimately there just seemed to be this thing within me that wasn't too right.

Tonight I found the answer. I've been looking at so many things and missing the most salient point - I've forgotten that Jesus is repeatedly telling me: I love you, I love you, I love you.

What joy, what comfort all that brings. To just know that the Ruler of the Universe loves me. His unfailing love, the Agape love. Love that surpasses all logic and overcomes all barriers.

God works in strange ways. Sometimes He babysits us through, sometimes he puts us through trials. But ultimately, we know that through all this, He is forever in our life, He'll see us through the seasons, because He loves us. He loves us so dearly. And when these trials have passed, we come out better and stronger. What more can we ask for?

Thank You Father, for the CF comm, for aunty Ros, for the people around me, for the trials You've put me through and above all, for Your unfailing love

Compassion fatigue

Compassion fatigue (also known as a secondary traumatic stress disorder) is a condition characterised by a gradual lessening of compassion over time. It is common among trauma victims and individuals that work directly with trauma victims. It was first diagnosed in nurses in the 1950s. Sufferers can exhibit several symptoms including hopelessness, a decrease in experiences of pleasure, constant stress and anxiety, and a pervasive negative attitude. This can have detrimental effects on individuals, both professionally and personally, including a decrease in productivity, the inability to focus, and the development of new feelings of incompetency and self doubt - Wikipedia

Today in clinics, one patient came in and spoke these few words that woke me up from my half dazed state "... It's about time I start becoming selfish and think about myself"

She was a teacher in some primary school who had a progressive case of back pain, so much so that now, she is sometimes unable to even walk properly - needless to say, it affects her work. Her work entailed more than just teaching in the primary school. She held a motherly figure amongst the students, acting as a counseller for them, being there for them in all situations, regardless of school or non-school related incidents e.g. she was there for a student who's dad passed away - there for him to cry out because that student didn't want to cry in front of his real mum for fear of worrying or further upsetting her...

And right then, while she was sitting with a terrible pain in her back, her concerns weren't so much focussed on her terrible pain but rather they were on people around her: her family and her job.. or more accurately, her students. The doctor spoke of what was called "compassion fatigue". About how taking up roles such as counselling makes us feel good when we counsel the first or the second person. But what about the 20th person, the 200th person? Can we go on forever counselling these people without us ourselves being affected one way or another?

Today, the doctor ended his clinic past 7pm. Not so much because he had too many patients, but rather because he (very willingly) spent so much time with each and every patient, addressing their concerns and expectations and even going on to talk about their daily lives. I heard from his Medical Officer that he sometimes ends past 9pm. Surely he himself has been or one day would be a victim of this 'compassion fatigue'?

But the thing is, he definitely doesn't seem to be hit by this problem. If going home everyday around 7-9pm is part of his routine, while other doctors are going home before 5pm, surely there is this something that's keeping him going, something that drives him forward to maintain this compassion without being fatigued...

It so happened that this very night, I met my aunt in the wards who was extremely concerned about her mother in law, who was just warded. She was so worried that she even asked me for a "second opinion" about her condition. After a period of (attempting to) giving advice and reassurance, she was so grateful and so relieved just to have me around, explaining things to her - and that's even when she knows that I'm coming from a position that is far from a qualified doctor, and even possibly a misinformed person.

The rewards of this job is definitely great, fulfilling and immesurable to say that very least. But then again, there comes the balance between self and others. While this profession calls for a selfless person, is it really possible to uphold this position when fatigue simply sets in?

~~~Just another one of my random thoughts~~~

On a side note: My aunt ended with: I wouldn't really call myself a Christian, but this time I'm really praying to Him, hoping that He will see her through....

Talk about inspiration

Back in the comfort of God's Hand

The Godhead, Three in One and One in Three
Fully God and fully Man
Omnipresent and omnipotent
How can man fully understand Your Power and Your glory

The past month of clinicals have been rather easy going, but ironically, at the same time, just plain tiring. Add on the 1 week trip to Hong Kong + needing to catch up (without knowing what to), it was seriously exhausting to say the very least...

After a 1 month hiatus of going to Church, I finally went back last Sunday to the House of God. The feeling of familiarity, comfort and joy simply swept over me once again. I came to realise that the past month of exhaustion was largely due to spiritual emptiness within me, one that couldn't be fulfilled with leisure or rest. Once again, I was reminded of the importance of Christ in one's life and the centrality of Christ in all that we do.

This week in SGH wouldn't have been very different from TTSH if not for the fact that I've relived the joy of resting in God, finding renewal of strength and energy from Him. The smallest things could bring me a cheerful smile, while the toughest things wouldn't bring me down. Not forgetting, He has also blessed me with so many special moments repeatedly and that will definitely keep me going, however tired I may get. Once again, I've begun to recognize and count my blessings around me, giving thanks to Him who is faithful and giving Him the glory that is due.

"If I see, I will believe"

"Believe, and you will see"

Start of year 3

I recall that a few of my posts made when holidays end are always along the lines of: darn, school is starting, I want more holidays T_T

Well ok.. that still holds true hahaha but one thing I'm really thankful for these hols is that it has been one of my most fulfilling holidays in uni thus far. I managed to catch up with friends from JC and BB while going on trips/outings with uni friends. Time may have flown past, but the time that flew past brought precious memories that will stay. Indeed, God is faithful and blesses infinitely according to His grace. Those kairos moments that I posted about once or twice - I definitely had them. Those moments, however short, were immeasurably special to me and I believe they will be the times I look back on to laugh and smile in times of distress next time.

Well, the post has been rather rushed, coz it's 1am right now, I'm really sleepy and school is starting in <7 hours hahaha but just wanted to make a post before school starts, so here it is! Ok, off to bed for a much needed sleep...