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Who are the FeLIPes?

We’re a newly-minted husband-and-wife team who got together because of our common interests in reading, writing, science fiction, history, traveling, collecting gadgets, watching movies, eating out, and all things medical. We both also like to surf the Internet, and we’ve recently discovered blogging, which we intend to add to our extensive list of shared pastimes.

PS. A special HI to our beloved family and friends, especially to those from PHC, CMC, SLMC, UP and UST. We wouldn\'t be where we are without you!

Through Thick and Thin

October 21, 2016
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A tracheostomized patient

I made my first home visit as a consultant today.

The patient was *Miguel, a hypertensive 57-year-old former architect who had been hospitalized for a stroke.  It was his second in three years.  He had somehow recovered from the first one with almost all his faculties intact, although he had been unable to return to work.  Fortunately, his wife *Nelly had been able to take up the slack through a medical supplies business; also, their kids’ ages ranged in age from fifteen to twenty-four, so they could at least take care of themselves.

And then, four months ago, Miguel was found unconscious in the bathroom.  His wife rushed him to the hospital, where he was found to have bled into the same place in his brain as the first time.  He was referred to me because he was intubated and unable to breathe for himself.  For two weeks, we tried to wean him from the respirator, but when we finally  extubated him, he destabilized within hours. We put his endotracheal tube back and I regretfully told Nelly that we had to have him tracheostomized (put a breathing tube through his neck).  She accepted the news stoically; after all, they had gone through the same process not long ago.

All in all, between various complications and infections, Miguel stayed in the hospital for around seven weeks.  Not surprisingly, the hospital and all of his doctors received promissory notes upon his discharge. I wasn’t really sure I’d see him or his family again.

And then a few days ago, Nelly made contact, asking for a follow-up appointment.  She said that they had tried to bring him to my clinic, but when they tried to carry him to their car, his BP dropped and he turned blue. Apparently, his autonomic functions were still unstable and posture-dependent. After this lengthy and sheepish explanation, she at last got to the point: would I consider going to their house instead? She would be happy to pay me extra for my trouble.

I was hesitant at first, as I didn’t really want to set a precedent, but I thought about how helpless Miguel was, and how desperate Nelly must feel, so I said yes.

When I arrived at their house, I immediately felt like I’d entered  a drugstore surplus store. There were boxes of gauze, surgical masks, and whatnot stacked everywhere.  Besides  the usual coffee table books or vases of flowers, there were bottles of alcohol and bags of cotton on the tables. The living room had been partitioned into two equal parts; the second had been transformed into a makeshift hospital room complete with hospital bed, suction machine, oxygen tank, and other accoutrements necessary for the care of a bedridden invalid. I was impressed.

Miguel looked thin, but otherwise seemed as healthy as could be expected.  His skin looked clean and moisturized. His nasogastric tube and trach looked well-cared-for. He had no bedsores that I could see. He had some whitish secretions, which his wife immediately suctioned right in front of me.  His vital signs were stable, and his lungs were clear. Again, I was impressed.

“I’m surprised that you’ve been able to do all this,” I commented offhandedly as I prepared the vaccines that I was going to give him.  Nelly shrugged resignedly.

“I hardly get any sleep. But the kids and I take turns, so I get a few hours here and there.”

I shook my head.  She did appear haggard and exhausted, and seemed thinner than I remembered. I couldn’t see how she could keep this up for months, much less years.  “And what is his level of activity nowadays?”

“Well, it’s a bit hard because his sleeping cycle has reversed.  But when he’s awake, he seems conscious and engaged.  He watches TV, follows us with his eyes… so we stay up with him even until early morning.”

I observed her face as she said these last few sentences, and her face was alight with love as she gently stroked his hair away from his face.  Her devotion was simply astounding. And inspiring.  Miguel was relatively young, and with tireless care, could probably live like this for decades yet.  And she seemed perfectly prepared to give it to him, to the extent of selling their much-beloved house (which he had designed) and sacrificing her own health.

I laid a quick hand on hers.  “You should take care of yourself more.  It won’t do your family any good if you get sick, too.”

After saying that, I suddenly had a eureka moment, and bent to scribble a prescription.  “Tell you what. Aside from your refills for nebules and mucolytics, I’ll give you something to make him sleepy at the right time. Let’s try to nudge his cycle back to normal so you can at least get a good night’s sleep.”

She gave me a tired smile of gratitude. “That would be lovely.”

I left that dark, lonely house feeling a little more aware of my own luck. There’s nothing like an in-your-face reminder to make one grateful for blessings that one often takes for granted.  At the same time, I was also thankful for the opportunity to make someone else’s life a little better. So as we drove away, even though I don’t really want to do house visits as a rule, I told my husband, “Let’s remember how to get back here. I have a feeling we’ll be returning.”

 

*Names and some details changed

 

 

 

 

A Willing Ear

October 25, 2016

She was in her late forties; a high-level executive, by her own admission. She certainly seemed the type; dressed well, in a crisp pantsuit and practical heels, with expertly applied makeup and minimal jewelry. Her tone was sharp and commanding, and her manner was brisk and businesslike. She spoke in short, succinct sentences, punctuating each salient detail with downward chops of her hands. I could easily picture her heading a board meeting, outlining projects and delegating responsibilities with that imperious voice. I think that she was deliberately trying to intimidate me, the obviously younger doctor, but I kept my face composed and my back straight.
The reason she had come, she proclaimed, was because of a productive cough that had come on the heels of a cold last week. It was stressing her out, inflating her blood pressure, and disturbing her sleep. I immediately felt on firmer ground.
“So, you said this cough is making you lose sleep. Did you notice if you cough more at night or in the very early morning than during the day?”
“No, I don’t. It’s the same all throughout. And I never said that it bothers my sleep.”
Ok. Back up.
“So, you’re unable to sleep because of…?”
“Stress. Nervousness. When I’m idle, I start thinking about what illnesses I might have. That my blood pressure might be going up. That I might be dying.”
I fought not to furrow my brow in perplexity. “So it has nothing to do with your cough.”
“No. I can handle my cough. What I can’t handle is my constant feeling of anxiety, of thinking so much about my blood pressure that I can’t sleep.”
I rubbed my forehead, because I didn’t think it would look good if I scratched my head. “Why are you afraid of your blood pressure going up?”
“Because it went up two weeks ago. I was freaking out over something, then I had to be rushed to the emergency room. My BP was 160/90.”
Which isn’t actually that high. But I didn’t say anything to that effect. “Do you have a cardiologist?”
“Yes. I saw her a few days ago. She said that my heart is fine, that I just needed some adjustment of my medications. My 2D-echo and ECG are perfect. All my laboratories are normal. She said that I shouldn’t worry.”
This time, I couldn’t hide my confusion. “So why are you worried?”
“Because I don’t feel as well as she says I should!” She looked as frustrated as I felt. “I feel jittery, out of sorts, anxious. I have palpitations, especially when I’m alone. I have headaches. I’ve gained weight. I feel hot and flushed, even when everyone else isn’t.”
Ok, I felt out of my depth, here. And we’d completely forgotten about the cough. I combed through her past medical history.
“Okay, it says here that you were hypothyroid, then hyperthyroid. What medications are you on?”
“Nothing. My endocrinologist says that I’m euthyroid now. Take a look.” She thrust a thyroid function test result at me, dated two weeks ago. Sure enough, it was normal. Okay, that was one theory out the window. Unfortunately, there didn’t seem to be anything else of note.
And then I noticed one little detail.
“You had your uterus and ovaries taken out? A TAHBSO, two years ago? For what?”
“A uterine myoma. We could have done something less extensive, but I said, take it all out. After all, I have three kids. It wasn’t like I needed any of it any more.”
A bell rang in my head. “And did your OB-GYN give you hormonal replacement therapy when you had this done?”
“No.”
I leaned forward and locked eyes with her. “And when did all of this—your anxiety, your headaches, your flushing—start?”
“Oh…around two years ago.” I actually saw her eyes widen when she made the connection.
“You mean…you think I’m just being menopausal?”
Bingo. “It’s a distinct possibility. ”
“Oh.” She stared down at her lap, then finally looked up at me with an expression of overwhelming relief. “Oh, thank God.”
“You’ll have to confirm it with your OB-GYN, of course,” I said, “but if she does, she might be able to give you something to make you feel better. There are lots of options, now.”
She shook her head, then grinned shyly at me. It was a startling change on her severe face. “Frankly, doctor, I’m just happy that you took me seriously. That’s why I was so defensive at the start, and I’m really sorry for that. The others that I went to thought that I was going crazy.”
I didn’t say anything, but she must have understood my questioning look. “I went to five doctors before you. Most of them said that I was imagining things. Some of them just gave me antidepressants or tranquilizers. One or two told me to repeat my thyroid tests, saying they must be wrong. All of them told me that I was working too hard.”
“Well, you probably are,” I told her sternly. “Regardless of what other illnesses you have, your job shouldn’t be so stressful that it compromises your health.”
She lifted her shoulders in a resigned shrug. “You’re right. I’ll think about cutting down on my workload.”
“Good, and now for the footnote.” I lifted an eyebrow at her. “Can we finally talk about your cough, so that I can fulfill my subspecialty as a pulmonologist?”
That got an honest laugh out of her, which I would have thought impossible when we first met.

The Problem with Raising a Bilingual Child

October 18, 2016

My eldest is almost five years old. He is ferociously precocious and whip-smart. He first started showing signs of a prodigious memory at the age of 18 months. By the age of three, he had already started reading and writing three-to-four letter words, and had even begun to understand the concepts behind Addition and Subtraction. Now, after having skipped junior kindergarten after a year of nursery, he is already in senior kindergarten, with plans to enter the first grade by next year. His spelling, grammar, and reading skills are probably that of a third or fourth-grader.

Academically, we have almost no problems with him, as he is actually eager to study and do homework (his present preoccupations involve learning about famous landmarks all over the world and memorizing capitals). However, his one big weakness is Tagalog (Filipino), and consequently, any subject taught in that language. And yes, that is supposed to be his mother tongue.

But it’s not. English was his cradle language, and we only started talking to him in Tagalog when he was about to start school. He’s been catching smatters from his nannies, but not enough to counteract his prevailingly (American) English way of talking and even thinking. These days, whenever we tackle Araling Panlipunan (Social Studies), I have to translate everything just so he can understand the topic. It’s not so bad when he can read the questions in his homework and quizzes, and he can understand some vernacular, but his comprehension falls apart when his teachers actually talk to him in the formal Filipino required for school.

It hasn’t actually affected his grades that much, but with the start of extracurricular activities in his year level, including quiz contests which his teachers have been all too keen to include him in, his deficiency has been thrown into stark relief. Yesterday, he was part of the elimination rounds in an Araling Panlipunan quiz contest involving Philippine historical landmarks, a topic which he likes. I spent an hour the night before reviewing him, even Googling pictures of each place so that he would be more interested. But…I translated each detail into English, as usual, which I probably should not have done.

If the quiz had been done in English, he might have placed, or even won. As it was, he scored a resounding zero, ostensibly because he could not understand the questions or even the directions, all given in pure Filipino. The teacher even told his yaya (nanny), in affectionate exasperation, “Brent is a genius, but he doesn’t do well in Tagalog.”

Tell me something I don’t know.

And yet, I’m not particularly worried. After all, the language that he is fluent in is the lingua franca of the world (at least, for now). And it’s not like I didn’t have the same problem when I was young. My cradle languages were English and Ilonggo (a Visayan dialect). I didn’t learn how to speak Tagalog until I was six, when I was already in the first grade. I remember some teasing (“Nene Bisaya”), but otherwise, I’m not aware of any enduring side effects. And I certainly learned how to speak Tagalog quickly and fluently enough from my classmates.

His yaya has already noticed that he knows more Tagalog now, after a year and a half of school, although he still speaks it with a American accent. And this little thing, strangely enough, makes me just as proud as any of his other achievements.

How about you? Have you, as a parent,  encountered this problem,  and how did you manage it?  

Miles to Go Before We Sleep

May 19, 2015

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A new hashtag is trending in social media, accompanied by photos of people sleeping anywhere, anytime, in the middle of whatever it is they are doing. Curiously, they are all of doctors or medical students snoring on textbooks, pillowing on half-filled-out charts, or even sprawled unconscious against a wall after grueling marathon surgeries. To those who haven’t heard of it yet, #YoTambienMeDormi (I also fall asleep) is the medical community’s answer to a blogger’s criticism of a resident passed out on a nurse’s station (at 3 in the morning).

Every clerk/intern/resident/fellow has experienced being on intermittent 24-hour call (referred to in the Philippines as a “duty”). It’s part of the job description. Anything that happens on his tour is his responsibility. So if there is any doctoring, documenting, explaining, comforting, etc. to be done, he’s the one who has to do it.

Those stressful, sleepless nights in the hospital are a gauntlet that all trainees dread experiencing, but once they’re over, we remember them with a mixture of relief (that they’re over), pride (that we survived them), and gratitude (because those were the times when we learned the most).

What most people don’t realize is that these supposedly 24-hour shifts often last much longer than that, and are hardly physiologic. For example, consider a typical day in the life of a pulmonary fellow-in-training; a person in his thirties who (if single) is probably still living with his parents, or if married, may have a young family in another province:

7:30-9:30 AM: Endorsement of inpatients (formal hand-off of responsibility to on-duty fellows)
9:30-10:00 AM: Breakfast
10:00-10:30 AM: Weekly Quiz
10:30 AM-12:30 PM: Start of inpatient rounds
12:30-1:00 PM: Lunch
1:00-1:30 PM: Presentation of service patients to consultant on deck
1:30-3:00 PM: Didactic/Journal/Subspec Conference
3:00-4:30 PM: Inpatient rounds with consultants
4:30-5:00 PM: Formal hand-off of ER patients to on-duty fellows
5:00-8:00 PM: Resumption of inpatient rounds with consultants
8:00-8:30 PM: Dinner (If you’re lucky)
8:30-12:00 MN: Conclusion of inpatient rounds
12 MN-5:00 AM: Possible window of “rest” while simultaneously fielding calls for admissions, referrals, troubleshooting, codes, etc.
5:00-7:00 AM: Morning rounds
7:00-7:30 AM: Printing of daily census.

This schedule means that a pulmonary fellow is expected to heed the beck and call of 60-100 inpatients (not counting those who come in at the emergency room) for 24 hours straight, while also trying to find time to go to the bathroom, eat, type up medical documents, study, make PowerPoint presentations, and conduct research studies. However, unlike other high-performance jobs where the person gets to go home afterwards, the from-duty fellow often has to stay until office hours the next day. At my institution, he would still have to accompany all patients for diagnostic imaging, do procedures such as thoracentesis or pleurodesis, and otherwise participate in other daily activities such as the quizzes or lectures. He would only get to go home at 5 pm the following day (and finally get to take a bath and change clothes, sleep in an actual bed without interruption, etc). This cycle is usually repeated every 3 days. For at least 2 years.

When I was a fellow, I would often fail a quiz if it fell on a from-duty day (because my memory by that time had already ceased to function), or I would doze off in the middle of a conference. (It was even worse when I was a from-duty clerk during our OB rotation at a government hospital. My batchmates and I often nodded off while talking to our patients. Literally in mid-sentence.) This phenomenon is so common and so understandable (or it should be), that fellows who succumb to sleepiness aren’t necessarily reprimanded. In fact, an essential part of the our quarters is a small room with a single bed where people can crash in if they aren’t doing anything. Because almost anyone–even doctors–will collapse if you keep them on their feet for almost 36 hours straight.

Even as a consultant, I still experience a mild form of this. Whenever a patient asks me for my cellphone number, I give it with a caveat: that they not call at ungodly hours (which they sometimes do), or misuse it by attempting to funnel an entire free consultation through text (which they OFTEN do). We try to do so many things in the name of service, but in the end, our minds and bodies are only human. And, as is so often forgotten, we have lives too.

Thus, the compromise is this: we, who put everything on hold for our patients, promise to uphold our obligations as well as we can, as fast as we can. But during the brief lulls that we are granted, we would hope not to be begrudged of a few moments of rest.

So please, before you judge or criticize the people who could be responsible for saving you or loved one’s life, try putting yourselves in their shoes first.

Behind the Doctor’s Mask

May 19, 2015

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This photo went viral a few months ago.  In it,  a southern California ER physician is grieving for a 19-year-old patient that he had just lost.  It struck a chord with a lot of people, primarily, I think, because it contradicts the stereotype that doctors don’t–or shouldn’t–show emotion.

But why shouldn’t we? For some reason,  there appears to be very little middle ground in this issue. Some people believe that health specialists should maintain a veneer of detached professionalism even if it makes us look cold. At the other end of the spectrum, some patients complain that we don’t make enough of an effort to understand how they feel. That we request frequent blood extractions without knowing how much a needle hurts,  or that we prescribe medications without realizing how much they cost.  The typical doctor comes across as an emotionless automaton, churning out orders and prescriptions that don’t take into account the patient’s (or relative’s) feelings and financial status.  

This is sometimes,  regrettably, true. A fraction of health professionals,  because of either a prior predisposition or a stress overload (or both), can only endure so much before their souls become callused, and they stop seeing patients as human beings.  Diagnoses replace names,  people are referred to as cases,  and deaths become nothing more than a statistic.

The most egregious example of this mentality that I’ve ever encountered is when I rotated through a government obstetric hospital during clerkship. Pregnant women were stuffed into the labor and delivery rooms like sardines.  The muggy air was redolent with the combined smells of fresh blood,  old sweat,  feces and lochia.  You could hear moans,  supplications,  and agonized shrieks at any time of the night or day.  Into this noisome stew,  babies were born left,  right,  and center into the trembling arms of young doctors who had been on their feet for more than 24 hours. It was hard enough for us,  rotating through  that purgatory for 1-2 months at a time.  And yet,  the midwives and OB residents had been working in such an atmosphere for years.  A lot of them had become inured to the mothers’ pleas for more anesthesia,  and to even worse forms of pain. 

During one interminable shift,  I delivered a premature fetus that was just 24 weeks old.  He was tiny,  with translucent skin,  an enormous head,  and hands the size of my thumbnail.  But he was still alive.  He kicked his little feet,  arched his back,  and made convulsive gasping motions as if struggling to breathe.  It was obvious that he wasn’t going to survive,  but I couldn’t stand by and do nothing. When I asked the closest resident what to do,  I was shocked by her casual answer: “Just toss it onto a nearby table.  It’ll die soon enough.” It was hard to believe that she was talking about a baby,  who,  if only given a few more weeks in the womb,  would have become a perfectly viable and healthy little boy.  Ignoring her,  I wrapped the fetus in a blanket,  gave him some oxygen via a face mask (which dwarfed his body),  and positioned him under a drop light.  Every now and then,  I left my post to check on him.  True enough,  he didn’t last an hour.  But at least I could console myself that I had made his few minutes of life a bit more comfortable,  no matter the resident’s smug,  “I told you so.” After that incident,  I could only pray that I would never reach the level of indifference that she obviously had. 

However,  not all health professionals act this way because they’ve become jaded or cynical.  In fact,  some of us care too much, and thus we try to detach ourselves from the situation just so we can do our jobs. It’s the suppression of empathy, not the absence of it; or sometimes, a deliberate dissociation between what we ourselves can tolerate and what we ask others to bear.  After all,  if we have personally experienced an arterial blood gas extraction,  would we order one several times a day? If we knew how painful a bone marrow aspiration is,  would we subject a patient to it before ruling out everything else? But if we don’t request for that blood gas,  the patient might develop life-threatening respiratory failure and die.  If we spend months tiptoeing around that bone-marrow biopsy,  we could miss the window of treatment for what would turn out to be leukemia.  It’s a fine line,  but someone has to walk it. 

It is estimated that before a doctor finishes training,  he or she manages to kill an average of three patients. This is a horrifying statistic, and one which we could possibly decrease by not letting trainees make life-or-death decisions.  But if they aren’t subjected to real scenarios,  they would not learn the significance of their actions,  or remember the consequences of their mistakes. Like in all things,  there is a trade-off to be made: a small number of lives to save many.  Or,  as mentioned,  we health specialists have to numb our capacity to feel, in exchange for the ability to think objectively in the face of suffering.  It’s ironic that in order to treat humanely,  we sometimes have to appear a little less human.

At least,  just until the end of the day,  after which we can finally take our white coat off and cry about that patient we had failed to save. 

By Dr. Irene Felipe, 05/19/15

Why I Don’t Care That You Think I’m Fat

May 18, 2015

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I am fat.  Or at least,  I’ve thought that for most of my life,  whether it was true at the time or not.  I used to be very hard to feed as a kid (my mother still recounts stories of having to follow me around the neighborhood with a loaded spoon),  but that stopped when I was about 10. Since then,  I’ve conducted an extended love affair with food.  The only 2 things I won’t eat are adobo (don’t ask why) and ampalaya (a kind of vegetable that’s too bitter for my taste).  I’ll eat almost anything else,  be it balut (fertilized duck egg) or an exotic cuisine I’ve never heard of. I also have an unhealthy predilection for junk.  I especially like potato chips and flavored popcorn. Unfortunately,  I’m not one of those people with bullet-train metabolisms who can eat anything they want without gaining a pound.  If I overeat,  it shows immediately.

The funny thing is,  I’ve caught more crap about it from my own family than from my peers.  Even at the peak of my “bullied” years in  school,  no one called me out for being overweight.  (I was more likely to be called a “weirdo”.  But that’s another article.) And yet,  I’ve had my own cousins call me a “pig” or “tabachoy” (fatty) when I was a teenager.  Tell me,  is being 5 feet tall and 100 pounds obese?  If so,  I wish I could be obese again.  Because I’m certainly much heavier than that now. 

When I was in college,  I actually got my weight down to 95 pounds by not eating rice and exercising for 2 hours a day.  Maintaining it was hard as hell.  Of course, my friends then started to call me malnourished,  so I gladly stopped,  and bounced up to 103 pounds.  In Med school and internship, I got by at around 105-110 pounds.  Was I fat then? Some people said so,  and they made me think so,  too.  But it didn’t seem to slow me down any.  I was into dancing, basketball, badminton, and table tennis. I joined the Glee Club, danced and sang at events, joined literary and quiz contests,  and even once represented my class in a school pageant. I got roses from 12 different boys one Valentine’s day.  They didn’t seem to mind that I was fat.

During Internal Medicine residency,  I was up to 110-115. Did that increase make me fat? Maybe.  By that time,  I’d been in two long-term relationships before meeting my husband.  None of them particularly harried me about my weight. When I got married,  I was at 112. And that was the last time I ever got below 120.

When I got pregnant with my first little boy,  I gained a LOT. Healthy women with a singleton pregnancy are usually encouraged to gain about 25 pounds. I gained more than 40. It didn’t help that in the 3rd trimester, my baby was found to be a little underweight on the ultrasound,  so my OBGYN encouraged me to eat more,  and to even take colostrum supplements.  Near the end,  I was round as a ball, heavy as an anvil, and so bloated with water that my heart developed a murmur and I almost fainted twice. My abdomen was riddled with violently purple stretch marks,  and my swollen feet ballooned from a size 5 1/2 to 7. My fingers looked like sausages.  I prayed that it was all worth it–that my firstborn would be normal.  And he was,  at 2.9 kilos.  When I learned that, I was filled with relief, and I didn’t even care that I would have to sweat the rest of the blubber off. 

I had decided to breastfeed/pump exclusively, which makes one ravenous, so I let myself go for a while; eating whatever I wanted, hanging out in maternity clothes even though it had been several months since I’d had the baby.  After a while,  though, my limited wardrobe choices started to bother me,  so I actively tried to lose weight. I cut down on the snacks.  I tried to eat just salad for lunch or dinner.  I exercised at least 30 minutes a day–using my favorite video,  Hip-hop Abs by Shaun T.  It took more than  a year to lose those 40 pounds, and I never did get back to my pre-pregnancy body,  but I was satisfied. 

And then,  just as I was reveling in my old “slim” self,  I got pregnant again. 

That was 27 months ago.  Since then,  I’ve regained most of the 40 pounds for the second pregnancy,  given birth to a 2.85 kg baby boy, lost 32 pounds in time for my brother’s wedding,  and gained back 15 pounds afterward… just because I could.  After all,  I’m a practicing physician, a wife, and a mother of two boys.  I’ve got nothing to prove.  I’ve resigned to the fact that I’ll never fit into my old clothes without a major (probably surgical) overhaul,  so I packed them away.  I still occasionally wear maternity clothes because I find them exceptionally comfortable,  but I’ve also bought new outfits in sizes that would have horrified me five years ago.  My feet have settled permanently into a size 7. I’ll have to resize my real wedding ring if I want to wear it.  I have a stubborn spare tire around my middle, arms and thighs like a wrestler’s,  and more cellulite than a seal.  Do these things make me fat?

Probably.  In the definition of our body-conscious culture,  certainly.  But being fat doesn’t automatically mean that one is gluttonous,  lazy,  or undisciplined.  It doesn’t preclude being sporty,  fashionable,  or popular.  I am Me despite my weight,  not because of it. 

And if I do decide to do something about it,  it would be my choice.   It might be because it’s the healthier option, and not because I care what strangers think.  Because I need an allowance for the third baby that we’re planning to have,  and not because I’m trying to conform to someone else’s standards. The reasons may be few or many,  but the important thing is,  they’re mine.

Ever since we got married, I’ve asked my husband almost everyday (and usually while scowling at a full-length mirror): “Papa,  am I fat?”
His usual response has been an honestly puzzled frown.  “Yes,  probably.  But you’re beautiful, anyway. And I like you just the way you are.”

He has unfailingly answered this (and with utmost sincerity,  I would hope), regardless of my makeup,  my clothes,  or my weight. And when I fret that he’s the only one who thinks this,  he gently asks me whose opinion should matter. 

He knows how to put it into the proper perspective, every time. 

The Trouble with Sean

May 9, 2015

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The patient,  whom I’ll call Sean, had a certain look that set off my warning signals immediately.  A homosexual male call-center agent in his late twenties, he was emaciated, pale, and panting even while just sitting there in my clinic.  He coughed intermittently,  but it was the dry,  non-productive kind. He had come in because of respiratory symptoms and fever for about a week,  and now,  it seemed like he couldn’t get enough air. 

It was the second time that he’d presented himself to me looking like this.  The first time was eight
months ago,  when I’d admitted him for a kind of pneumonia that only affects the severely immunocompromised.  I’d advised him to follow-up for additional laboratories and treatment,  but he never had. 

Now,  I gave him a stern look. 
“You were supposed to return after a week, ” I said. “What happened?”
He had the grace to look shamefaced.  “Work.  I got busy, and then I forgot all about it.”

I was actually surprised that he’d managed to stay away as long as he had.  Someone with an immune system as depressed as his shouldn’t just be treated,  but also given prophylactic medication,  which I’d never had the opportunity to prescribe. 

I examined him closely,  although I already had an idea of what I’d find.  His temperature, heart rate, and respiratory rate were all elevated,  while his blood pressure was borderline low.  I asked him to open his mouth, revealing his dry lips and furry white tongue. His skin was dotted by small abscesses, especially on the fatty areas like the thighs and buttocks. His lungs sounded clear,  but that didn’t necessarily mean anything. I got out my pulse oximeter and checked his oxygen saturation. 

Eighty-four percent.  The normal value is ninety-five to a hundred percent for most people. No wonder he was short of breath. 

“You need to be confined again,” I concluded.  “I think you’re coming down with the same kind of pneumonia that you got last time.”

He grimaced, but didn’t protest,  which told me just how bad he felt.  He was the kind of person  who tried to self-treat until he was almost too sick to drag himself to the hospital.

I hastily scribbled a set of orders and gave it him. “I’ll call admission to expedite the process,” I assured him.  “One last thing,  though.  Where’s the result of that test that I ordered last year?”

We both know what test I was talking about. The HIV test.

He avoided my gaze. “Um, I haven’t gotten the results yet.”

After eight months. I sighed in resignation. “Well, try to get someone to retrieve it for you by tomorrow. Because we’re going to need it for the Infectious Diseases consultation.”

Miraculously, he had the test result by the following day, when I checked him at his room. And the CD4 count (a measure of immunity), which the ID specialist had ordered, had also come back.

“This is why you keep getting sick with all sorts of weird bugs, ” I explained, pointing to his unbelievably low CD4 count of three from a normal value of above five hundred. “And this is the reason why it’s so low in the first place.” I pointed to the positive HIV result. “We’re going to resolve the pneumonia first, then the ID specialist will follow up with you for the rest of your treatment.”

A horrible thought struck me. “Have you been sexually active?”

Sean nodded, not looking at me (he had become very adept at this). “Yes. I have a partner. But we haven’t had relations in months. Not since my…rear started bleeding. And anyway, he hasn’t been feeling good, lately, either.”

Great. Just great.

“You need to get him to my clinic ASAP,” I muttered, thoughts whirling. “Does he know about what happened to you last year, or about your confinement now?”

No, said my patient, he didn’t. And apparently, Sean hadn’t told anyone else close to him, either. Not his parents, not his siblings, not his friends. No one.

My gaze slid to the closed door. Waiting outside was a bored-looking young woman whom Sean had asked to leave the room when I had entered. She had shrugged and left without a word.

“Who’s that outside?”
“Just a helper. ”

I watched him blow his nose on a piece of tissue, and drop it carelessly by his bed, where there was already quite an untidy collection. His sores and abscesses were now covered, but before his confinement, they had been weeping blood and fluid everywhere. Even now, there were dots of yellowish red on the sheets where the pus had seeped from his dressings.

And then I thought of all the people who came into frequent contact with him: his partner, with whom he could have been intimate in other ways; his two roommates with whom he shared an apartment and a single bathroom to cut costs; and his two siblings, who visited him there frequently. All ignorant, all not as careful as they should be. The entire situation was a disaster waiting to happen.

“Sean, ” I began delicately, “you have to tell someone. At least, your family and closest friends. So they can help take care of you, but also so they can take care of themselves. Because it has to come from you, you know.”

Too late, I noticed a crafty look taking over his expression. “You mean… You can’t tell them if I don’t want you to?”

I shrugged helplessly. “No.”

“In that case… ” He settled back on his pillow, looking more relaxed. ” I’ll ask my sister to come over later. But I don’t want you to tell her–or anyone– anything. At least, for now.”

It looked like my plan had backfired. In desperation, I gestured a hand over his bed, especially the strewn tissues. “Well, can you at least be more hygienic, especially when you’re with other people? You are contagious, you know.”

But he just nodded absently, the sally sailing right over his head.

I guessed that I’d hear more about that issue, and I was right. A few days later, a young woman named Marie came into my clinic, claiming to be Sean’s sister. In a point-blank manner, she asked about his diagnosis.
“Its pneumonia,” I answered. “Pneumocystis jiroveckii pneumonia.”
“I’ve never heard of it, ” she declared. “Is it an uncommon type, the kind that you can only get with… HIV?”

Ahh, the trap. “It is an unusual kind of pneumonia,” I said carefully. “But HIV isn’t the only thing that can predispose you to it. Other circumstances that depress your immune system can lead to it, like steroids, some cancers…”

She frowned, obviously not liking my answer. “But HIV is what he has, isn’t it? Look, doc, you can tell me. I’m his sister. I love him, no matter what. And so do his friends. We’ve talked about it. We have a fair idea of what he’s got, not that it matters. We just want the facts so we can protect ourselves. Unfortunately, I can’t get a straight answer out of my brother, which is why I came to you.”

I couldn’t think of a rebuttal to her argument. Because she was right. I had those same concerns myself.

But that wasn’t the point.

“Look, it’s not like I don’t want to tell you, ” I explained tiredly. “It’s that I can’t . There’s such a thing called Patient-Doctor Confidentiality. You may have heard of it. So unless he tells you firsthand…”

“… you can’t preempt him.” Marie rubbed her eyes in frustration. “Is that really how it works?”

I spread my hands. “Think about it. What would you do, if you were in the patient’s shoes?”

Marie pondered for a minute. “I guess I wouldn’t like my condition possibly being the subject of gossip, either,” she conceded reluctantly. She finally sighed and stood up. She still seemed stressed, but at least she didn’t look as if she wanted to strangle me anymore.

“Thanks anyway, doc. I’ll try to worm it out of him. Somehow.”

“Thank you for understanding.” I watched her go. Her visit had given me an idea of how I could get through to Sean. At least, I could give it a try.

The following day, I went right to the point after entering his room. “Sean,” I said, looking him straight in the eyes before he could turn away. “Why don’t you want to tell your friends? Or even your sisters?”
“You know why, doc.” He ducked and started picking at his blanket. “You know about the stigma of this disease. People will start avoiding me. They’ll find excuses not to touch me, or even be in the same room with me. I don’t think I can bear that.”
“They wouldn’t do that, not if they really cared about you, ” I argued gently. “Protecting your reputation doesn’t have to mean risking your health or that of your loved ones. They’ll understand.”
He glared belligerently at the floor. “How would you know that for sure?”
I paused for the coup de’grace. “Because they said so.”

Sean gaped at me. Quickly, I told him about his sister’s surprise visit to my clinic the previous day, and the conversation that had transpired. Initially, he seemed angry at her stubbornness, calling her “nosy” and “interfering”, but in the end, he was almost in tears.
“You don’t think my parents will disown me once they find out?” He asked in a small voice. “Or that my roommates will evict me? Or that my boss will–”
“Sean, ” I interrupted, “according to your sister, they already have strong suspicions about what you have. You’ll just be confirming it. The important thing is, they don’t care. Have you noticed any change in the way they’ve been treating you, lately?”
He paused for a moment, but I already knew the answer. I’d seen them: his two older sisters taking turns at his bedside; his roommates visiting with food and jokes; and a few of his officemates dropping by with flowers and get-well cards. No one acted disturbed or repulsed; if anything, it was Sean who held himself apart.

He apparently realized this too, and seemed a little happier. “I guess I can tell Marie.”
I gave a silent sigh of relief. It wasn’t a perfect solution, but it was a start. “Yes, I think she’d like that.”

By Irene Felipe, 05/09/15

Note: This piece is inspired by a true incident. Some names and details have been changed to protect the patient’s privacy. Unfortunately, that story is yet to be resolved to everyone’s satisfaction.

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