The Dead Speaks

Part of the benefits of a physician practicing in a teaching hospital is that there are regularly scheduled academic conferences and meetings where you can attend and learn something.

This morning I attended the Medicine Grand Rounds which was a clinical and pathological presentation of an interesting case.

A senior medical resident talked about a woman admitted in our Intensive Care Unit several weeks ago, who came in very ill. Her condition deteriorated quite rapidly that she died in less than 24 hours after admission despite of all the efforts to save her. An autopsy was requested from the family, to know what caused the patient’s demise, and in addition it was felt that the information from it would help us care for future patients.

After the history and the hospital course was presented, the Pathologist revealed his findings. He showed pictures of the gross and microscopic features of the autopsy. He then gave the verdict on the cause of death. And it was something unexpected. At least for me.

For all the medical specialists, it is the pathologist that always have the correct and final diagnosis. When I was still in medical school, which was more than 20 years ago, I have heard this saying:

“Internists know everything but they don’t do anything.” (Meaning internist like me have all the knowledge but don’t open up and explore the patient to intervene.)

“Surgeons don’t know anything, but do everything.” (Meaning, even though they don’t know yet, they open up and explore the patient to find out.)

“Pathologists know everything, and they do everything, but it is too late.”

Though in fairness to the surgeons, nowadays, with the advent of all the high-tech imaging modalities, like CT scan and MRI, they almost always have all the information they need before they cut open the patient.

I would say that part of a doctor’s learning is from the morgue. In fact, when we have a patient that died and we were granted permission for an autopsy, I make it a point to have my medical residents rotating with me, to come down to the morgue during autopsy and learn what the findings of the pathologist were. I think this is essential for a good training.

I am not trying to gross you out, but that’s the reality of our line of work. Though with all the TV shows, like CSI and NCIS, anybody can witness an autopsy, whether it is real or imagined.

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scene from an episode of NCIS

My first exposure to a real autopsy was when I was a 4th year medical student in University of Santo Tomas, in the Philippines. I was rotating in Forensic Medicine at Fort Bonifacio. There was a victim with multiple gunshots, and two pathologists were performing the autopsy. It takes a lot to gore me out, so it was no big deal to me. Plus we have been exposed and even dissected cadavers in our Anatomy class. By the time we got used to it, we can even eat our lunch in the Anatomy Hall.

While the autopsy was underway, an army sergeant walked in into the morgue with several new army recruits in tow. The sergeant told the recruits to stand in the corner and watch the autopsy so they know what would happen to them if they were killed.

As the pathologists extricate the internal organs one by one to examine them, I have noticed that the new army recruits who were standing in attention started to sway. Their stoic faces started to grimace. Well, who wouldn’t? I guess it was a sort of cruel initiation for them.

Since then I have witnessed several more autopsies over the years, not including what I watched in NCIS. It is not that I enjoy them, but I have to admit, I learn from them.

However I have maintained my utmost respect for the deceased. These bodies that were cut open for us to study were once living individuals. They were persons. They have a name. A purpose. A life. But now gone. Yet in these hallowed halls, they still speak.

Inscribed over many entrances of morgue, medical examiner’s office and anatomy hall is the Latin maxim, “mortui vivos docent,” meaning “the dead teaches the living.” Yes, indeed.

 

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)

Autumn Leaves

It was a rainy foggy autumn morning. I accompanied my family to our local YMCA, where my children would practice their swimming strokes in the lap pool. My wife went with the kids in the pool area, while I went to the exercise/weight room. I prefer to run than swim. Besides, I feel intimidated when I swim with my doggie-paddle strokes.

After I had my morning jolt, I meant exercise not coffee (exercise is a much better pick-me-upper than caffeine), I went out to the gym’s lobby. I sat down in one of the lounge chairs while I waited for my family. I picked up the newspaper and leisurely read. I wish everyday was like this, where I could take my time, sweat up a bit, then relax and read the morning paper without worrying that I would be late for work.

You see, I have taken some days off for a badly needed break from the stress of work. Even though I was on vacation, we did not plan for any far-away travel, as my kids were doing school and they have many scheduled activities for the week. So I just spent time at home.

People say that sometimes the best vacation, is the one you stay at home (staycation). I agree. It is less expensive too. Much less. For many times we are forced to work more just to pay the expenses we incurred from the last vacation we had.

As I was flipping through the newspaper, I happened to open to the obituary section. I don’t usually read this section. But does anyone? Well, that’s not true. I have a partner who regularly reads through the obituary section and relays to our office staff which of our patients would not be coming back for their follow-up. Because they’re dead. Somehow this updates our record.

For some reason this day I read the obituary. Not surprisingly, I saw a name that was familiar. It was one of our patients in the ICU that we took care for a prolonged period of time. I knew he was really ill. He finally did succumb two days ago.

As I was reading our patient’s obituary, it said there that he was always been the “life of the party” with his “ridiculous jokes.” I did not know that. I have only met him in the hospital and I guess his illness sucked away the life out him, and it was hard not to be grim if you were in the ICU. It also said in the obits that he had a “fierce spirit.” No wonder he fought that long. Yes, the disease may have defeated him in the end, but he did fight a good fight. Beyond what we have expected.

Maybe that was one good thing you gain for reading the obituary – you learn more of the person that you never knew before. But again, it’s too late. They’re gone.

As we arrived home from the gym, the day remained gloomy. I knew the sun was somewhere up in the sky, but the dark clouds and the fog was covering it. It seems like it was still night. The weather was like a perfect setting for an eerie movie. It was Halloween season after all.

For me though it was more than the gloomy morning. I couldn’t shake the thought of our patient that died. In fact, I mused on all the patients that despite of our best efforts, still died. Yet I know and have resigned that that is beyond our control.

Do you think it is easy to forget them? Especially the recent ones? Including the one that died on my procedure table a few days ago? I tell you, it is not. And it can be haunting at times. Not the scary-type of haunting like the Halloween. But haunting, that is poignant like the falling leaves.

I looked out our window. The rain was pouring down. The wind was blowing. And the autumn leaves were falling. One by one to the ground.

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photo taken at our friends’ yard

Daddy is Home

It was a long day.

In reality, it had been a series of long days, and long weeks, of a long month. You see, I have been the ICU attending physician for the past 4 weeks, and the stress of work and taking care of very sick patients was like a dragon breathing down my neck. It was wearing me down.

I came home feeling depleted and defeated.

Even though it was late, my wife and kids were just happy to see me home. My wife has even waited for me to eat dinner, though I knew she was tired and hungry too. It felt good to be home after such an arduous day.

Before we went to bed, we had a family prayer, just like every night. My son led the prayer, and I heard him say, “Thank you God, for bringing Daddy home.”

Suddenly, all the day’s cares melted away. I felt so blessed.

As I rest my head on the pillow, I thought of the other fathers in the world that were not able to come home. The overseas contract workers. The soldiers deployed somewhere away from their home. And the others for some reason or another that cannot come home tonight. Including our patients that were languishing in the ICU. I felt sad for them and their kids who cannot say the prayer of thanks that my son did.

I especially thought of the father I took care earlier today. He will not come home. Ever.

May he rest in peace. And I pray that his family find peace.

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waiting for daddy

(*photo from here)

When Doctors Cry

It’s alright Melissa. You can dry your tears now. This is just part of the job we do. I know, textbooks and medical school did not prepare you for situation like this.

Melissa* is our young medical resident (doctor-in-training) who was on-call that night in the ICU. I received a call from her a little past midnight for an admission, who was doing poorly. So I had to go back to the hospital.

Our new patient was a 19 year-old kid. Yeah, I consider that age a kid. He was brought to the Emergency Room (ER) after he complained of unable to breathe, then collapsed, and became unresponsive.

When the ambulance arrived, he was not breathing and had no pulse. They did CPR (cardiopulmonary resuscitation) and worked on him for almost 30 minutes before a heart rhythm was re-established. Thirty minutes are an eternity to have no heart beat.

In the ER, he was treated for cardiorespiratory failure, thought to be from severe asthma attack. He was hooked to a ventilator and started on medications for asthma. He was subsequently admitted to our ICU.

After the patient was transferred to my care in the ICU, I thought that the story does not make sense, though asthma can be very severe at times. Plus, the heart shadow on the chest x-ray appeared to be huge in my opinion. So I asked my resident to get a CT scan to rule out a blood clot in the lungs or other pathology.

The result of the CT scan caught us by surprise. It showed a big tumor in the middle of the chest, compressing the heart and the main airways. No wonder, our patient cannot breathe. Furthermore, he had extensive “free air” in the abdomen, signifying that he had a ruptured bowel. What caused it? I could only speculate.

The situation had turned from serious to grim.

When I examined the patient, I noted that aside from being comatose, his pupils were fixed and dilated. He did not respond to any stimuli at all, but was having “seizure-like” movement. That was an ominous sign. It was indicative of irreversible severe brain injury, perhaps from the prolonged anoxia (lack of oxygen) to the brain. What else could go wrong?

I then went to the ICU waiting hall to meet my patient’s family. The room was dark, as the lights have been dimmed. In every corner of that hall, were relatives of other ICU patients, who were sleeping on the floor or make-shift beds. They have camped out in this room, some for a few days, others for weeks. I know each of them have a sad story to tell.

I found a quiet space in the waiting hall to meet with the family of my 19 year-old patient. There were two sisters, and the grandparents. We spoke softly, so not to disturb those who were sleeping. I informed them of the severity of the situation. I was frank and direct, telling them that I have no good news. It was all bad. The family was distraught. And understandably so.

When I asked them who would be making decisions in behalf of the patient, I heard more depressing news.

The family told me that it would be her mother who would make the final decisions. But she herself was sick.

The mother had been a patient in our hospital less than a year ago. She suffered a devastating stroke and was in our ICU for more than a month. She slowly improved, and after a couple of months in the hospital she eventually was discharged to a rehabilitation facility, where she stayed for several more months. Finally she was able to come home two months ago, only because his son took responsiblity of fully caring for her.

That son, was now in our ICU.

How about the patient’s father, I inquired. The grandfather glumly told me, that he died not too long ago from an accidental electrocution at work. Was this the saddest string of unfortunate stories or what?

After my talk with the family, one sister planned to get their ill mother at home, so she could see and say her goodbye to her son. And then they will decide whether to wait it out a little longer, or take him off life support.

I went back to the ICU’s workroom to write my note, and that’s when I saw my medical resident crying.

Perhaps she was emotional due to changing hormones, as she was pregnant. Or perhaps she was just exhausted, and it was already 3 o’clock in the morning. Or perhaps these medical sad stories was too much for her to handle.

I know, it was too much for me too. And twenty years of experience did not make it easier at all.

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(*names have been changed)

Bloody Sunday

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

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

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.

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(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

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

“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)