November 12, 2002

     I still remember the days back then, when I was just a humble "JI" trudging the halls in A-UP and C-UP and LPR. Always, with emphasis on "always" carrying a sphygmomanometer because my main job was to obtain vital signs. Of course, while doing other "scut work" like inserting IV’s or catheters, doing CVP cutdowns, performing occasional CPR’s and wound stitching or squeezing Ambu-bags continuously for hours because the hospital did not have enough Ventilators. And yes, while also trying to study a little bit and prepare for the inevitable scourging during the Morning report and rounds next day.

     Hopefully things have changed for the better since then, just a mere 8 years later. Yes, there was a lot of learning, not just head knowledge, but actual practical medicine. Plus: innovation, resourcefulness, and the bottom line of simply just doing what you must with what little resources are available. Surely, many who read this back home know what I mean, and still experience the same stuff in one form or another.

     What stuff? Like boiling needles, and washing gloves. Then knowing the art of "properly" wrapping these for autoclaving so they can be recycled (or boiled as the case may be). Or flushing used IV catheters (sometimes from a different patient) so a poor unfortunate recipient can reuse it. Yup, I hope a privileged Nursing or Medicine student is reading this now and appreciate the fact that he or she did not have to spend a substantial amount of his time doing the dirty, dangerous task of washing USED needles and gloves. God knows where they have been, or what they have touched and what microbes have contaminated them. Pity the unwitting victims who will get communicable diseases because of them.

     Sometimes, perhaps often, risks have to be taken because of financial constraints and neglect future possible harm for what is needful right now. It is actually a form of THE END JUSTIFIES THE MEANS. I hope that any sane doctor or administrator who knows about this and tolerates it will exert to the best of his or her ability to stop this appalling practice.

     How long and how much should an Intern, or a Resident, or a Fellow work? If a Consultant reads this, the answer would probably be "as much as it takes and as much as I want him to". Right. Because it is a tradition that the next batch needs to experience the same hardships you had. And it is for his or her learning anyway, right? The more cases they see or do, the better their skill and education becomes you may conclude.

     Baloney. This reasoning, to my opinion, is pure unadulterated professional pride and conceit.

     Now be honest, how many mistakes did you commit because you were just damn sleepy, tired or hungry? Now really be very, very honest and acknowledge how many patients you actually harmed or even killed because you were drowsy or exhausted? Well, it is not entirely your fault because you had no choice. It is your job, you are "toxic" that night, nobody else will do it, and your senior resident or Attending/Consultant is breathing down your neck. If you are familiar with Medical Ethics, this also redounds to "the captain of the ship" principle.

     In the Philippines, there are still no rules limiting work hours and shifts of residents and other medical staff. In the USA, there is a regulatory board for teaching programs to ensure against house staff abuse and overwork while assuring proper and adequate education. The rules are based on multiple large studies published in journals like The New England Journal of Medicine, Journal of the American Medical Association, and Annals of Internal Medicine among others. What did these studies conclude to cut to the chase?

     House staff that work more than 36-48 hour shifts or go on call/on duty more frequent that every 3 days or so commit more mistakes, medical care goes down the drain and more patients are harmed. In addition, they have a higher incidence of motor vehicle accidents (duh, sleeping on the wheel), have more social problems (domestic squabbling, drug abuse, depression, drop outs), and perform worse on the academic side. Therefore, shifts should be shorter, less frequent, and staff should get a REAL day-off or two every week.

     You may say, there are simply not enough residents. Then get more. No money? Find some. If we want better doctors and fewer dead patients we better act on this too. Or simply allow doctors to also "have a life".

     Oh well, it is just one of the litany of problems we have in the country which are all interrelated…..and nobody wants to lift so much a single finger.

     Let’s get back to needles and gloves.

     Hypodermic needles were designed to be used only ONCE. Studies have shown, that reusing them increases the incidence of local injection site infections and injuries. If you place the needle tip under a microscope you would see that it has kinks after being used twice and it is actually jagged by the third use. Sometimes, you can actually see that it is already crooked. You wouldn’t want your butt at the other end of that needle. Man, I will assure you that it will hurt a lot more! I have not even mentioned all the blood borne pathogens it can carry: HIV, Hepatitis B and C, malaria, Dengue, etc etc. The prior diseases also survive autoclaving by the way, so you can get Creutzfeldt-Jakob disease after routine "sterilization".

     Most gloves are made of latex, like condoms. Who recycles a used condom? The function is essentially the same: protection of the user or sometimes the other person. Latex breaks down after prolonged use, especially in a moist environment. Condom-users know this. It easily gets torn, loose or damaged. Gloves act the same. In fact, studies have recommended that they should be changed during surgery if it has been donned over 6 hours or so. Why? Because blood, sweat and water breaks its structure so that some viruses and later even bacteria can penetrate through. Autoclaving actually may do more harm than good. The high temperature can melt the glove. There have been numerous incidents when I found out too late that my glove actually had holes in them. Or that they contained solid debris (whatever it was). Of course, you would not want that while doing a rectal exam or operating on an undiagnosed AIDS patient.

     Enough belaboring these; it is just a random thought that I hope the folks in the nice offices in hospitals everywhere in the country would act on.

     If I were to suggest what needs to be invested upon for the hospital? First of all, PEOPLE. Good people, well trained, conscientious, educated and not hired or accepted due to nepotism or bribe. After this, all they will need are the EQUIPMENT AND MATERIALS TO WORK WITH. Such as a decent Laboratory, with a wide array of assays and tests with a fast turn around time; and a better Radiology department with scanners to bring us closer to the 21st century. Down to the basic stuff like IV pumps, hospital beds, Ventilators, and the humble needles, catheters and gloves. If only we can tap those NGO’s, rich foreign grants, and get the money from those unnecessary, exorbitant expenses from drug companies, it will redound to better healthcare and benefit the patient.

     After all, the patient is why we are in business. Or so I would hope to believe.

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     The author's e-mail address is at docdan1@pol.net.

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