This talk of Kara Mia, the ridiculous show from GMA7 made me remember a patient when I was a junior doctor in a clinic in the province.
I was fresh out of medical school when the local clinic contacted my family. They were our family doctor and because I was frequently sick when I was a child, my mother and I developed a good relationship with the doctor and staff. The doctor was getting old so he wanted a fellow doctor to lighten the load. I jumped to the opportunity immediately.
The clinic was the same as I remember it, and I remember it well. This was in the early 2000s. The doctor's main room was organized with several filing cabinets although he told me back then that we would digitize them with his brand new computer (which we did. He was surprisingly good with computers.) There was a comfortable recliner where I spent most of my childhood clinic visits sitting on, a lightbox where he checks the X-ray charts, and several stethoscopes. On the far end of the room, there was a mini lab where they could test urine and fecal samples. For more complex tests, however, the doctor still refers to our local medical laboratory.
Most patients who visit the clinic are simple cases of flu. But what I admire most about the doctor is how he would press for more details on each symptom for an accurate diagnosis. Every now and then, he would ask me for my diagnosis and I would feel like I'm in med school again. Of course, I would get them right all the time.
Another thing to note about the doctor was how he considered the financial standing of the patients. The consultation fees were cheap and he prescribes the cheaper medicines instead of the branded and more expensive ones. Out of three local clinics in our area, only ours would get long lines during clinic hours.
The more challenging ones were the repeat patients. After getting our prescriptions, following them to the letter, and there's still no improvement, it's time to think of zebras.
One of the popular sayings in the medical world is this handy diagnostic instruction: "When you hear hoofbeats, think of horses, not zebras." Horses are common while zebras are quite rare. In diagnostics, when you see a symptom, don't immediately jump to rare and novel diseases. But keep them in mind nonetheless.
For these patients, I would try to find the right diagnosis but the doctor would always remind me that we're a small town clinic. We are not equipped to deal with these types of disease. So we would refer them to the hospital located in the nearby city.
But I digress. You're here about the Kara Mia connection.
The patient's name was Ramon Cunanan. I will never forget the name. And I certainly would not forget his face. Or faces.
Ramon was suffering from a condition called diprosopus or craniofacial duplication. Unlike the fictional counterpart, this is a rare congenital disorder where parts of the face or the whole are duplicated. This disorder is not actually caused by the fusion of two embryos as in the case of conjoined twins. It is caused by abnormal activity of the Sonic the Hedgehog protein (Yes, that is the actual name). This protein signals the facial pattern during early development so when it malfunctions, it results in wide facial features, and rarely, face duplication.
The first time Ramon came to our clinic, it was very late in the afternoon when we were about to close up. I asked the doctor if he would still accept a consultation, he said yes, so I let Ramon in. When he entered, I didn't immediately notice his disorder. He had long, unkempt, and very smelly hair and he wore a hooded jacket. He seemed agitated, fidgeting his fingers or scratching his knees over his tattered jeans every now and then.
When we asked him what's wrong, he muttered "Nosebleed."
"Tilt your head so we could check your nose," I said. Trauma is the usual cause of nosebleed, but if he blew his nose too hard, it could destroy the blood vessels within. Ramon removed his hood but instead of tilting upward, he parted his hair and tilted his head to the left.
And then, we saw it. Another face looking at us with drooping, dead eyes.
If you looked at Ramon's face from afar, you would probably mistake this dark grey flesh for a birthmark. But when you looked at it up close, you would see the gnarled and twisted features that was very much like a decaying version of his actual face but isn't. Cotton was stuffed inside what looked like the nose of the face.
I told the doctor that only a handful of cases were written about craniofacial duplication and all of them were either stillborn or dead after a few weeks. "We have a grown human in front of us with the condition. We could write a paper about it!" I told the doctor.
But the doctor commanded me to diagnose and prescribe medicine. "Think of the patient," he said.
I removed the stuffed cotton and saw the coagulated blood. There were still some flowing but it looks like it has started to clot. "Did the nose always looked this bent?" I ask him.
"No," said Ramon.
"It's a broken nose then. Did you get your head bumped or something?"
"He told me to."
"Who?"
"Him."
The doctor and I looked at each other. "Does he speak?"
"No," said Ramon, gesturing to his temple. "But I hear him here."
"How so?"
Ramon hesitated. "Sometimes, when I laugh, he would sneer at me. When I am sad, he would laugh. And every night before I sleep, he would whisper things. I tried to smash my head against the wall to stop him. I want to sleep. But he would laugh anyway."
"Would you like me to refer you to a hospital?" said the doctor. "I have colleagues in a hospital in Manila who would want to treat you."
"The whispers?" said Ramon.
"No. I'm afraid we are not the right doctor for that. But they could check if they could remove your facial disorder. You won't have to pay. If you agree to the treatment and if you let us write about your condition, I'll pay for it."
Ramon kept fidgeting, muttering something incomprehensible. After half a minute, he told us that he will think about it. Meanwhile, I straightened the nose of the other face to stop the bleeding.
I still swear to this day that those dead eyes were looking straight at me.
When I finished, we gave him some pain medicine and a prescription for the bleed then sent him on his way. The doctor told me that he would stay in the clinic for a bit and that I could go home, so I did.
The next morning, there was grave news. The doctor was found dead in the clinic beside Ramon. Initial investigations stated that Ramon went back to the clinic an hour after I went home and strangled the doctor with his own stethoscope. Afterwards, the suspect, probably overcome by guilt, committed suicide by slicing his own neck with the knife. The police said the motive was probably a grudge related to the doctor's profession, basing it on the suicide note the suspect left:
"He made me do it."
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