Farewell (One Late Posting)

Seemingly the time has arrived for me to say goodbye. Yep my intership period is about to terminate. It seems almost unreal we've been here for nearly a year. But no matter what has happened along the way, good or bad, it's brought colors in my ordinary life. And I should be thankful for that. Trenggalek has definitely taken up a space within my heart.

First and foremost I thank Allah Almighty for His bless and everything He has granted upon me. Not to forget our supervising doctors of whom we're so respectful: dr. Malukyanto, dr. T. R. Liliek, dr. Fonyta for having been like our parents while we were away from home. To all doctors, nurses and staffs at Community Health Centre of Gandusari, wards and emergency unit of Dr. Soedomo Hospital (whom I impossibly mention one by one on this page) for having shared their expertise and been such a great help. What would my whole year in this town be without you?

Last but not least, my 14 previous colleagues who have been such great companies and have always been supportive and enthusiatic to carry on this internship year in Trenggalek. We made it at last! Yet we're about to open another new chapter of our life. Let's just continue to pursue our dreams, shall we?

posted from Bloggeroid

Dropping Your Brain On The Paperwork

I’ve heard many times people say that they have the best job in the world. To tell you the truth I’ve never really been able to relate mine to that kind of statement, not until today. In fact, today was supposed to be like any other days I’d lived before. I was one of three physicians in charge at the emergency unit this morning. I came an hour late for work because I felt like somewhat sleep-deprived by the time I woke up to the alert ring from my cell phone I set up regularly at 4.45 a.m. Besides I decided to go on foot to the hospital this morning since I realized I had been in my second week of physical inactivity. I missed my 60-minute Sunday morning jogging cos I spent a couple of weekend back at my parents’ home in Surabaya. 


By the time I arrived at the ER around 8 a.m. there were already four or five patients awating in the ward. There I went doing my job, taking history, doing necessary physical examinatons, then going back to my seat ready to rearrange the stories the patients told me on their medical record. This is inarguably my favourite part of the job, trying to rule out some differential diagnosis, thinking of all the possibilities to pave the path for establishing the most accurate diagnosis. I call it a creative process of dropping your brain on the paperwork. A process in which your academic capacities are put on test for real. A process uniquely by you that yields a result which sometimes leaves your signature, your flavor that makes you differ from your colleagues. Then, once the diagnosis is established, it’s not that difficult to administer the proper treatments to the patients. But truly this is among the most fulfilling part, it gives you a good feeling at the start and confidence along the recovery process of the patients. 

My Very First Time Using Defibrillator

Chains of survival

The title may sound corny or rather sappy, but the first time of doing something particular is mostly so memorable. This was a real scene that took place at the ER when I and a friend of mine were on call one Tuesday morning. Really just a couple of days after my ACLS training. So it was a real test for me, though I already saw plenty of similar case prior to the ACLS. I wanted to perfom a more algorithm-based medical intervention for ACS case like what I had been trained to.

This is what ventricular fibrillation looks like

So there come a 50-year-old man with a chief complain of having chest discomfort or much like chest pain. The pain was dull as if there were weighty thing being put on his centre of sternum and on area to the left of it. But he was unable to point out precisely where the pain was originating from. He also felt that the pain was somewhat referred up to his back. There was neither nausea nor vomitting, but he was having cold sweat. He was fully awake with GCS score of 15. Blood pressure 140/90 mmHg, heart rate 80 times per minute, respiratory rate 22 times per minute, temperature 35,6oC. History of type-2 diabetes, chronic hypertension, and dyslipidemia were all denied (but I was skeptical, just like House says: Everybody lies!). Signs and symptoms suggested that he might be suffering from acute coronary syndrome, but since it conveys a wide range of causes, we needed some more detail examinations. We set IV line access, giving oxygen through nasal cannula (NC). We run ECG test on him (which laterly suggests STEMI with wide anterior infarction) while giving order to the nurses to administer aspirin (to be chewed), clopidogrel, plus sublingual ISDN. Unfortunately before those medications could even be administered, the patient collapsed (mostly caused by unbearable pain). We advised an injection of 3 mg morphine, but in short he fell into cardiac arrest. No carotid pulse was palpable. Such a nightmare for both the family and healthcare poviders. I shouted to start the chest compression before I ran quickly to get the defibrilator machine which had been in its absolute dormant period for too long since nobody knew how to operate it. But not again after my ACLS training. I was highly determined to come all out this time. Once the defib machine was set, I ran a quick look using the padles. The ECG suggested a pulseless ventricular tachycardia (VT) which was an absolute indication to perform the electric therapy of defibrillation (the other being ventricular fibrillation (VF) and polymorphic VT (Torsades de points)). I gave him a 360 joule shock (since it was a monophasic defib machine) followed by 2 minutes of CPR and an injection of 1 mg epinephrine (following the VF-pulseless VT algorithm). After 2 minutes I ran another quick look, the ECG suggested normal sinus rythm and palpable carotid pulse. We assumed he already came to ROSC (return of spontaneus circulation). We were ready for secondary survey. We fetched a deep breath. Thanks God. Did it end there? No. The patient is losing his carotid again in just five minutes. The ECG read sinus rythm, so it was a PEA (which was an absolute contraindication of defib, the other being asytole). The chest compression was soon started following the PEA-asystole algorithm. After a few cycles it turned into VF again, I did the defib. No amiodarone was available in the hospital. So adrenaline kept being in use. It’s a drug than can boost peripheral resistance and increase the contractility of heart muscles. Then it turned into asystole over and over again until we decided to cease the long series of CPR of 45-60 minutes. We did our best, but our patient wasn’t granted a second chance. It should always be reserved for God's privilege.

Pocong Malam Jumat Legi

Jika saya boleh memberikan satu lagi julukan bagi kota Trenggalek, maka julukan itu adalah Trenggalek kota mistis. Malam Jumat 25 Agustus 2011 yang lalu agaknya akan menjadi salah satu malam yang akan selalu saya kenang dalam hidup saya. Bagaimana tidak? Malam itu saya melihat penampakan POCONG walau orang berkata bahwa dalam bulan Ramadan setan-setan dibelenggu. Entahlah. Yang jelas saya telah melihat dan mengalaminya sendiri. Singkat cerita, saat itu seperti biasa saya ikut solat tarawih berjamaah di masjid dekat salah satu SMKN di Trenggalek. Waktu menunjukkan kurang lebih pukul 19.45. Saat rangkaian ibadah solat tarawih usai, saya bergegas pulang. Hanya berselang beberapa langkah setelah keluar dari masjid, saya mendengar suara anak anjing yang belum bisa menggonggong (mirip suara burung juga sebetulnya). Secara spontan, saya menengok ke kiri-kanan untuk mencari sumber suara tersebut. Gagal. Suara tersebut masih terdengar. Lalu saya mendongakkan kepala. Dan di atap plesteran semen dari rumah sebelah masjid itu saya melihat bentukan mirip karung beras berwarna putih. Saya tidak terlalu kaget, hanya merasa penasaran. Saya kedipkan mata berulang kali sambil mengamati. Bentukan yang tadi saya kira karung beras itu bergerak-gerak. Ada tali pocong di bagian puncak. Sayang bagian muka terlihat hitam. Semakin saya pandang ke bawah makin nyata lekukan-lekukannya. Bahkan ada lekukan mirip orang bersedekap. Bagian kaki nampak tertekuk ke arah perut. Bentukan tersebut dalam posisi tidur miring. Takjub dan masih tidak percaya dengan penglihatan saya. Saya terus berjalan sambil tetap saya amati bentukan tadi sebelum saya akhirnya harus berbelok di ujung gang. Dan bentukan itu masih berada di sana.

Dalam perjalanan pulang, baru saya benar-benar yakin bahwa yang saya lihat tadi itu pocong! Terus terang saya tidak terlalu histeris sebab ini bukan kali pertama saya melihat penampakan makhluk dari dunia lain itu. Setelah saya hitung-hitung, ini kali ke lima sejak pengalaman pertama saya saat duduk di bangku taman kanak-kanak. Tapi pengalaman yang terakhir ini adalah yang paling sensasional. Saya sendiri tidak tahu faktor predisposisi apa yang saya punya sehingga saya memiliki afinitas yang tinggi terhadap hal-hal semacam ini. Entah.

C’est complѐtement FOU

Il y a deux jours qu’on s’est retrouvé. Un rendez-vous du soir dans un typique resto ambulant qui a, en fait, monté au bord du trottoir. Pas le meilleur que l’on pouvait trouver, mais ça va ok car le prix nous convient ;) On s’est discuté les choses qui sont arrivées derniѐrement. Mais, y a certainement une chose qui me rend un peu étonné. C’est un lieu commun de dire que les marié(e)s aiment commettre un adultѐre ici. Et bien, il me semble que cette petite ville est l'endroit le plus ouvert, le plus libéral, le plus accuelillant au monde (aprѐs les États-Unis????) en rapport avec les relations sexuelles hors de la vie maritale. A mon avis, c’est fou!! -Lestroisrebelles-

Being Handsome Versus Being Good-Looking: Which one do you find more flattering?

Kurang lebih satu jam yang lalu saya pergi ke alun-alun kota Trenggalek mencari sesuatu untuk makan malam. Saya menjatuhkan pilihan pada salah satu kios/warung kecil di sebelah timur alun-alun yang menyediakan nasi pecel. Kemudian saya duduk mengantri setelah meminta kepada sang ibu penjual untuk membungkuskan satu porsi nasi pecel. Lima menit berlalu dan saya beranjak untuk membayar dan mengambil pesanan saya. Tiba-tiba saya dikejutkan oleh suara dari arah belakang yang memanggil “Mas, mas ‘jenengan putrané sinten tho?” (terjemahan: “Mas, mas Anda putranya siapa ya?”). Ternyata dia adalah bapak berusia paruh baya yang juga sedang membeli makanan di situ. Dia terlihat begitu penasaran dengan sosok saya (hahahaha I felt funny somehow). Lalu saya jawab, ” Putrané Pak B***” (saya bergumam dalam hati: emang loe kenal bapak gue). Dia balik bertanya, “Pak B*** sinten tho?” “Anu pak, kula sanes tiyang Nggalek. Kula saking Tulungagung, nembe mawon dines ‘teng mriki” (terjemahan: “Anu pak, saya bukan orang Trenggalek, saya dari Tulungagung, baru saja berdinas di sini) , saya balas menjawab. Lalu bapak itu mulai berkelakar dalam bahasa Jawa yang kalau diterjemahkan kira-kira seperti: “Lha iya kok bagus (ganteng) banget , saya kok meragukan di Trenggalek ini ada orang sebagus Anda”. What the f***??!! For an instant I couldn’t believe my ears. Komentar orang ini cukup membuat saya malu di depan umum apalagi sang ibu penjual pecel dan penjual minuman di sebelahnya ikut-ikutan mengiyakan komentar bapak tadi. Duh. Saya langsung cepat-cepat angkat kaki dari warung itu. Tapi omong-omong kenapa saya merasa (atau saya yang gedhe rumangsa alias ge-er) semenjak saya pindah ke kota Trenggalek ini, orang melihat saya dengan pandangan yang tidak biasa, lumayan berbeda dengan yang biasanya saya terima di Surabaya. Sumpah saya ke-GR-an sebab saya merasa wajah dan penampilan saya biasa-biasa saja. Saya bukanlah aktor, artis, pesinetron ataupun pesohor yang biasa mereka lihat sehari-hari di layar kaca. Juga bukan politisi terkenal, mafia pajak atau koruptor apalagi. Jujur saya benar-benar merasa saya hanya lelaki biasa dengan penampilan yang sederhana. Saya merasa cukup heran jika ada orang yang menganggap saya menarik (Do I sound too naïve here??). Walaupun ini bukanlah kali pertama saya mengalami kejadian ini, masih saja saya merasa belum terbiasa. Pernah juga pada waktu kami diperkenalkan oleh kapus kepada para stafnya, ketika giliran saya memperkenalkan diri tiba-tiba beberapa staf nyeletuk: lho ini dokter apa peragawan. OMG, what the f***? Saya tahu mungkin mereka bermaksud bercanda, atau menggoda, atau entahlah, but c’mon could they just keep that thought for themselves. Why did they feel the urge to speak it out? It seriously made me feel awkward hu hu hu. If I were that good, I swear I’d pose naked for Cosmogirl magazine hahaha.

Mungkin ini waktunya untuk menyadari bahwa ada yang berubah dalam kultur masyarakat Jawa. Orang-orang Jawa yang sekarang bukanlah mereka yang dulu dikenal sebagai orang yang gemar memendam pendapat atau perasaan. Pesatnya kemajuan teknologi agaknya berhasil mengubah atau bahkan mengenyahkan sifat kekolotan itu. Dan saya rasa ini perubahan yang cukup baik, mungkin saya yang yang terlalu reserved. Tetapi apapun itu saya tetap bertanya-tanya pada diri saya sendiri, sudahkan cara pandang mereka terhadap dunia ikut berubah?? Berikan saya waktu untuk mengamati lagi. Salam hangat dari Trenggalek.

My Health Promotion Week

This week health promotions are on the top of the list of my daily routines. Today I was invited to the village hall in Jajar to help raise the community awareness concerning some diseases that have emerged lately in Gandusari. I came up with the idea of educating the audience about dengue fever and dengue shock syndrome. I find it necessary and still relevant to bring out this topic because we had some patients infected by this disease last week, even a young pregnant lady (including the baby in her womb) lost her life to the profound shock she'd been suffering. I feel deeply sorry for her.

The crowds --" Moms and their toddlers. I did need to level up the volume of my voice while giving my "speech"

A lane in the midst of sugarcane fields (up) and the road scene in the village of Jajar (below)

Une Excursion Au Bord de La Mer

The incomplete members of Agatha L to R: Bayu, Dewi, Ana, Rachma, Sharie, Thiwit, Age, Yoga, Me, Achmad, Ertsda

Le week-end du 28 février, nous, les médecins stagiaires à Trenggalek, sommes partis à la plage de Pasir Putih. Elle est située à environ 30 kilomѐtres du centre-ville de Trenggalek. Cela n’était pas justement la premiѐre fois que j’y vais, mais car j’en n’avais plus de bonnes mémoires, ce voyage m’a fait du bien. Il faisait beau le long du trajet de 30 minutes. Mais lors que nous y sommes arrivés, le ciel était un peu couvert. Quel dommage :’(

On s’est fait payer 5000 roupies de droit d’entrée. Nous nous sommes figurés parmi les premiers à mettre pieds sur le sable de plage. La plage n’est pas si longue, mais trѐs ravissante. Au loin il y avait plus qu’une douzaine de petites îles inhabitées. Aoutour d’elle il y avait beaucoup d’arbres de coco et de collines vertes qui nous donnaient l’impression qu’elle restait non affecté par l’exploitation humaine. On peut y voir aussi le vent faissant des vagues calmes qui pouvaient être fortes parfois. C’était magnifique tout simplement. Je pouvais sentir son éternité. Aprѐs avoir marché au bord de la plage, nous avons rencontré un homme qui nous proposait de faire un voyage en son bateau. Il était assez chѐre de louer son bateau, mais heureusement nous pouvions partager les frais. Alors nous avons passé 45 minutes en traversant la baie qui forme la plage. Nous avons pris beaucoup de photos!!! Asurément, je n’ai oublié pas de me faire prendre en photo ;) Nous nous sommes bien amusés en bateau. Nous profitions du beau paysage côtier. Le temps s’écoule lentement. À midi on a déjeuné dans un petit restaurant qui sert un menu superbe de fruits de mer qui était bon pour la santé et les papilles ;) La plupart de nous a demandé du thon grillé au feu de bois qui nous a livré une saveur délicate. Ça se vendait à 9000 roupies piѐce. Et puis nous avons continué notre excursion à la grotte de chauve-souris qui est la grotte la plus longe dans la région Asie du sud-est. On a dû payer 4000 roupies à l’entrée per personne. Pour y arriver, il faut traverser un petit pont suspendu sur un ruisseau. Aprѐs une courte promenade de 500 mѐtres, on peut voir la bouche de la grotte. Il n’y en avait pas beaucoup de lumiѐres mais cela ne nous a pas fait peur. Dans l’obscurité on peut toujours regarder de innombrable stalactites et stalagmites qui se présentaient sous diverses formes. C’était superbe. Dans la fin de l’aprѐs-midi nous sommes rentrés chez nous. Nous avons passé une journée trѐs agréable. Nous attendons nos prochains plans de vacances avec tant d’impatience. Au revoir!

P.S.: En fait, c’est toute la premiѐre fois que j’écris en français donc je crois que j’écris mal. Corrigez-moi s’il vous plaît, si vous trouvez des erreurs de grammaire. Je serai le bienvenu.

Idyllic sea side. Just a perfect temptation

The sturdy rocky cliff facing the ocean (up) and me posing at a corner of the road overlooking the bay (below)

La deuxiѐme partie: The Need to Nail Down the Support

Le 23 février 2011

Seems like I’ve been running out of inspirations to fill up my blog page these days. I’m stucked, frankly speaking, and it surely happens for some reasons. Today marks our second day to work at a community health centre (widely abbreviated to Puskesmas in Indonesian) of Gandusari, Trenggalek. On a été bien accuelli, but anyhow we can tell we’ve been spotting some unkind faces smiling around. But not all are detected, the list of those who deserve to be slapped may potentially extend. We should be more alerted next time. FYI, the list has had some lead figures’ name in it ha ha.

Aside from all the screwed up things, all is going well basically, all happy. The small group of 5 was laterly split up on a personal basis to run and assist the medical service at five diferent units, each for a week term. That’s how the rotation works. This week I’ll be working au cabinet médical (j’ai aucune idée comment exprimer cette phrase précisement en anglais, it’s kind of a GP’s consultation room). In it are 2 doctors and a nurse. The room is compact, but luckily it’s shiny. On average the daily patient visits revolve around 20-25. So I was partly relieved knowing this info he he. Most of the patients come with a number of diseases such as acute respiratory tract infection, non-dehydration acute diarrhea, hypertension, diabetes, gastritis, osteoarthritis, rheumatoid arthritis, dermatitis are on our daily menu. I felt somewhat funny cuz I nearly forget a series of drugs I had memorized the night before, you know most of the patients had multiple chief complains which led me to an utter confusion (as a newbie doctor he he) to pose the diagnosis. Thanks God I had dr.Mariana who helped me a lot with the art of prescription he he. She taught me also the drug combination to write into the prescription. That was way sooo refreshing. But shame on me he he.

During my last night’s shift with colleague, Achmad, we found nearly the same pattern of the diseases except for a case of CVA (a 60 something nan having difficulty to talk some 9 hours prior to her admission, BP 210/110, we found impaired 7th cranial nerve in form of labial palsy, weakness in left upper and lower limbs). We suspected her to suffer from hemorrhagic stroke. Since there’s none of diagnostic tools available in the centre and patient declined to be referred, we could only administer intravenously kind of neuroprotector which was actually insufficient. Shame on this fact. What bothers me often while working here is that the questionable use of AB in this centre. For example: a KID coming up with acute diarrhea would likely be treated with antibiotic(s) despite the absence of suggesting indications as such bloody diarrhea, mucous stool, diarrhea with seizure etc. So my biggest apology to all the paediatric professors, vos rѐgles ne sont pas valables ici. But all in all I’d suggest that the delusional use of AB here must be reviewed.

La premiѐre partie: Notes Des Médecins Stagiaires à Trenggalek, Le Déménagement

Sun rises over nearby hills in Trenggalek

Meet the gang,there are 15 of us. Fresh grads of Airlangga med school, adventurous, smart, cool, energic, loveable and low-paid (not jokingly said cuz we think it’s something to be proud of T_T). And this is Dian Prakoso, MD writing ;P
Since February 5, the East Javanese small town of Trenggalek has officially been a place I call home for a year ahead. Trenggalek is 186 km away from the provincial capital of Surabaya that equals some 4-hours trip by car. People might not have any ideas how much I really wanted it to be. I had waited for long to live separately from my mom and dad, and at last that day arrived this February. I couldn’t be happier. Trenggalek is at the very opposite pole of Surabaya. Both are simply incomparable in terms of the pace of development. Completely like heaven and earth. Trenggalek is very much a sleeping laid-back hamlet. The town centre is not supposed to exceed 2x2 km in dimension. Fringed by endless rice fields, nearly surrounded by hills and mountain, the town occupies an area of fertile valley making it naturally susceptible to annual floods. The worst of it took place back in 2007. To make the thing sound worse, people really need to have a proper insight that touring the town center after 7 pm is like attending a funeral ceremony. It’s nearly no signs of life you can observe at every corners during these hours, not even the townsquare that’s just filled with dozens of street vendors selling tasteless food. Mama mia. The rumours have it that the town is moderately haunted, but luckily we’ve not yet seen any ghost sightings here, not once. T_T

For housing, we decided to rent a quiet fashionable house not far from the town market. Only 6 out of 15 who’ll live in the house, the others go with their own preference for housing. Our new house was formerly resided by a local tycoon owning more than a dozen of jewellery shops scattering across East Java. For the rent we have to pay 9 millions IDR a year. We thought it was a good bargain since we knew our colleagues who got stationed in neighboring town of Pacitan had to pay some 34 millions IDR for a house shared by 12. By the time we set foot in the house, it was a complete mess. The floors and the walls are all awfully dusty. The ceilings are covered by spider webs, not to forget the missing lamp bulbs there and here and the dysfunctional water pump machine. It was like a wreckage that it needed tons of clean ups. But fortunately all of us were willing to give a hand and we started to work on them. All set by the end of the day, except for the water pump since we had to call the mechanic from the nearby town of Tulungagung. We got it fixed by the next day.

For transportation we brought here 3 motorcycles and a car all the way from Surabaya. Transportation is rather difficult here. The only way you can get out of town is by taking a bus.

Two days after we met some lead figures of the medical service in this town, but most importantly we got introduced to our dearest supervising doctors i.e. dr. Fonyta Sugianto and dr. Lilik Rahaju. They’re among the senior general practitioners at the hospital in which we’re going to work. They, just like everyone we’ve met here, are extremely nice, supporting, and helpful. They are the ones responsible for making this internship stay on the right track. We promise to carry on this program as well as possible in a hope not to let them down. We do love them both just like we love our own parents.

We’re split into three smaller groups of 5 to do the working rotations as follows: community health centre, out-patient unit, ER for 4 months respectively. We’ll start working by February 21, so for the time being we’re on our 2-week orientation period.

A road scene in Trenggalek, Jalan Soekarno-Hatta

Doing the errands in the traditional markets of Trenggalek (up) and another road scene, Jalan Kartini (below)