Little Girl in ICU

She was sitting in one corner of the room. With big headphones on her ear, and with an iPad in her lap, she appeared to be preoccupied and was in her own little world.

She was a 6-year-old girl, with beautiful blonde locks, sitting in one of our ICU room. Her back was turned from the door entrance and was facing towards the window. But she was not our patient. Her father was.

A couple of feet away from the little girl was her father, lying in the hospital bed. He was half-awake and half-asleep. He was obviously in distress. Every breath was a struggle that slowly zap whatever energy and life remaining in him.

He was 33 years of age, and for the past 6 years had been battling testicular cancer. And I would say that he gave a good fight. A hardy and courageous fight.

Sadly to say, the cancer was winning this battle. It now had spread to his lungs making it more difficult for him to breathe. His CT scan of the chest which I just reviewed prior to entering his room showed hundreds of big and small masses scattered throughout his lungs. The cancer had spread into his brain too causing him severe headaches.

For the past several weeks he had been in and out of the hospital. He continues to receive chemotherapy, though despite of this the cancer continues to progress. During this present hospitalization, he had been admitted to the ICU twice due to problems stemming from the cancer itself or from the complications of its treatment.

As I entered his room with my ICU team, I spoke to him and his young wife who was in his bedside, about the grim situation. We spoke in low tones, almost in whisper, keeping in mind that their little girl was in the same room.

I relayed to them that in spite of everything we have done, we have nothing more to offer, but one. And that is comfort. Meaning, we cannot cure him or treat him, but we can at least make him comfortable. We can offer medications that can take the edge off from his suffering. Something to numb his pain. Or something to blunt his sensation of air-hunger. Something to lessen the agony as he faces the inevitable.

I recommended that we transition to hospice care.

The patient and his wife agreed, as perhaps they know as well that it was time. The wife silently cried, though not so much, trying to compose herself and trying to show strength so not to upset her daughter, who was oblivious of our discussions.

As a parent myself, I can only imagine the predicament my patient and his wife were in. Oh how we wish that we can protect our young kids from the harsh realities of life. Yet I learned that it was the patient’s wish to have her daughter in his room as much as possible.

As we end our talk, the patient’s wife asked me how we doctors can deal with this kind of situations without crying. I softly answered her, “No, we do.” Or at least I speak for myself. Maybe not in front of our patients, but doctors do cry too.

When I exit the room, I glanced at the little girl. I don’t have the heart to disturb her. She was still quietly sitting in her corner of the room. Her back was still turned away from the bed and from us. She still had her big headphones on. Still busy playing on her iPad. Sheltered from what was happening a few feet away, or so it seems. And at least for now.

Does she know that her daddy will not be able to give her piggy back ride anymore? Does she know that he will not be able to chase butterflies with her again? Does she know that he will not be there to teach her how to throw a baseball or how to shoot a basketball? Does she know that her father will not be able to comfort her anymore when when she falls from her bike and scrapes her knee? Does she know that he will not read her bedtime stories anymore? Does she knows that he will not be able to tuck her in bed anymore and kiss her goodnight? Does she know that her father will not be coming home?

She will.

And I hope she has enough memories of what a father’s love is.

*******

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Post note: Two days after I had the talk with the patient and his wife, he suffered a grand-mal seizure and became comatose. He died a few hours later.

(*photo taken somewhere in Grand Teton National Park)

More Than A Game

The 2014 Winter Olympics in Sochi is officially over. For the past two weeks it provided the world something to watch. It was an entertainment to some, a distraction to others, and an inspiration to many of us.

There were notable moments in that Olympics. One instance of spirit of sportsmanship for me was when Russian Anton Gafarov crashed hard during the cross-country skiing competition, but he still tried to finish the race with a broken ski. He was really struggling, until someone came to his rescue and replaced his broken ski. It was not his Russian team but the skiing coach of the Canadian team.

Or who can forget the crushing upset of the US by the Canadian in the finals of women’s ice hockey? The American team was leading all the way, but Canada made 2 goals in the last 3 minutes of the game to equalize, and eventually winning it in overtime.

Or maybe you were just watching what Tara Lipinski and Johnny Weir outfit would be. Besides their colorful reporting and commentaries on the sideline, they really were a fashion statement.

Being originally from the Philippines, one of the indelible moment for me, was just seeing a fellow Filipino compete in figure skating. Michael Christian Martinez, was the first Filipino figure skater, and even the first one from a southeast Asian country to compete in this specific Olympic event.  Coming from a country that never sees snow, just like the Jamaican bobsled team, he inspired us.

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Filipino figure skater

Last Friday, as I was making my way to the Endoscopy suite of the hospital to do my bronchoscopy procedures, I passed through the Radiation Oncology department. In its waiting room was a television that was showing the live action of the semifinals of US vs Canada men’s ice hockey game.

Of course we all know now, that Canada won that match. For the Americans, better luck next time. It was said that President Obama lost a wager of cases of beer to the Canadian Prime Minister. There was even a funny news item that the unofficial bet on this game, was that the loser got to keep Justin Bieber. Darn!

Anyway, as I passed through that waiting room, I stopped for a moment to watch the game. It was already 4th quarter with only a few minutes left, and Canada was leading 1-0. I watched with hopeful anticipation that something exciting would happen. But no more goals were scored, and Canada won.

As I was intently watching the game, even for a brief period of time, I happened to look around and observe the people sitting in that patient waiting room. One, was a frail woman on a wheelchair. Another one, a cachectic-looking man hooked to a small tank of oxygen on his lap. And then another one, a middle-aged woman with a brightly colored bandana covering her bald head.

None of these people were paying attention to the televised hockey game. They were oblivious to the exciting action on ice unfolding in front of them. They don’t seem to care about the battle going on.

Why? Because they have their own battle that they were fighting. A fight that was more than a game. The stakes were more than medals made of cold metals. Where losers don’t get another chance.

I hope they win.

(*photo from yahoo news)

Time Under Heaven

One Friday afternoon one of my partners signed out to me the patients in the ICU. I was taking over and would be going on-call that weekend. One of the patients endorsed to me was the patient in ICU Room 26*. Her story was quite sad, to put it mildly.

She was in her early 40′s and was diagnosed with a very aggressive type of breast cancer, several months back. She had underwent radical surgery, followed by radiation therapy and intensive chemotherapy. However, despite of all the exhaustive interventions, the cancer still proved to be more aggressive than the treatment. It continued to advance.

The cancer had spread to the lungs and pleura (sac around the lungs), causing fluid to accumulate  in the pleural space. It also spread into the pericardium (sac around the heart), also causing fluid to build up inside the pericardium. It had involved the liver and studded the peritoneum (lining of the abdominal cavity) as well, causing water to seep out into the abdominal cavity. In fact, the cancer is everywhere, that it was hard to imagine that she was still alive. Well, barely.

For the past couple of months, the patient had been in and out of the hospital, that she literally lives in the hospital than home. Due to multiple complications of the widely metastatic cancer, she had undergone several surgeries and procedures. She had surgery to put a pericardial window (made a hole on the heart sac), so fluid could drain out and would not drown the heart. We also placed  tubes on both sides of her chest to drain the fluids around her lungs to prevent her from suffocating. She underwent multiple drainage of the abdominal fluid as well, to decompress her distended, pregnant-like belly.

Several times she thought of throwing in the towel, and considered hospice care. Hospice is the type of care that focuses on comfort and palliation of terminally ill patients. In other words, it is a philosophy allowing a dying and suffering patient to pass on peacefully by letting nature takes it course. Hospice is no way the same as euthanasia, which is illegal in the US. Euthanasia is a subject on its own that I will not divulge in here, but suffice to say that I believe, is morally wrong.

But once she felt a little better she would change her mind and would like to go full court press, and be as aggressive as ever with the treatment again. She was tried on investigational treatment and was even referred to a top cancer center in the US, but had received the same disappointing verdict of “nothing else we can do.”

Now, she was transferred in our ICU for severe shortness of breath. She struggles, but still fights with every breath, clinging for dear life. Still hoping against hope, that somehow she would survive one more day or one more night.

My partner then told me, that if I have time, maybe I could sit down and talk with her, and discuss alternative options of management, like palliative care or even hospice, and the further direction of her care.

We have heard the cliché that it is not quantity but quality that is important. Perhaps you also heard of the adage that it is not how long we live, but how we live is what matters. I am a firm believer that living is different from mere existing. Alive does not always equates with “a life.”

With the modern medical technology nowadays, we can support a person to continue breathing and his/her heart pumping, even though “life” has long been sucked out of the body. Sometimes medicine, as a discipline, do interventions just because we can do it, but may not be necessary for the best interest of an individual. I believe that there comes a time that death should be received as a repose to the suffering and not always be feared as an unwelcome guest. For death is as natural as birth to all humans. There is a time to be born, and a there is a time to die.

The next day, as I made my rounds in the ICU, I was ready with my “heart to heart” talk with our patient. As I entered room 26, I was caught unprepared with the sight I saw. The patient was silently lying in her bed with her eyes closed. Her breathing was labored as she heaved with every breath. A boy, probably 7 or 8 years of age, whom I assume was her son, was sitting very close to the bed. The boy’s head was buried in bed, muting his sobs, as he leaned against her mother’s side, while her feeble hand gently strokes his head.  It was so heart-breaking to witness: a mother who was on borrowed time, and who was in much discomfort, yet still trying to comfort her son.

All the reasonings I have in mind, and the discussions I have prepared, went out the window. Who am I to say to that boy, that his mother’s caressing hand was not worth living anymore here under heaven, even if it just for another day or even for another hour. For that boy, it was still worth it.

I walked out of ICU 26, without uttering a word.

(* room number was intentionally changed for privacy)

Battle Scar

Cancer. That’s one word that the mere mention of it can bring shivers through the spine for most people. (And I will mention that word here several times.) Especially if you or a loved one is on the receiving end of that word.

As a medical doctor, I have tackled with that word as part of my work. I have diagnosed, treated, cared, and sadly to say, lost patients with cancer. With my subspecialty, dealing with deaths from cancer goes with the territory. Lung cancer is the leading cause of all cancer deaths in both men and women. Though the most common malignancy for men is prostate, and breast for women.

Even with my daily exposure to cancer, including my training at Memorial Sloan-Kettering Cancer Center, nothing prepared me, when it was my mother who was diagnosed with it. It was always just part of my job before, but now we were on the receiving end.

I was home in the Philippines for the holidays, after celebrating 15 Christmases in a foreign land, away from home. It was then that my mother informed me that she was noticing blood in her stools for several weeks. It could be just hemorrhoids, I told her, but we needed to be sure. So I scheduled her to see a specialist. After a diagnostic procedure, my mother was diagnosed with rectal cancer. It was 2 days before Christmas.

Colorectal (colon + rectal) cancer is the third most common cancer, as well as the third leading cause of cancer related deaths in both men and women. What does Former President Corazon Aquino, Peanuts cartoonist Charles Schulz, and actress Audrey Hepburn have in common? They all died from colorectal cancer.

Former President Cory Aquino

With the advent of recommended screening for colorectal cancer, the mortality from this cancer has declined. The screening includes, yearly fecal occult blood test (checking for traces of blood in stools), sigmoidoscopy or colonoscopy every 10 years after age of 50 (or more often if high risk), and the dreaded (at least from my stand point) digital rectal exam. These screenings help diagnose colorectal tumors in their early stage.

For people who have close relatives diagnosed with colorectal cancer, they may need screening colonoscopy much earlier than age 50. I know my close friend who is a gastroentorologist, had already told me to have one, but I have not heeded his advice yet. But I would (doctors are the worst patients, you know).

Advanced age, strong family history, diet high in fat and low in fiber, smoking, heavy alcohol intake, and obesity are all related to increased risk for developing colorectal cancer. My mother has the first two risks, that is age and genetic predisposition. There is nothing you can do about that, as you cannot stop aging nor choose your family’s genes (maybe in the future we can).

After further work-up and more consultations with other specialists, my mother underwent surgery to remove her cancer. And that was twenty months ago.

Currently she is alive and healthy, and still enjoying life. In fact, she is currently visiting us here in the US for a couple of months. Though she has a constant reminder of her battle from cancer – a permanent colostomy. Yes, caring for a colostomy could be a nuisance, but for a survivor like my mother, she regards it as a battle scar. A scar that she dutifully embraced and is wearing it with pride. For she fought…..and won.

O cancer, where is thy sting?

Making Things Right

“I just want to make things right.”

That was what my patient told me not too long ago. Wanting to make things right. Don’t we all? Here is his story.

He was in his 50′s, and he presented to the hospital with leg swelling and worsening shortness of breath. After initial work-up in the Emergency Room, he was diagnosed with blood clots in the legs and lungs (veno-thromboembolism). Serious condition.

His chest CT scan also showed a lung mass. After further work-up, which includes a biopsy, it was found to be cancer. Cancer in itself is a risk for developing blood clots. Bad prognosis.

After further more work-up, it was determined that the lung cancer was far advanced. It has spread to the bones, liver, and lymph nodes. Grim outlook.

During his hospital stay, his condition deteriorated and was transferred to the ICU.

I approached him as he laid in his ICU bed. Knowing the severity of his condition, I asked him about his “code status.” That is, what he wants us to do if in case he cannot breathe on his own, does he wants us to place a tube down his throat and have a machine breathe for him? Or if his heart stops, does he want us to shock his heart or pound on his chest and try to resuscitate him? Or, does he just want us to let him go peacefully?

There was a long pause before he replied, as he breathed heavily under the oxygen mask. “I want everything done,” he finally answered. “I want everything done, until I have done one thing. I want to get married.”

Get married? Did I hear him right? Is he of a sound mind or is he confused and hallucinating?

As he continued talking, I ascertained that he was very alert and not confused at all. I did not ask why he wanted to get married, but he explained to me the reason why. Perhaps he saw the quizzical look on my face.

“I just want to make things right,” was his reason. Apparently, he was living-in with his girlfriend for twelve long years. He wanted to make their union legal. This would make her girlfriend the legal decision-maker for him if he becomes incompetent. And she would also inherit his estate without questions, when he dies. But more so, he just wanted to show her how he loved her over the years, but did not quite made it to the altar. Now, he was “making things right.”

Two days later, there was a wedding ceremony in our ICU room. A bride, a groom, a chaplain, and a couple of witnesses. That was all you need for a wedding. Of course there was a gown too. No, not a wedding gown. A patient’s hospital gown. And it was the groom who wore it.

There was many well-wishers too, courtesy of the ICU staff.

The patient’s son was also present. I believe he was his son from a previous relationship, and he came from out-of-state to visit his very ill father. He was probably expecting to attend a funeral, but was surprised that he was attending a wedding instead.

A few days after the wedding, our patient’s condition improved that he was able to be transferred out of the ICU to the Oncology floor. Perhaps, getting married gave him hope and a different outlook in life, and willed himself to get better.

He was started on combined regimen of radiation therapy and chemotherapy. Hope springs eternal.

Two weeks later, his condition started to decline once more. He grew weaker and weaker. It became more and more difficult for him to breathe. This time, he told us, he does not want to be resuscitated if his heart stops or if he cannot breathe on his own. I guess, he already accomplished his one wish, and now he was ready.

Then one day, he quietly faded in the break of dawn. And he left a newly wed bride, a widow.

Cancer stumps hope. A so familiar scenario, sadly to say.

Yet love conquers all.

The Dying and the Baby Robins

It was late Sunday afternoon one spring day and I was on-call that weekend. Being on-call since Friday night, and after a grueling day of taking care of sick patients in the ICU, performing procedures, seeing consults in the wards, and after almost 10 hours of continuously seeing patients in the hospital that day, I felt so exhausted and mentally drained, and just wanted to finish my rounds and go home. My last stop will be the Oncology floor.

I entered the dimly lit room and saw the patient lying quietly in his bed. His eyes were close and his mouth was half-open with an oxygen mask covering it. His breathing was labored as his chest heaved with every breath. It was obvious he was silently suffering. He has lung cancer, and in spite of the best of medical care and technology, with rounds of chemotherapy and radiation therapy, his cancer continued to advance and now it has metastasized all over his body. He is one of those poor souls that I as a doctor have nothing else to offer, but sympathy and comfort.

I approached his bed and greeted him softly. I perfunctory asked him how he is doing though I know the answer to my question. I was surprised when he said “I’m fine”. Maybe his answer was perfunctory too, or maybe he was tired of telling the doctors all that ills him, knowing that we cannot offer him anything anyway, or maybe he knows something that I don’t.

As I was talking to him, I happened to glance in his window and saw something that stopped me in mid sentence. Just outside my patient’s room window was a tree with a bird’s nest sitting in one of its branches. It was less than 15 feet from where I was standing. I can clearly see three baby robins with their heads bobbing out of the nest with their eyes still unopened and with their mouth gaping, waiting for their parents to feed them. It was a fascinating sight to see to say the least.

“So you have seen my robins”, stated my patient, as my thoughts was drawn back to him. “Those hungry baby robins make their parents very busy”, he continued, his eyes were now open and his mouth now with a half-smile, as I sensed some excitement in his voice. Obviously he had watched those baby robins and somehow might have given him temporary joy as it diverted his concern from his own affliction.

After I examined my patient, I silently headed to the door and again glanced back at the window. The similarity and yet the stark difference of the sight hit me. Eyes close, mouth open – one prayerfully waiting for mercy, hoping that his misery will soon end as he pants for every breath; the other expectantly waiting  for sustenance as it begs to keep up its existence. One life is losing its battle and nearing its end; the other just starting its struggle as it begins its passage. And yet both will not pass without the watchful eye of the all-knowing One.

As a familiar hymn goes “If His eye is on the sparrow” (and the robins too), “and I know He watches me”….yes, even when I am going through suffering. Perhaps my patient knew this and found solace on this fact as I saw peace and reassurance in his face permeating through his agony.

Few days later, another patient was enjoying the view on the window with the baby robins…. my patient passed gently into the night.


Once Upon a Starry Night

During my medical clerkship rotation in UST, we had a patient in the Neurology ward, a girl named Melissa, who was about 7 or 8 years old. Her little body had been racked by illness, and every day she softly cries in pain,  “Tatay, nanay, ang sakit sakit po ng ulo ko” (Dad, Mom, my head really hurts). But in spite of her suffering she remained courteous to the nurses and doctors, always answers with “po” and “opo”. Her family is poor and they can hardly afford the medications let alone the ancillary tests needed for her work-up. Because a head CT scan cost a fortune during those days (and still is today), this imaging study was not immediately performed until the necessary paper works from the social services (SAGIP) has been approved.

I was on-call that night when finally, Melissa was scheduled to have the head CT. It was around 10 at night when we accompanied her to the CT suite. Since she was in the Charity division of the UST hospital and the CT suite is located in the Pay or Main Hospital, we had to take her for a little trip across the campus. It was a clear night and we took a shortcut across the parking lot instead of the covered hallways. While lying on the stretcher, Melissa saw the beautiful starry sky above us. She requested that we stop for a while at the middle of the open lot, so she can gaze a little bit longer on the glittery sky. And for a moment she forgot her pain while basking in the beauty of a starry night.

Upon entering the main hospital, the hallways were already empty and dimly lit. As we turned a corner we passed a statue of Santo Nino, which was flooded with lights, shining like a beacon in the dark night. Again Melissa requested to stop for a while in front of the statue so she can linger a little longer as she laid there in awe. “Ang ganda ganda po ng Sto. Nino” (The Sto. Nino looks so beautiful), she stated. It was a sight to see, a frail sick child tortured with disease, finds restful peace by gazing at the face of the Blessed Child.

In the CT suite, our worst suspicion became reality. Melissa’s head CT scan did not just show a brain tumor, but multiple tumors of varying sizes giving the appearance of a starry night. It was a death sentence for the little girl.

It was almost midnight when we headed back to the Charity ward. Melissa’s father, who was with us, was holding back tears, hiding his sorrow from his daughter. We were all silent as we walked our way back, with our heads hung low, except for Melissa who was oblivious of the gravity of her prognosis, and continued to marvel at the spangled sky.

When we arrived at the Neurology  ward, Melissa asked her father to sit with her by the window so she can again see the stars. They both sat there until her tired little body gave in to exhaustion and finally falling asleep. Since then, for a couple of nights, you will find a feeble child in the Neurology ward, sitting by the window, suffering in pain, but finding comfort at the beauty of the stars.

Starry Night by Vincent van Gogh

One morning, as I entered the Neurology ward, I glanced at Melissa’s bed. It was empty, and the mattress rolled up. She passed away peacefully into the night.

Looking back after many years, in my dizzying and hurried schedule, I feel that sometimes, I need to stop for a while. Perhaps gaze up into the sky. Appreciate the small things that I have been taking for granted. A beautiful sunrise, a warm sunny day, a sincere smile, or a simple “thank you” from one of my patients. Perhaps I should see the world through the eyes of a child like Melissa – to see the beauty of this world instead of its difficulties; to see the faint light of the stars instead of cursing the dark night.

I was in deep thought when I was interrupted by my son, “Daddy, come outside, look at the full moon”. I cannot miss this. I have to go.