With bated breath..

So tomorrow the Metro will finally be placed under General Community Quarantine (GCQ). While this relaxation of quarantine rules means that further economic activity can proceed, it also comes with a sudden increase in people on the road. Granted that more activity would be welcome in light of all the sacrifices people had to make while adhering to the rules of quarantine, but I can't help but be a little bothered by the fact that Filipinos are notorious for not following the rules, or at least trying to pakiusap their way out of everything. Its just sad that the Filipino mindset like is that of a privileged beggar:

"Kawawa ako kasi tinatamad akong maglakad pa ng onti kaya kailangan pagbigyan mo ako kahit tumawid ako ng wala sa tamang tawiran", or

"Dapat pagbigyan mo ako sa di ko pagsunod sa traffic light kasi nagmomotor ako, kaya nga nakamotor kasi walang pera bumili ng kotse", or even

"Kotse ka at motorsiklo ako, so dapat pagbigyan mo ako dumaan kahit na parang gago ako magmaneho, at kasalana mo kung magkabungguan tayo kahit na maayos ka naman magmaneho, dahil ikaw ang mas malaki ang sasakyan".

These are typical scenarios I encounter every day, even during this quarantine period. Nakakainis lang. Mahirap maawa kung alam mong kinukupal ka lang. Don't get me wrong, people in big cars are sometimes jackasses too. There's just so much jackassery to go around, but those jerks on two wheels are just too much!

Ok, traffic rant over.. A lot of people are making gloomy predictions about the outcome of this GCQ because lets face it, wala ka namang maasahan sa mga tao. Marami ang pasaway na di susunod diyan. These individuals would then probably spread the disease, and would render other people's efforts to properly distance, wash up, stay indoors, moot and immaterial. If we're lucky, these troublemakers would end up as casualties of the disease and we would be better off without them..

We at the frontlines continue to toil away, and we are faced with the potential of a larger wave that would come crashing down on everything we have worked hard for up to this point. Nakakapagod na, but we have no choice except to go on, because if we don't, then who will? So for those people, do what you like, flaunt your gross inability to follow the rules. I'll be waiting to see you on the opposite side of a body bag zipper.

The reintroduction of productivity

There's (hopefully) about a week left of the Modified ECQ  (Enhanced Community Quarantine) that was imposed here at the Metro. I would think that things have "stabilized" a bit. Relaxing the measures has helped a bit, as more people are now able to return to work, and the streets look a lot less lonelier.

Make no mistake, I still, and will always advocate for proper social distancing measures, frequent hand-washing, wearing of masks out in public, and other interventions that have stemmed the tide of this pandemic thus far. I'm not a fan of people going out and being stupid just because, and I feel that those people (who do something stupid without cause) deserve whatever infection they manage to get if they are irresponsible about it.

I'm just so tired of everything. Yes, as a front-liner, I do get to go out daily instead of being cooped up at home, but as what I have said in a previous post elsewhere, being on the front lines does not exempt you from being afraid for your life, or the lives of the people around you who are dear to you.. I have taken measures to make sure I minimize the risk I bring home to my family, even once doing laundry in the middle of the rain just so that my dirty clothes will be properly disinfected before anyone else gets to be exposed to them (I prepare a bleach soak when I get home, and we have an open laundry area). Despite all the disinfection routines I do, I'm still fearful because at the back of my mind, any lapse, any breach, any careless moment, could still hurt my family in ways I do not want to imagine.

Taking stock of the recent numbers that I find here, the numbers have appeared to have stabilized somewhat, and that is in spite of increased testing capabilities, so hopefully the numbers will be more reflective of the actual situation on the ground.

180 new cases in the face of an average daily increase of 200+ is not exactly a total win, but I'll take what I can.. Number of new COVID deaths is in the single digits.. Still not good since people are still dying, but I would say its' a little better than the peak of 50 mortalities last April 13..

Everyone is getting tired of this, especially the people at the hospitals.. I could see it in the faces of the nursing staff, the training fellows, and even the consultants. Despite their smiles, there is a palpable sense of weariness, and a desire to see the end of all this.. Our colleagues at other institutions have already taken strides to reopen their other services in order to serve the greater part of the population who are suffering from ailments other than COVID. These efforts are commendable and are very well thought-out and inspiring. We actually hope to be able to resume other services soon also, to introduce some hint of normality into our institution that has underwent massive changes in order to accommodate the patients with the disease. I just hope there isn't another surge, because even though we are still functional and healthy, a second wave could very easily break the spirits of everyone ...

I mentioned that I was cautiously optimistic, and still I remain so. I guess it helped a lot that I was able to enter a mall again to get stuff other than groceries. It was also refreshing to see other stores and stalls open again, and am hoping for everybody's sake that things will only get better from here on in.

Training has been going great, and we have streamlined certain new procedures as we adjust our way of doing things. These measures are not exactly the most efficient, but I guess getting something done is better than nothing. I just hope I will be able to complete the required census of patients before the training year ends..

Our center has the dubious reputation of being a COVID referral center, and it would be understandable if patients have apprehensions of coming in for consult. as things get better though, we can show everyone that everything is under control, and things could get back to the way they are (for the most part anyway).

Normalization?

By my estimate, its already about 7 weeks into the lockdown, with measures projected to ease up by the 16th.. As always, I should really be doing something more important, yet here I am, blogging away.. Hehe

Being a frontliner, I have the privilege of having a bit more freedom of movement, and I have been at the hospital on a daily basis since my official "start" of fellowship. I consider it to have been a stroke of luck that I chose to toss my hat back into the ring and train yet one more time. At least this move was able to secure me a small but constant source of income as the world eventually recovers from the pandemic.

It has been pretty interesting to say the least. I'm actually enjoying being able to hang around the faculty room with my esteemed mentors, giving mr the opportunity to casually interact with them and pick their brains. The best thing about it is that they consider me as somewhat of an equal now, except where the subspecialty training is concerned of course. I'm a sucker for a good storyline, and I'm loving the way all theses different batches come together, working towards a common goal. Its a lot of fun hanging out at the callroom, telling the newbies stories of how it was before the covid days, and what they would be facing once things eventually settle back to normal, whatever normal will mean in the next few months.

Its really fascinating seeing the composition of the consultant staff, myself included. It seems that our generation has finally bridged the gap in leadership, with the most junior of the senior consultants being around 10-12 batches our senior. I'm honored to be a part of this crew, and hopefully when I complete my training, I get to be a part of it again. Few people are presented with this unique opportunity to be a part of something great, even though I know I will always just be a bit player.

I find myself cautiously optimistic about Covid in the country. I really believe that the lockdown has indeed done its job, and that the numbers (at least in the metro) will soon be going down to manageable levels. I wish I could say the same about the provinces though. Places outside Luzon were a bit late in their lockdown measures, and presently we are seeing numbers peak in the Visayas... A lot of us yearn for a resumption of normalcy at the hospital, so that the training programs can finally start in earnest, and hospital operations can resume to serve patients who have nothing to do with covid. The necessary game-changer would be a rapid CoViD PCR test (*not antibody) that would allow triaging to the appropriate area (covid or noncovid) at the ER level. This would certainly save a lot of headaches and free up rooms filled with patients who are usually awaiting swab results which would then finally enable proper cohorting. It certatinly does not help that there is such a backlog of results at the laboratory, as the testing capacity has been overwhelmed by a deluge of tests (some of them unnecessary and are from certain agencies) that patient management is already compromised at times. Yes, I am bitter, but I'm sure you would too if you find out that the facility's scarce resources are being channeled to other endeavors outside of its' primary mandate..

Readers may have noticed the vitriol I have against the origins of the virus... Those statements were written in the heat of the moment and will not be revisited anymore, although they will not be retracted. I'm still pretty pissed that all this was allowed to happen due to stupid policies and whatnot. I just with they would outgrow their foolish (and selfish) ideology and just function as normal global citizens. I could go on and on about the country in question, but I decided I won't waste any more of my precious time.

Fellowship has been getting interesting. Thanks to the magic of video conferencing, we have been able to hold three lectures already, and has enabled participation of my batchmate who is still locked down in his province since the travel ban is still in place. Luckily, bulk of the initial necessary learning of the subspecialty deals with reading results from a screen. Hopefully s measures ease and the patients return, we would be able to wade deeper into the thick of things with patient interactions and interesting cases.

I'm actually a little confused with my status right now. I am recognized both as a member of the staff, as well as a subspecialty trainee.. I just hope I'm not overstepping any boundaries by hanging out at the "faculty room", but then again, our section head is part of the faculty as well. I guess I will just stay put until we are able to move into our temporary home, since the ward where our section is housed is still being utilized as a CoViD ward.

I really hope that the trend we are currently observing holds true until the end of the pandemic, so that we would be able to resume our state of normality, with adjustments ..

1 month in..

I changed venues this time around.

Am presently in the hospital for COVID, not as a patient though. Being a part of one of the teams of consultants that rotate every couple of weeks to see inpatients (and I guess because I am a member of the staff anyway), I have the opportunity to have some quiet time here in the office (or "faculty room" as I would prefer to call it).

It is now more than a month since the lockdown here in the Philippines. Tonight we expect the chief executive to make an announcement regarding the plan going forward.. Either there will be an extension or relaxation of lockdown measures currently in place. More draconian measures can also be expected for those areas whose citizens have been belligerently non-compliant, given the nature of this machismo-fueled administration.

Over the past weeks, we have seen how this virus turned the world upside down for everyone all across the globe. Schools and malls closed. Places of worship shuttered. Hospitals filled to the brim. It seems all too crazy to be real.. However, it is, and there is nothing to do but to survive and adapt to a new reality that would emerge once we get this pandemic under control, if ever..

A lot has already been said by experts about how to manage this going forward, so I will just limit this post to a number of opinions and observations I have formulated in the past days:

- The virus, despite being respiratory in transmission, seems to cause a lot more systemic damage than originally thought. At the outset of the pandemic when people were scrambling to understand the disease, everyone was focused on the respiratory side of things. Evidence is now presently emerging that the main problems encountered seems to be cardiovascular in nature, and treatments are adjusting according.

- What the hell is happening in the US? Its such a long fall from grace, from being seen as the protector of the free world to the current laughing stock, all because they decided to elect a selfish bully into office.

- China is the main culprit here. and they can't bullshit their way out of this. Evidence (which is being suppressed as we speak, because China) is emerging that the virus originated from one of the biolabs there in Wuhan, probably due to poor safety standards (because China?)? Therefore, I shall always be calling this virus as the China Virus, to give credit where it is due. They manufactured it after all. I once joked that that the only thing real that comes out of China are viruses. The communist government deserves the big part of the blame. It actively suppresses information that makes it look bad, brainwashed its people that China can do no wrong (even though it does a lot of wrong, because China), and has deprived the people of moral standards and basic decency through the suppression of religion (because communism). Having a religion, or at least a belief in a higher power curtails the basic human tendencies to be selfish and uncaring towards others (sadly, this reality holds true even in nations with religion though, but the apathy tends to be more systemic if you ban religion altogether).

- It will be a very long time before I trust anything that comes out of China ever again, however the leadership in this country appears to give them a backchannel entry because they are compromised already, either as spies, moles, or just plain greed. Never underestimate the the greed of the power-hungry..

This has been just one long rant, and rightfully so. I don't think there is anything good to talk about anyway..

Locked Down

Damn.. A lot can happen in a  couple of weeks..

We are currently about 1 week into the lockdown of Metro Manila which was brought about by the onslaught of the new coronavirus which originated in a wet market somewhere in China *why am I not surprised?).

It hasn't been pretty. Thousands have died in China alone, and although it is seemingly fizzling out already there (new case rates have allegedly bottomed out to ZERO for the past several days in mainland china), it is just emerging in other parts of the world..

An actual PANDEMIC.. I never thought I would see this in my lifetime..

Tensions are running pretty high, but I guess people have kinda adjusted to this new norm. In my part of town people have been generally compliant, although I'm not too sure in the less fortunate areas where people are often belligerent about following rules and regulations due to a poor understandign of the current situation.

There were some really crazy scenes during the leadup to this lockdown. I witnessed firsthand a couple of panic buying situations at the local supermart. We had luckily stocked up on other esentials just the week before, so I wasn't reallly pushing around a cart with a mile-high pile of tissue paper. :P It was soo errie. The mall where I had clinic was basically closed except for the basement level containing the supermarket, a bakery, the clinic, and a cafe (presumably for those senior citizens awaiting their companions who went for groceries). The fastfood was obviously closed. Since I had some lead time before my clinic hours, I explored a bit. The air conditioning was turned off, and the mall was deserted.. I had never seen that place so quiet, save for the occasional footsteps of random store staff checking on their places of work.

As the days went by, stricter measures were put into place, hence the second wave of panic buying. The entirety of Luzon was now under community quarantine, with travel out of homes strictly being monitored and implemented by the local officials, law enforcement, and armed forces. It has been peaceful thus far, with most of the battles being waged in the hallways of hospitals across the country. Being a respiratory physician, I find myself thrust into the frontlines of this new conflict, and I have to admit that I am afraid not only for my life, but more for the people I love.. But these are trying times, and I have to put up a brave front to do what I have to do because this is what I signed up for.. Make no mistake, there is a great temptation to just run away and stay huddled indoors amidst the safety among family. There could always be excuses, to take the easy way out. But this is not compatible with the reality on the ground..

I want to go on, but it feels so heavy already. So much sad news in such a short span of time..

What's with the Title change?

In the grim darkness of the far future, there is only war..

Some of you may be wondering why I decided to finally drop the Organized Chaos title for a more stylized handle. To the 40k fans out there, I'm sure its quite obvious to you that I have found the lure of the Imperium quite appealing. :P

Seriously though, I think it has more to do with growth.. I began blogging sometime before medschool I think.. I had initially started out here, then decided to take my talents to Multiply before it sold out and became this grotesque marketplace which was unrecognizable from the creator's paradise I once enjoyed being a part of.

Ok, so I just visited Multiply.. Its no longer this online marketplace, but a kind of trendy website catering to  the yuppie crowd.

So after the old Multiply shuttered, I found myself crawling back here to Blogger, with all my previous Multiply posts in tow. At least Multiply was gracious enough to allow us to migrate our content as much as possible to other platforms.

All through these three stages, the blog title has remained the same. I felt that all my musings and ramblings would seem totally random to the outside observer, hence the equivocal label which lazily excuses the lack of coherence of the content.

I guess I felt it was time to grow up, and te blog had to grow up with me. I noted that I am no longer slinging out random nonsensical rants. Make no mistake, I still rant a lot, but now my rants have acquired a certain sophistry and coherence compared to my sophomoric tirades of yesteryear.

Why a Warhammer reference though? Simply because I have found it fascinating in recent days, and I have been dicing deep into the lore of the Imperium of Man, as well as the Xenos that inhabit the universe of the 41st century, looked in an epic struggle  across millions of worlds and costing trillions of lives.

Pilyoship part 2

That went better than I expected..

I had an exam and interview a few days ago for a position in (yet another) fellowship training program. When I was way younger, I used to look with awe at those people who took training a few extra steps further. I mean, medicine by itself is already challenging, and residency is definitely not for the weak of heart. Sub-specialty training in is often a must among Internal Medicine residency grads who intend to practice in urban centers, and is no walk in the park either.

After I was done with fellowship training several years ago, the concept of going for further "sub-subspecialty" training seemed like such an abstract idea for me. Maybe its because I felt that I didn't have what it takes? Or perhaps after having been in training so long, I wanted to do things on my own terms? Or maybe because I was just tired of going through the entire process?

To give you an overview of the life of a person in medical training, here is a breakdown of the average years spent in education of someone who would eventually be a sub-specialist:

College degree - 3-5 years*

Medical School - 4 years

Postgraduate internship - 1 year

Residency (Specialty) Training - 3-5 years**

Fellowship (Subspecialty) Training - 2-3 years***

For the sake of simplicity, I chose not to include the INTARMED program popularized by UP Manila.

* College courses in the Philippines are 3 to 5 years in length depending on the university of enrollment and the coursework involved.

** Residency training ranges from 3 years for Internal Medicine and Pediatrics, to 5 years for General Surgery. Not included among these are the so-called "Straight programs" offered by some institutions wherein trainees have a lengthened residency period but are already qualified to take the sub-specialty examinations upon completion (common among the surgical sub-specs like Neurosurgery and Orthopedics).

*** Fellowship training for most sub-specialties like Pulmonology and Gastroenterology last around 2 years. Cardiology and Oncology fellowships are usually longer by a year. I have little idea about the subspecialities for other feilds, but I know Thoracic Surgeons have to take an extra 3 years after their General Surgery residency.

People may opt to take things one step further and pursue either a new sub-specialty (like one of my bosses who is BOTH a Pulmonologist and Oncologist), or delve further into the specialty by choosing a focused area of study to concentrate on (e.g. Interventional Cardiology, Hepatology (Gastroenterology), Sleep Medicine (Pulmonology). The length of this further training is variable, depending on the extent of training required.

From what I have seen, specialization can range from all-out fellowship programs lasting a year or two, to short trainings abroad (2 weeks to 6 months) for the emerging and newly-established fields of study.

Medical practice has been continuously evolving by leaps and bounds the past few decades, and the growth of specialization was inevitable, since it is necessary to keep up with the tremendous amount of new research and advanced techniques.

Having said all that, I made the decision to go and try for further training. Since my practice is in the highly competitive environment of the metropolis, its easy to get lost in the background noise and be considered irrelevant unless you have something that can help you stand out. ;)

I just hope everything eventually works out in the end.. :)