Tag Archives: ICU

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.

The Wedding

7 February 2013

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The young couple looks gorgeous that day. He looks impressive in his impeccable Marine Corps Dress Blue uniform. While she looks beaming in her gorgeous flowing white dress with a beautiful bouquet of flowers in her hands.

The minister was ready. The most important guests were in attendance and ready. The place was basking in radiant lights and ready. It was time for a wedding.

Many would dream to have their wedding in a big historic cathedral. Others would prefer in a more Edenic scene, like an enchanting garden. While some would choose a more relaxed yet romantic place, like an exotic beach.

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photo I took in a beach at Ilocos Norte

But the wedding that I witnessed did not happen in any of the above special places. Instead it happened in one of our mundane Intensive Care Unit (ICU) room.

Yes, you read it right, a hospital ICU room.

At least the room has a big window with a view of an old nearby church. At least the room was warm and bright, as it was gloomy and cold outside in that wintry afternoon. Not to mention that it was a very expensive room to be in. A day’s stay in the ICU is far more costly than a night in Ritz-Carlton Hotel in New York City.

The groom’s mother had been sick for a while. She had been in and out of the hospital for several months for a variety of medical problems. And now she got seriously ill and had been lingering and languishing in our ICU for about a month. She had been on mechanical ventilator and we were unable to get her weaned off of it.

The groom’s father had been sick as well. In fact, he was admitted also in the hospital and just got out a few days ago.

But the young couple wanted to commit to their vow to each other, whatever the circumstances may be. Perhaps they have been planning for their wedding for some time. The groom even came home from overseas where he was stationed. And I’m sure that the original plan was not to get married in a hospital. But you roll along with what life offers you. It must go on.

So in the presence of their parents and choice guests, in that cramped hospital room; there was no bright glare of church’s grand chandelier, but instead a glow of ICU floodlights; no wedding bells were ringing, instead intravenous pumps were alarming; no melodious birds were singing, instead the constant chirping of the ICU monitors; no sounds of ocean waves lapping on the sand, just the low hum of the ventilator: where the two lovers exchanged their sacred “I do’s.”

There is no such thing as a perfect place for a wedding. No such thing as a perfect day to get married. There is no perfect circumstances. Not even perfect couple. Just perfect love.

In the midst of sickness and suffering, when life hangs precariously in a dance between life and death, in a world of uncertainty and unclear tomorrow, love still conquers all. It always will.

May you all have a meaningful Valentine’s.

*****

(*This is the second ICU wedding I witnessed; read the other one here.)

Angel’s Wings

2 February 2013

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It was a dreary snowy day in January. I drove to the hospital with snow coming down and with strong blowing winds, that it was almost a blizzard-like condition. Unlike schools and other offices that can close down for a snow day, hospitals runs business as usual, with or without blizzard. Besides, I am in-charge of the Intensive Care Unit (ICU) that month. I got to be there.

I knew I had a very busy day ahead of me. I had 17 ICU patients to take care of, 5 scheduled bronchoscopy* I need to perform, and 1 new consult for hyperbaric oxygen therapy** I need to dive. It would be a long, long day.

Our ICU was bursting in its seams. It was the height of a “bad” flu season. We were always pressed for beds, and we had to juggle patients, sending them out of the ICU as soon as we stabilized them, only to replace them with more sicker patients.

Then during the course of that day, as if my plate was not yet full, I had 4 more additional admissions to the ICU: 1 coming from the operating room, a patient who had a cardiac arrest while in surgery; 1 coming from the medical floor, a patient who had received a lung transplant years ago and was now in respiratory failure needing mechanical ventilation; 1 patient coming from another hospital who had an advanced liver disease and was on liver transplant list, and now with fulminant hepatic failure; and 1 patient who was brought to the Emergency Room (ER) with fever and chills.

Since there was no more available ICU bed, the patient in the ER had to stay there, until we open up some beds.

That was when I went down to see the patient in the ER. I brought along the senior medical resident with me.

Our patient was in her 70′s. She was diagnosed with malignant melanoma several months back. Unfortunately the melanoma had metastasized to her bones and lungs. She had received several treatments including investigational therapy. In fact, she was involved recently in a clinical trial in Mayo Clinic, and according to them the drug seems to be working, but the study was discontinued and she stopped receiving the said therapy. Needless to say her cancer continued to advance.

Now she presented to our ER with a high-grade fever, shortness of breath, low blood pressure and worsening confusion for 2 days. I reviewed her labs and radiographic tests, and it was consistent with severe pneumonia. Due to her immunocompromised state (from cancer and chemotherapy) she cannot adequately fight the infection. She had an overwhelming sepsis and was in septic shock, a very serious condition.

I swiftly examined the patient, who was barely awake, confused, and was incognizant of her condition. After that, I approached her husband and introduced myself (even though my name and specialty was already clearly embroidered on my white hospital lab coat) and told him the severity of the situation. I gently laid the facts to him that she was indeed critical yet we will give her our utmost care, but mortality can be 50% or higher.

The patient’s husband silently broke down in tears. He told me that she was his best friend, his life’s partner, and wife for 48 joyful years. “Please take care of her and treat her as your own,” he stated submissively.

I politely told him that we will take care of his wife to the best of our ability. That’s when he patted my shoulders and said: “I know you will, I can see your angel’s wings.”

I paused for a moment. Never have I heard those words spoken of me before. I was really touched with his remark. I looked at him straight in the eyes as I respectfully and whole-heartedly thanked him.

I then quickly excused myself. Perhaps he noticed I have tears in my eyes too.

I am not sure I deserve the compliments (frankly, I received a chilly reception on my next patient), for I am merely human as anybody else. But it surely made me fly through a long and difficult day.

IMG_1954

(Photo of the hospital’s center courtyard that I have taken with my iPhone later that day. Please take note of my reflection on the glass window: I have no wings.)

* see related post about bronchoscopy here

** see related post about hyperbaric oxygen therapy here

The Letter

2 November 2012

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Dear Dr. (Pinoytransplant),

On July 12, 2012 you saved my life – and I’ll always thank you.

                                                                                    Kindly,

                                                                                    Mary Ann (last name withheld)

This is a letter I received a couple of weeks ago. As I read that short letter, I tried to think who Mary Ann was, and what did I do to deserve her gratitude. But I am really bad with names, so I had to look her up in our electronic medical records to remind me who she was. After reviewing the records, I remembered her clearly then.

I was the ICU attending physician that month. It was July, the deadliest month to be in the hospital according to a study*, let alone to be in the ICU. The reason July was determined to be the deadliest month, at least in the United States, is that it is the time when the newly minted physicians-in-training start their work in the hospital. And new physicians means, less experienced, and thus more prone to making mistakes. But there could be other factors too, like if it is a full moon, or if it is Friday the 13th, or if there is a solar or lunar eclipse. That is if you believe on those superstitions.

I know I was extra careful that time, and I was really supervising my medical residents (physicians-in-training) like a hawk, as I don’t want my ICU to be a part of the prevailing statistics. High mortality? Medical errors? Not on my watch. Or at least that was my intention. And there was even a Friday the 13th that month!

We were also very busy that month as I recall, averaging 15 to 20 ICU patients under our service in any single day. Then Mary Ann got admitted to our ICU. She had worsening lung infiltrates or pneumonia and deteriorating respiratory status. She underwent bronchoscopy (procedure to look directly into the lungs’ airways with a scope) and lung biopsy so we can determine exactly what was going on in her lungs. To make matters worse, she bled profusely after the biopsy due to her underlying blood disorder.

Our patient went into respiratory failure and was intubated and was kept on a ventilator for a couple of days. It was touch and go for a while (including that Friday, July 13th). However with methodical care, and her determination to get well, and perhaps also good luck (that is if you also believe in that) or plainly due to Divine intervention, she eventually improved. After five days of ICU stay, she was transferred out.

Mary Ann made a full recovery, and was ultimately discharged out of the hospital. She beat the odds, you may say. Definitely she did not become a casualty nor a statistics of July.

The kind of letter that I received from my patients, like Mary Ann, are few and far between. Most of the time, my ICU experience could be somber and downright depressing. With the current ICU admissions’ average mortality** of 10% to 29%, means a lot of deaths in any given day in my line of work. It is not really about the care (though that contributes), but more to the severity of their disease. And that can somehow get into you. Although I also have received a few letters from our patient’s family thanking me for the care I gave, even if their loved one had died. Those letters are more humbling.

So when I am feeling down, or when I start to doubt our efforts, or when I am feeling overwhelmed with the stress of the ICU, or when I feel troubled on how many death certificates I sign (see previous post here) - I have these letters to remind me, that it is still worth doing this.

Maybe I should laminate Mary Ann’s letter, and hang it on my wall.

*******

*study from University of California, San Diego, published 2010

**statistics from Society of Critical Care Medicine

Till Death Do Us Part

20 August 2012

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“I want to go home and take care of my husband.”

That was what Dorothy* said just shortly after we took her off the ventilator. She was an elderly woman in her late 70′s  who was admitted in our ICU after suffering a major heart attack. Her heart rate went berserk like a runaway train that we had to slow it down. She also developed heart failure, causing fluid to build up in her lungs like a dam, giving a sensation of drowning.

As she was extremely struggling to breathe spontaneously, we placed her on a non-invasive ventilator. This ventilator is like having a jet-fighter pilot’s mask strapped snugly in your face and then hooked to a strong blower machine, forcing air and oxygen into the lungs. This is similar to the machine that people with sleep apnea use at night.

Besides the cardiac and respiratory failure, Dorothy also suffered mild kidney and liver injury from the poor blood perfusion to these organs as her heart was like an overwhelmed central pump, barely sputtering to adequately supply its vital tributaries.

For three days Dorothy was on this non-invasive ventilator to assist her breathing. But with great care, supportive interventions and medications, she slowly improved. She improved enough that we were able to liberate her from the breathing machine. Now, all she just wanted was to go home, and be with her husband.

After talking to her at length, I learned that Dorothy was married for 56 years. A long time indeed. Her husband, believe it or not, was more sickly than her. She was supposed to be the healthy one of the pair. In fact, she was the primary care giver of her ill husband for many years now. She devotes her time and energy in taking care of him, so much so that she sometimes neglects taking care of her own self. Such dedication. Such love.

And now this happened. Who will take care of her husband now?

But Dorothy willed herself to get better. She was determined to get stronger. She will survive this heart attack. She will get over this congestive heart failure. She will recover from this respiratory failure. She will be going home to be with her husband once again.

The next day, Dorothy was out of bed and was sitting in a chair. She looks so good and was really doing fantastic. She improved so much that we told her that we were moving her out of the ICU, and if she continued to do well, she might go home in a couple of days. She was ecstatic.

This proves that many times it is really mind over matter. Our willpower can heal our ailing body. Our resolve can overcome our weakness. Our determination can make us stronger. We can will ourselves to get better. And in this case, love was the motivating force. Like some old songs would say “that’s the power of love,” and “love will find a way.”

Not too long after we left Dorothy in her ICU room, her daughters came. They came with a sad news. Terrible news! Her  husband – the one that she dedicated her life and strength, the one that she love in health and in sickness, the one that she willed herself to get well in order to come home with – suddenly collapsed at their home. He was dead on arrival at the hospital.

Two hours later, Dorothy was placed back on the ventilator. Life can be so cruel at times.

(*not her real name)

(**photo was taken inside the great hall of Salisbury House in Des Moines)

Puto Rounds

14 August 2012

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Sometime in the year 2000, in the heart of New York, New York. In the hallways of the intensive care unit (ICU) of Memorial Sloan Kettering Cancer Center, a world-renowned hospital, and one of the best cancer center of the world, if not the best. Five doctors – four were fellows-in-training and one young attending physician with a specialty in Critical Care – were in a huddle, making their rounds on the critically ill patients.

The doctors were scholarly in their discourse of each case, deliberating what the best management approach was for each individual patient. There was nothing really special in their rounds, especially given that it was a regular occurrence and practice in an academic center. Except that they were all speaking in Tagalog – deep in the bowels of New York City, a thousand miles away from Manila.

Of course English is the official language of the academe and of this country. And those Filipino doctors were discrete not to talk in their native tongue in the presence of other people. There were several other doctors-in-training as well as consultants of other races aside from Americans in that institution. But in this opportune time, with all of them Filipinos, they felt comfortable speaking in Tagalog. Who says Tagalog or Pilipino cannot be the language of the learned?

All of those young doctors finished their medical education in the Philippines. They came from different schools though: one from University of the Philippines, another from University of Santo Tomas, one from University of the East, one from Lyceum-Northwestern University  in Dagupan, and another from Saint Louis University in Baguio. That they  ended up in one place, at one time, is a happy twist of fate. And here they were all now, in an Ivy-league-affiliated hospital of Cornell University. Who said Philippine schools do not produce world-class graduates?

After a demanding few hours of rounding and working in the ICU, those Filipino doctors took a break. They did not go down to the hospital cafeteria for an american doughnut or for an English muffin. Instead they headed back to the fellow’s call room, and snacked on home-made puto (rice cake), brought by one of them. No one asked for dinuguan (blood stew) to complement the puto. I guess the gory sight of some of the ICU cases were deterrent enough to make dinuguan unappealing. So you’d think puto is only found in the streets and markets of the Philippines?

puto

Was the puto special? Does it have cheese on top? Or salted egg perhaps? Did only the Tagalog-speaking doctors eat the puto? Or did they share them to other people?Did the puto made the medical rounds noteworthy? Did the puto made the doctors more brilliant? Did the puto help cure the sick patients? Was puto prescribed to the patients to be taken at least once a day?

Is the puto even the focus of this story? I don’t know.

Twelve years have passed since those puto rounds. What has happened, you may ask, to those young Filipino doctors? The young attending physician then, is now the chief or Program Director of the said training program. One of the doctors after completing her training, went back to the Philippines, where she now practices her profession. She is also an elected congresswoman.

The other three physicians-in-training then, found their niche in different areas of the United States, where they are now specialists, involved in private practice as well as in some academic institutions.

How do I know this story as a fact? Because I was there. I was the one who brought the puto.

*****

(*image from here)

(**compliments to my wife for making the puto, and the story it inspired)

*****

Post script: This piece was later published in Manila Standard Today, on Oct. 2, 2012.

The Language of Grief

24 June 2012

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I was sitting in a consultation room of our ICU. I was having a discussion with the family members of one of our patients in the ICU who was not doing well. Not doing well is an understatement. On the brink of death may be more like it. With me were the cardiologist, our senior ICU resident, and the patient’s nurse.

There were several family members in attendance there in that room. Most of them don’t speak English, or understand very little of it, if at all. We were talking through the patient’s grandniece who speaks English, albeit with a distinct accent.

Our patient was a Cambodian man who collapsed at his home. When the emergency responders arrived he had no pulse and was not breathing. After gallant efforts to resuscitate him, which took them almost 30 minutes, they were able establish a heart rhythm. He was then brought to the hospital and eventually was admitted to our ICU.

We placed him on hypothermia protocol to try to preserve whatever brain function he have. This intervention is used in out-of-hospital cardiac arrest survivors as studies showed that this improves mortality and neurologic outcomes. The intervention entails lowering the patient body core temperature to 33-34 Celsius through cooling blanket and infusion of cold IV fluids.It also involves deeply sedating them and medically paralyzing them, while placing them on life support. This process is an effort to slow the metabolism of the body and thus prevent further ischemic injury especially to the brain. After 24 hours of cooling them, they are rewarmed, and sedation and paralytics are weaned off.

The moment of truth comes after the patient’s body is rewarmed. If the patient will show signs of recovery, they will wake up. If not, they will remain unresponsive or show signs of brain injury from hypoxia(low oxygen supply) stemming from the cardiac arrest. And that will be a very poor prognosis.

Sadly to say, our patient did not wake up. After rewarming, he remained comatose and he was even having seizure-like activity, a tell-tale sign of severe hypoxic brain injury. And that was what brought us to this consultation room. To tell the family the heart-breaking news and help them decide further direction of care.

After we presented the bleak situation to them, the grandniece interpreted for the whole family what we have said. What followed was back and forth discussions among the family members in their native tongue. Some spoke animatedly. Some in whispering tones. No doubt I was lost in their discussion as I have no idea what they were saying.

After anxious moments, one by one the family members started crying, some softly, some more loudly. I don’t have to guess what they were saying anymore. I don’t comprehend their words, but tears is a universal language. I understand it loud and clear.

After more minutes, the grandniece spoke to us, and stated that the family was in agreement, that they just want to have a Buddhist monk come and say a prayer for the patient, and then they will take him off all life support.

Not too long after we left the consultation room, a Buddhist monk garb in a traditional orange robe came. There were about 20 people who came and crammed in that small patient’s room. Usually our ICU regulation only allows 2 to 3 visitors at a time, but this was loosely followed to accommodate family’s needs. I heard incantations and prayers through the closed-door. Then this was followed by sobs and weeping.

Grief. It transcends cultures, religions, and language.

Postscript: The above article was published in Manila Standard Today on July 1, 2012.

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.

Teach? Just Let Me Sleep!

21 November 2011

2 Comments

I was on-call a few nights ago and I received a message from “Call-Transfer” at such an unholy hour of the night. I fumbled to reach for the phone in the dark and tried to shake myself off from sleep. It was a little past 1:00 AM.

“Call-Transfer” is our health-system call center (similar to the call centers that studded Manila) that handle all requests from other outlying hospitals and physicians to transfer their patients that they believe are so complicated to handle in their local institutions. These kind of patients they believed are better served in our tertiary, level-one trauma center, and academic hospital.

Most of the time, when I received these kind of calls they would like to transfer some kind of a “train-wreck,” a term we use for very sick patient with not just one but multiple problems. Usually they are intubated and on ventilator, or in critical cardiac failure, or in shock.

Frequently these patients will be fetched by our air-ambulance (helicopter), and would arrive after 30 to 45 minutes after I approved to accept them. Though almost 100 % of the time we consent for these transfers, except if there are no more available beds in our ICU. If the weather is too dangerous for the helicopter to fly, then they would be transferred by land ambulance and would arrive in our institution after about an hour to two hours depending on how far they are. Sometimes, we would receive a patient from more than 100 miles away.

I returned the call to the Call-Transfer and was soon connected to the Emergency Room (ER) of the outlying hospital. The ER doctor started to give me the history over the phone of the patient they are treating – a young volunteer firefighter who was fighting a brush fire for a few hours, and was brought to their hospital due to exhaustion, difficulty breathing and headache. My dreamy mind started to paint several different scenarios in my thoughts on why they would want to transfer this patient……..

Maybe the patient succumbed to smoke inhalation and was in respiratory failure and was intubated and required ventilator. Maybe he had airway thermal burns that requires me to do bronchoscopy (a procedure where a long flexible scope is inserted into the nose or mouth and down into the throat thru the vocal cords, and into the trachea and bronchial tubes, to directly visualize the upper and lower airways) to determine how extensive is the burn. Maybe he had significant smoke inhalation and suffered carbon monoxide poisoning and needed to be treated in our hyperbaric chamber (a pressurized chamber where patient is placed and subjected to 2-3 atmospheric pressure with 100% oxygen, like diving in a submarine, to eliminate the carbon monoxide in the body rapidly to prevent long-term neurologic sequelae). Maybe……

hyperbaric chamber

As the ER physician gave me more details of the history of the patient, it was nothing of the different scenarios I imagined. The patient was awake, alert and is not in severe respiratory compromise. In fact, he was even feeling better after several minutes in the emergency room with the application of supplemental oxygen by mask. His carboxyhemoglobin (carbon monoxide level in blood) is less than 10 %. A 20-25% or higher is dangerous and definitely need intervention, but less than 10% is usually insignificant.

I told them then, that I don’t think the patient needs to be transferred, and I don’t even think he needs to be admitted in the hospital. He just needed to be on supplemental oxygen for an hour or so and then can be released.

I was glad that I can go back to sleep and that I don’t need to leave home and drive back to the hospital. But before I can hang-up the phone, the ED physician told me that he was a senior resident, a doctor-in-training, who was moonlighting in that emergency room. He asked me what were the “teaching points” in this case.

“Are you kidding me? Do you have any idea what time of day it is?!!” Maybe that was my first thought, but that was not what I said. For I obliged, and was able to muster a few teaching points about carbon monoxide poisoning to this young physician even in my half-awake brain.

I know I was in that situation before. And I am thankful for all the teachers and instructors that gave their time and effort to teach and guide me. If it was not for them, I would not be where I am now. Now it is my turn to do the same. That is one reason I practice in a teaching hospital.

I laid awake for more than an hour afterwards and cannot get back to sleep after I hung-up the phone. Darn! So much for teaching points.

(*image from here)