Tag Archives: death

Bloody Sunday

2 April 2013

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Sunday morning. It was still dark outside, but I forced myself out of bed. Got to go to work.

I was on-call this weekend, and had barely 5 hours of sleep last night. And even those hours of sleep were interrupted by telephone calls. I was so busy yesterday (Saturday) that I left for the hospital before the sunrise and returned home late at night, that I never saw the sun outside. I rounded on 48 patients in the hospital, 21 of them in the ICU. When I came home last night I felt deflated, depleted, and defeated.

But today is another day. Maybe it will be different.

I started my ICU rounds again before the sun peeked above the horizon. My first stop was a 70-something year old lady that was admitted a few hours ago with gastrointestinal bleeding. I was informed by my resident that the patient is “crashing.” The GI doctor had already scoped her and found a big bleeding ulcer. She had received 6 units of blood already but continued to bleed. We just cannot stabilize her.

Only a few minutes have lapsed after I examined the patient and talked with her family, when she suddenly lost her pulse. “Code blue” (hospital code used to indicate someone requiring emergency resuscitation) was called and we started doing CPR. At least more than 10 hospital personnel came to respond to the code, and packed the room. Nurses, medical residents, respiratory therapists took turn doing the cardiac compression. It was fast and furious.

After about 15 minutes of resuscitation effort, her weeping son who was standing outside the room, and who had witnessed everything that transpired, told me to stop the CPR. Patient subsequently expired.

This is not a good way to start my day.

After offering my condolences to the family, I continued to the next ICU room. Patient was a lady in her 60′s with colon cancer. The cancer had spread almost everywhere in her body despite the most aggressive therapy. In fact she even went to Mexico last month to try “alternative” medicine for cure. But the cancer still progressed.

She currently was admitted with increasing shortness of breath, and was in our ICU for two days now. After work-up, her CT scan of the chest showed hundreds of cannon ball-like lesions in the lungs consistent with diffuse metastasis of her cancer. I told the husband upfront that there was really nothing else we can offer except for comfort. The husband, after making a call to his sons, made the decision to make the patient “comfort care” (a medical care focused on relieving symptoms and allowing the patient to die peacefully) only.

This definitely is not a good day.

The next patient I saw was someone I have been taking care of for several months for an auto-immune disease that had affected her lungs. Her lung condition had limited her severely that she can hardly tolerate any activity. I placed her on high dose steroids and she improved. She was doing well, enough to go to at least 2 out-of-state vacations recently. Unfortunately, being on steroids, which suppresses the immune system, made her prone to infection.

She got admitted in our ICU three days ago with a severe infection and was in septic shock. After a flurry of tests, we suspected that she has systemic fungal infection. Despite all our efforts (antibiotics and all)  she continued to “circle down the drain.” Multiple organs including her heart, lungs, kidneys, and bone marrow were failing. She was hooked to machines and medicines to keep her alive.

Her family, whom I came to know well, approached me after I examined the patient. They told me that she had expressed in the past that she would not want to “live” this way. In truth, they are just waiting for another family member to arrive and after that they would like to discontinue all life support. I told them that I will respect their wishes, and just to let me know when their family is ready.

This day is really becoming a bad day.

I moved on to my next one. Again, almost similar scenario. The patient had been in our ICU for more than two weeks now with respiratory failure that we have not determined the cause. We even performed a lung biopsy, but still no definitive diagnosis. After more than a week on the ventilator, he rallied and improved, and we were able to get him off the machine.

The patient remained in our ICU though as his condition remained tenuous. However, early this morning, he turned for the worse again, and we have to place him back on the ventilator.

The patient’s wife and son were eagerly waiting for me. After discussing with them the grave situation, they have decided as well, that the time had come to withdraw the support and transition to comfort care. We then took him off the ventilator. (He eventually died later that day.)

Not long after I left that room, I was called by the nurse that the other patient’s (the one with auto-immune disease) family were all here and they were ready. We discontinued all life support from the patient, and in few minutes, she was gone. The grieving family approached me once again, and thanked me for all my care. It is always humbling for me, when people are grateful despite the unfavorable outcome. The compassion we provide, sometimes is more important than the outcome.

I went on to see my next patient. He was a young man in his 30′s, whom we admitted last night after suffering a cardiac arrest. CPR was performed by his wife until the ambulance arrived. We placed him on “hypothermia protocol,” that is cooling the body temperature to 32 degrees C for 24 hours, to prevent further brain injury from low perfusion. He was chemically sedated and paralyzed, and was on mechanical ventilator.

After our initial work-up we found that his heart was dilated like a balloon, and was pumping very poorly. For such a young person, this was a horrible condition and carries a grim prognosis. His family was distraught, and was reasonably so. We got to give our best effort to help this man survive.

I looked at my list. Forty more patients to see. It will be a long arduous day.

I happened to glance at the window. It was already bright and sunny outside. The sun rays were being reflected on the glass windows of the nearby building. It is a beautiful spring day outside.

Life on this earth is a like a dew. It is so transient. But despite of all the deaths and the dying surrounding me, I still have hope. Hope that death is also transient. It is after all Easter morning.

Goodbye Ella Grace

20 April 2012

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Why does a song ends before it can be heard,

Why does a rainbow fades before it can show,

Why did you say goodbye before we can say hello,

We haven’t even embraced you, why do you have to go?

Why Ella Grace, oh why?

You came unexpectedly, and left more unexpectedly,

But you brought us expectant joy, even for so briefly,

You showed us how to dream again, and all the possibility,

That life indeed is wonderful. Yes, definitely!

Thank you Ella Grace, thank you.

We can never know your face, even how much we try,

We can only imagine hearing your laughter and your cry,

We wish to cuddle you close, and feel your beating heart,

A heartbeat that was snuffed out, not long after it start.

Goodbye Ella Grace. Goodbye.

We really don’t understand, but we submissively accept,

That you are not meant to live and be born on this earth,

But someday when all our tears and sorrows are taken,

Your mom and I will look for you, there in heaven.

We’ll see you, Ella Grace, we will see you.

*For all of you who shared in our family’s joy and sorrow, thank you.

** Written for my unborn child whom we lost at 7 weeks of gestation.

Time Under Heaven

22 January 2012

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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)

The Christmas Homecoming

17 December 2011

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He arrived with much fanfare. Clad in a brightly orange suit, with two escorts on each side. He made a jingling sound with every small step he made. People turned around and looked as he walked and passed through the hospital corridors, for it was an unusual sight to see.  But he did not mind their glaring stares. He came for a special purpose, and that’s what matters. He came to see his father.

His father laid in our ICU. He suffered an acute and severe bleed to his head. The bleeding was so extensive that he required a neurosurgical procedure to evacuate the large collection of blood inside his skull, and placed a shunt in his brain to relieve the high pressure, in an effort to save his life.

However despite of all the intervention, his condition did not improve. In fact, it even got worse. After the surgery, he had more bleeding and swelling to his brain. And no further surgery could fix or decompress the pressure that was squashing his brain. There were no “miracle” medicines that can be infused on him that would make him better. No further medical intervention left that could be done to save him. His condition was unsurvivable. Sooner or later, all the life-sustaining machines  hooked on him would be deemed worthless as he would be pronounced brain-dead.

Due to the grim development of events, the patient’s family were all in agreement to discontinue all life support. Though they had one request before that happens. They pleaded for the patient’s son to come before he dies. A son who had not seen his father for a long time.

In the past 10 years that I have been an ICU physician, I have signed for diverse medical and non-medical requests – a disability form for a patient who was critically ill, a leave of absence for a relative who’s loved one was in our ICU, a letter to the military requesting for a deployed soldier overseas to be permitted to come home to be with his mother in her last days, or a letter to the US consulate for a patient’s mother in a foreign country requesting for a visa to see her son, who was in near-death.

This time I signed a request for a detainee to be released briefly from prison, to visit his dying father.

And so he came.

The brightly colored clothes was not because it was the holiday season, but it was the standard issued jumpsuit from the prison. The jingling sounds as he walked, was not from trinkets or bells to announce some holiday cheer, but rather from the chink of the chains that binds his ankles. He brought no gifts as he came empty-handed, except for the handcuffs. There were guards that flanked him as he made his way through, and people watched and stared, but it was not a parade.

He was led into the ICU room where his father laid. Her mother who was at the bedside, cryingly welcomed him with open arms. It was an embrace of acceptance to their “wayward” son. Like a homecoming of a prodigal son, if you will. Yes, it was a sort of homecoming alright. A very sad homecoming indeed.

As the son stood silently beside the bed of his comatose and dying father, the tears began to flow from him. Prison, I supposed, did not harden him enough to be devoid of all emotions. If only his father can see his tears, but it was too late. Whatever demons he had in the past, and I don’t care to know, he was still human after all. Just like you and me.

Was the tears for his father, who he knew he failed, and who he would never see again? Or was the tears for himself, as he had caused his family such heartache and disgrace? Was it tears of painful loss and farewell? Or was it tears of remorse and repentance? Or maybe it was a combination of all of those reasons. Whatever it was, only he alone knows.

There will be no singing of Christmas carols, I guess, in his dark and lonely cell tonight.

Lost Sheep is Home

22 February 2011

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Since I started blogging a year ago, I have written in memoriam for friends and family who have passed on. It is not my intent to make this blog an obituary section. I know, I have also scratched the topic of death several times in my posts. It is neither my intent to be morbid. It is just that death is a real part of life.

Yesterday we learned that another brother of my wife had died. (One brother died 4 months ago.) He just turned 50.

He was known to be the black sheep of the family, the prodigal son, the lost sheep. But that was during his much younger years. As he became older and “wiser,” he returned to the fold and was found. It was ironic he said, that when he became blind (as his eyesight started to fail even at his age), it was then that he can “see,” and was not lost anymore.

With his life story, I am reminded of a famous hymn written by William Kirkpatrick: Lord, I’m Coming Home.

Coming home, coming home

Never more to roam;

Open wide Thine arms of love,

Lord, I’m coming home.

This time is very difficult for our family, especially to my mother-in-law, who has to bury his 2 youngest sons in such a short span of time. But it is reassuring to know that this lost sheep, had come home. Now he sleeps in the bosom of God.

Missing A Special Flower

5 February 2011

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A couple of weeks ago we visited an elderly lady in her home. We have missed her for a few months, as she had grown so weak to attend church anymore.

This is a woman that made us feel right at home when we first arrived and became members of a church here, in Des Moines. Even though we have been in the US for several years, we were always been a part of a Filipino congregation. In New Jersey, New York, Florida, and California, we have been attending church composed mainly of Filipinos. (We Filipinos wherever we are, tend to conglomerate, you know.) However, when we moved in Iowa, there was no such Filipino congregation, and thus we became a part of a church that is mostly white, with a sprinkling of other races, like us.

Whenever this lady would see us, she would greet us so warmly and would ask my kids to give her a hug, and would say for everybody to hear, “Here’s my beautiful family.” Of course it was so obvious that we were not related at all, just based on the difference in the color of our skin. However she made us feel like a real family. And without a real family in the area, that meant a lot to us. We then called her Grandma Dorothy.

Several weeks ago, Grandma Dorothy was diagnosed with cancer, and it was in its advanced stage. However due to her ripe age, she chose not to receive any treatment at all. She said that she had lived a full life and was ready to meet her Creator. And as the weeks passed, she became weaker and weaker.

During our visit with her, it was by chance, also her birthday. She is 97 years young. She may be weak but she still looks happy. She was sitting in a chair eating her lunch of soup and crackers. Her digestion was not so good anymore she said, but she still had room for dessert, as she finished a scoopful of ice cream. She was thankful for the flowers that we brought her and wondered how we knew that she likes yellow flowers. My wife confessed that we really did not know that she likes yellow, but she just picked this color since she likes this too.

Grandma Dorothy's flowers

Grandma Dorothy’s body may have been feeble but her mind was sharp as ever. She called us by our first names and reminisced the earlier days we had with her. She told us that our church is like a garden of flowers: some are roses, some are daisies, some are petunias, and pansies, and gardenias, and lilies, and lavenders, and daffodils, and irises and tulips. (To this I will add sampaguita, ilang-ilang, gumamela, kalachuchi, katuray and kampupot.) She said that every one is beautiful in their own right.

Today, we learned that Grandma Dorothy passed away around seven this morning. I guess, people just like flowers too, will fade away and die. But she surely let her bloom radiated so beautifully and her fragrance diffused so eminently while it lasted.

We definitely will miss a very special flower in our garden.

Pangarap sa (Buhay)Patay

30 September 2010

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Nuong nakaraang araw, dahil sa biglaang pagkamatay ng aking bayaw, ay napag-usapan naming mag-asawa kung ano ang gusto ko kapag ako ay pumanaw na.

Simple lang naman ang aking hiling. Hindi ko nais na ipag-tirik ako ng monumento. Hindi ko rin pangarap na mailibing sa musuleo. Wala rin akong hangarin na ipangalan sa akin ang isang kalsada o eskinita o kahit pa mabahong estero.

Gusto ko lang sana na i-cremate ang aking katawan at ang aking abo ay ibalik sa Pilipinas. Ang aking munting kahilingan ay isabog ang aking abo hindi sa Pasig River o Manila Bay, kundi sa baha. Oo sa mga binabahang lansangan ng Sampaloc, Manila. Hayaan akong magtampisaw muli sa tubig ulan (o tubig canal?), upang manumbalik at maging bahagi ng lupa na aking kinalakihan.

May isa lang pong problema. Mapapayag ko kaya ang aking pamilya, na sa imburnal ng Maynila ang aking magiging huling hantungan?

flooded streets of Manila (photo courtesy of World News Network)

Life is Fragile

21 September 2010

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I came home this morning from the gym and found my wife already awake and sitting in bed. It was barely 7 o’clock. Knowing that my wife is not a morning person, I sensed that something was wrong.

She was crying. Something was really wrong.

I then learned that she received the sad news that her brother passed away. He was only 44 years old. He was just a year older than me. His youngest child is just as old as my daughter. This news send shivers down my spine. Oh, the fragility of life.

My father died when he was 50. And with the passing away of my brother-in-law, this made me ponder on human’s mortality, especially my own. But instead of fearing how and when we will die, I think we should consider more of how we live.

Tonight, I’m hugging my kids a little longer. Or perhaps even let them sleep in our bedroom for the night.