Bad Night

We’re sleeping in the hospital now. It started this year. Our calls are now in-house as the hospital wanted us to physically man the ICU 24/7. This is besides the resident-on-call who is already in the ICU. Sleeping in a call room of the hospital about once a week, makes me feel like I’m a resident or a doctor-in-training all over again. But I understand, the times are changing, the practice of medicine is changing, and the liability of this profession is changing. We have to adapt.

Few weeks ago, I walked in at 5 in the afternoon to take over the call for the night. The moment I walked in, I was called by my partner who was in charge of the ICU all day, to meet her in the cardiac catheterization lab (cath lab) so she can sign out to me the patients.

When I came down there, I found out that there were two patients currently in the cath lab that were both going to the ICU.

One was a man in his 40’s with severe pancreatitis and was having multi-organ failure, including severe respiratory failure that was not improving even if he’s on mechanical ventilator. So large-bore catheters were being inserted in his neck and groin, so we can place him on Extracorporeal Membrane Oxygenation or ECMO (see previous post about ECMO).

The other patient in the cath lab was a man in his 70’s that had a cardiac arrest. He required prolonged resuscitation. The cardiologist was putting an Impella device in his heart, a device placed inside the left ventricle of the heart to help pump out blood. When that’s done, the patient would be transferred to the ICU. He was already on ventilator as well.


Impella device (photo from

Then my partner told me that there were two more patients already in the ICU that she was called to evaluate, but did not have the chance to see yet, as she was stuck in the cath lab for the last hour or so, assisting in this patient that require ECMO.

One patient in the ICU was a transfer from another hospital, he had fever with very low blood pressure. He also has advanced esophageal cancer and on chemotherapy. He has no immune system to fight the infection. After the initial work-up, he turned up to have Influenza A.

The other patient in the ICU to see was a trauma patient, who was in a vehicular accident. He had several broken ribs and a collapsed lung. The Trauma Team has admitted the patient, but they were having difficulty oxygenating him despite being on a ventilator, thus they were consulting us for assistance.

She also told me that we have 21 other patients in the ICU that were relatively stable at the moment, but can turn volatile anytime, besides the four new ones that needed my immediate attention.

Lastly, she said that she declared the patient in room 15 as clinically brain-dead, hence, legally dead. Patient was a young lady in her 20’s who overdosed on drugs, and unfortunately was not found immediately. When she was brought to the hospital, she was too far gone. The patient’s family agreed to have her organs donated, so she’s still on life support until they can harvest her organs. The Transplant Team wants us to do a bronchoscopy to assess if the lungs and airways were normal and appropriate for harvest.

Hearing the long laundry list, I thought to myself, this would be a long night. That’s not even considering more new patients that may come.

Shortly thereafter, I got a call from the Transplant Team asking me when could I do the bronchoscopy in room 15. I told them that I would take care of some more pressing issues, and when I get free, I’ll do it, but I already contacted the endoscopy nurse to come and set up for the scope. I thought, let me take care of the living first, before I deal with the dead. But I didn’t tell them that.

When I came up to the ICU, the patient from the cath lab who had a cardiac arrest and got the Impella device, also arrived in the ICU. I evaluated the patient, and it was obvious he was doing poorly. He was requiring 3 IV drips (1 drip is a poor sign already, let alone 3!) to keep his blood pressure up. This was despite the device in his heart to pump blood. He already looked dusky and gray.

I sat down with the patient’s family, and told them that the odds were not in our favor. I don’t believe he would survive the night. I also told the cardiologist that I felt bad for him as well, as all his efforts may be all for nought.

The patient died less than 2 hours after he came up from the cath lab.

While I was working on this patient, I got a call from the Emergency Department about a new patient that needed to come to the ICU. The patient was in her 80’s, with advanced dementia, and was from a nursing home. She was septic, perhaps from a urinary tract infection. I may think that she was not the best candidate to spend my limited time and resources at that time, but who am I to say who lives and who should not. A life is still a life. So I sent my resident to evaluate and admit the patient.

When the ECMO patient came up to the ICU from the cath lab, that was where I spent most of my time and effort. We even consulted Nephrology to start the patient on dialysis too. However, despite all intervention, with ECMO, dialysis, mechanical ventilator, and several IV medication drips, the patient continued to deteriorate. I felt like we’re just spinning our wheels without gaining any traction. I noticed that the patient’s heart rate and blood pressure were drifting down. Definitely an ominous sign.

I gathered the patient’s family and brought them at bedside to the patient. I honestly told them, there’s nothing else we could do.

The patient died 5 hours after he was hooked up on ECMO. I felt defeated and deflated with these events.

In between the deaths of my 2 patients, I was able to squeeze time to do the bronchoscopy on room 15. It looked healthy, so I relayed to the Transplant Team, they can perform their harvest.

After midnight my night quiet down a bit. I caught up and was able to see all the patients I needed to see. When I had some down time, I reflected on what I accomplished and those I failed to accomplish.

At least I was able to stabilize the elderly patient from the nursing home, right? She will get better from the infection, then she’ll go back to the nursing home in a few days, and spend the rest of  her existence in bed with very poor quality of life due to her advanced dementia. How about the patient with metastatic esophageal cancer? He’ll get better from the influenza. But he still have to deal with his cancer and more chemotherapy with bleak hope of a cure. And the sad list just goes on and on.

Nights like this, make me question if it’s really worth doing this. I got several more pages through the night, but I survived to see the morning.


A couple of weeks after that disheartening night-call, I received a letter. It was from the Organ Donor Network. They were thanking me for my effort in assisting to obtain donor organs for transplant. Because of this, they informed me that a young man was given a new lease in life as he received new lungs. There were other patients too that received “gifts of life” with their transplanted heart, kidneys, cornea and so on.

I then realized that even in patients who died under our care, we can make a difference. It still worth it after all.

(*photo of dawn, taken with an iPhone)

Ang Lola Kong Adik

(Addict: a person who is addicted to an activity, habit or substance.)

Sang-ayon sa mga balita, marami raw adik sa atin sa Pilipinas. Pero nababawasan na raw ito dahil sa takot kay Duterte. Noong ako’y bata pa, kapag kami ay lumuluwas sa probinsiya, ay mayroon akong natutunghayan na kakaibang adiksiyon.

Sa bahay ng aking lola sa Norzagaray Bulacan, ay nakatira rin ang isang tiyahin ng aking tatay. Maaaring sabihin na kasama siya sa mga kumukunsumo ng adiksiyong ito. Hindi ko na sasabihin ang tunay niyang pangalan, at tawagin na lang natin siyang Nana Pula.

Aking pinapanood si Nana Pula na uupo na lang sa sahig sa isang sulok ng bahay. Tapos ilalabas na niya ang mga nakasupot niyang paraphernalia. Dito mag-uumpisa na siyang mag-gayat. Magdidikdik. At magbabalot.

Pero bago ninyo isipin na shabu o crystal meth ang kanyang dinidikdik, o kaya’y marijuana ang kanyang binibilot, ay hindi ito gayon. Ang kanyang ginagayat, dinidikdik at binibilot ay nga-nga.

Siguro alam ninyo kung ano ang nga-nga (betel quid). Sa mga nakababatang Pilipino na maaring hindi na pamilyar sa sinaunang bisyo na ito, ang nga-nga ay nginunguya. Hindi ito sinisinghot o hinihithit.

Ang nga-nga ay ang combinasyon ng: ikmo (betel leaf), bunga (areca palm nut), at apog (slaked lime). Gagayatin ang bunga, tapos papahiran ng apog, at ibabalot sa ikmo. Minsan dinadagdagan pa ng dahon ng tabako, para mas matindi ang tama.


nga-nga (image from the web)

Matapos bilutin ni Nana Pula ang kanyang nga-nga, ito ay kanya nang isusubo at nguguyain. Habang nakasalampak, ngumangata at sumisipsip ng katas ng nga-nga, ay paminsan-minsan siyang dudura ng mala-dugong laway sa siwang ng sahig na kawayan. Para siyang kambing na ngunguya-nguya, pero kontento sa kanyang buhay. At pag-ngumiti si Nana Pula? Pula ang kanyang bibig at mga ngipin! Kaya nga Nana Pula.

Meron din kaming ninuno sa Bulakan na ang tawag sa kanya ay Tatang Puti. Pero hindi dahil sa puting ngipin, kun’di dahil siya ay tunay na maputi. Siya ay meztiso at dugong Kastila. Tunay naman na may lahing meztisuhin ang aking angkan. Pero hindi ako kasama sa mga mapuputi, dahil nakuha ko ang kulay ko sa aking nanay na dugong Ilokano. Teka, naligaw na yata ang usapan.

Balik tayo sa nga-nga. Ang tradisyon na ito ay matagal nang umiiral sa Pilipinas, bago pa man tayo sakupin ng Kastila. Nabanggit ito ni Jose Rizal sa kanyang nobelang Noli Me Tangere, kung saan sa unang kapitulo ay sinaad niyang inalok ito ni Kapitan Tiago sa kanyang mga bisita. Sa kapanahunan noon, hindi Skyflakes at softdrinks ang inihahain sa bisita, kun’di nga-nga!

Ang kustombre ng pagnguya ng nga-nga o betel quid ay hindi lang sa Pilipinas. Maraming bansa sa South at Southeast Asia, at sa kalawig na mga isla sa Pacifica ay kilala ang sinaunang tradisyong ito. Sabi ng World Health Organization, maaaring may 600 milyong tao ngayon ang haling sa bisyong ito.

Ang pag-nguya ng betel nut ay ipinamana sa atin ng ating mga ninuno. Sa katunayan, sang-ayon sa mga archaeologist, may nahukay silang bungo ng tao na may apat na libong taon ang tanda, at ang ngipin nito ay may bakas ng elemento ng betel nut. Ganoong katagal na ang nga-nga!

Gaya ng sigarilyo at iba pang bisyo, bakit kaya nakaka-adik ang nga-nga?

Ang bunga o “betel” nut, ay mula sa areca palm (scientific name: Areca catechu). Ito ay may natural alkaloid, na ang tawag ay arecoline. Ang arecoline ay mild stimulant. Kaya ito’y nakapagbibigay ng energy boost at feeling of euphoria. Sa madaling salita, nakaka-high! Kaya kapag ngumunguya na sila tatang at nanang, ay sumasaya sila at para na silang lumulutang. Tripping na si lola!

Ngunit parang nicotine mula sa dahon ng halaman ng tabako (scientific name: Nicotiana tabacum), ang arecoline mula sa areca palm nut ay nakaka-adik din. Kaya bago pa naging palahithit ng tabako, o bago pa magsipagbilot ng marijuana, ay ngumangata na ng nga-nga ang Pilipino. Lahi nga kaya tayo ng mga adik?

Maliban sa nakaka-adik ang nga-nga, may iba pa bang masamang epekto ito?

Sang-ayon sa mga pag-aaral, ang nga-nga ay maaring maging sanhi ng kanser sa bibig. Iyong ibang matatanda sa atin, nag-nganganga na, nagtatabako pa, tapos nasa loob pa ng bibig ang sindi ng tabako, kaya’t mataas ang insidente nila ng kanser sa bibig.

Dahil laging ngumunguya ang kumukunsumo ng nga-nga, ito ay maari ring magdulot ng oral submucous fibrosis. Ang kondisyong ito ay sanhi ng “stiffness in the mouth and eventually the loss of jaw movement.”*

Isa sa pinakamalinaw na sanhi ng nga-nga ay ang pamumula ng bibig at ngipin. Para silang nagpahid ng sangkatutak na lipstick, pero kasama pati ipin! Maari rin itong sanhi ng tooth decay, gum disease at bad breath.

Kaya noon pa man, kapag nag-nganga-nga na si Nana Pula, umiiiwas na akong pahalik sa kanya, dahil baka mag-amoy nga-nga at apog ako. Pero nagmamano pa rin naman ako kay Nana Pula.

Subalit kahit may kakaibang adiksiyon si Nana Pula, ay mapayapang mamamayan naman siya. Mapagmahal din siya sa kanyang mga kamag-anak at kaibigan. Maaring sabihin na adik siya sa pagmamahal sa kanyang mga pamangkin at apo, kasama na ako, kahit gaano pa ako kakulit noon.

Isang araw, matahimik na pumikit si Nana Pula, lumutang at pumailanglang sa walang hanggang kawalan. Wala sa aming nakababatang pamilya ang pumulot ng kanyang bisyo, kaya’t ito’y naglaho na rin sa pagpanaw ni Nana Pula.

(*from Journal of the American Dental Association)

Fevered Musing

I called in sick. I have not done that a lot. In fact, this is the first time I did it. Many times, I just grit my teeth and willed myself to work, even if I felt like I was ran over by a truck.

I have this notion that doctors should not get sick. For who will take care of the patients? But am I really be of help or be more of harm if I go to work, while I myself is sick? After much deliberation, and after foregoing the feeling of guilt, I made the call.

Don’t get me wrong, I am no superhuman. In fact, I get sick more often than my wife. She chided that I am built poorly and of cheap quality materials. During my childhood days in Manila, we call our classmates who get sick easily “Made in Taiwan.” We pride ourselves to be “Made in Japan” or “Made in USA” if we’re the only ones left standing. Nothing against products from Taiwan. Accept it or not, we Filipinos sometimes can be racist. I am sure being made in Taiwan nowadays does not have that connotation.

I am trying so hard not to get sick. I exercise regularly, and I try to eat healthy, and I even got my flu shot. But I still got sick. Being a physician, when you’re dealing with ill patients all day, and they are coughing in your face, it’s just a matter of time that you’ll get it too. Plus we are in the middle of the flu epidemic and it is particularly bad this season.

I am in bed for 2 days straight now. I know, that in itself can make my head hurt. I am popping Advil every 4 to 6 hours round the clock, just to get relief from the fever and the body aches, even though I don’t like taking medicine.

I isolated myself in our bedroom, as I asked my wife to sleep in another room, so she’ll not get what I have. This is not the time for ‘sharing.’ I also put on a mask whenever I go out of the room, and ate separately away from the table.

I was having chills and fever when my thoughts wandered into the times in the past, when I was also sick in bed.

I was in our home in Manila, with high fever. I was still so young, that I don’t go to school yet. My body was full of red spots that were very itchy, and I’m trying my best not to expose them. (Bawal daw mahanginan.) I believe I got the measles. My mom would continuously put a wet towel in my head to try to lower my temperature. But despite of that, I was to the point of hallucinating, that my mother said I was seeing things that were not there.

Then there was the time I was in Kindergarten, when I again had a fever, and one side of my face swelled up. I looked like a squirrel that has an acorn in one of its cheek. I had the mumps. My folks painted a bluish gooey something on my face. It is a concoction of clay, blue dye and vinegar, which was a popular folklore remedy for mumps in the Philippines. My classmates in Kindergarten stopped by our house to visit me, and they saw me with my painted blue puffed-up cheeks.

I know, I know, you may be asking, why did I get both the measles and mumps when I was a child. Why was I not vaccinated? Were my parents against vaccination? Not really. I was just born before the era when MMR (Measles, Mumps and Rubella) vaccine became available worldwide. It was later offered in our school when I was older, I think I was in Grade 2 or 3. My classmates and I lined up and I received those injections despite my silent protestation as I was scared of needles.

There were several other times that I was sick as a child with colds, and my mother would put Vicks Vaporub in my chest and back. Even in my nose, when my nose was clogged up and could not breathe. She would also put Vicks Vaporub in my feet and then put socks on me, telling me that will help my fever. For many Filipinos, Vicks Vaporub and White Flower ointment were a cure-all treatment for any ailment. To this day, I hate the smell of them.

Now that I have the MD degree after my name, I know that the blue paint on my cheek and the Vicks Vaporub on my feet perhaps caused nothing to help my sickness. But perhaps just the fact that I am loved and my parents were showing they care, the best that they know how, was enough to make me feel better. And that eventually healed me of my illness.

Many times, showing people that we care for them, is enough to relieve them of their malady. I know I have plenty of that in my home as a child, and in my home now. Even when I feel terrible with this illness, I know that I am being attended to, not necessarily by a medical team, but more importantly by people who really cared for me. In fact, I still have the cup of salabat on my night lamp stand that my wife brought me this morning, and I could already smell the sinigang that she is cooking.

I was having chills when I glanced outside the window.  Snow is now falling softly. I am not going anywhere. More reason to snuggle under the covers the whole day.


(*These thoughts were concocted 3 weeks ago. I think I got influenza, and I was house-bound for 5 days. Photo taken with an iPhone.)



Concert in the ICU

Inside ICU room 34* of our hospital, there is an ongoing musical performance. One young man is playing an instrument and another young woman is singing.

Music therapy is a burgeoning field of science. We have known since the history of man, that music has a healing property. During Biblical times, young David was summoned to play his harp whenever King Saul of Israel was stressed and troubled. Pythagoras, Plato and Aristotle all wrote about how music affects health and behavior.

Now, modern science and current medical studies back this up. In Harvard’s Health Blog, one article mentioned that music therapy can aid pain relief, reduces side effects of cancer therapy, restores lost speech in people who suffered stroke, and improves quality of life for dementia patients among other benefits.

One study from Austria conducted in General Hospital of Salzburg, has found that patients who are recovering from back surgery had increased rates of healing and reported to have less pain when music was incorporated into their rehabilitation process. I consider Austria a leading authority in music science, after all that’s the country where great classical composers like Mozart, Strauss, Schubert, Czerny and Haydn all came from.

Several years ago, when I was doing my Critical Care Medicine training in New York City, we had a music therapy team that plays to our patients in the ICU. The team, composed of a flutist, a violinist and a cellist, would go from room to room in the ICU and would play for about 5 to 10 minutes in each room. Even if the patient was medically sedated or comatose, they would do it anyway. It was soothing for us medical staff as well, when they come, as we got to listen to their music.


ICU music therapy (image from

Since music therapy is the in-thing right now, I even told my daughter to look into a career in this field, that is if she would be interested, since she is pursuing a music degree. Perhaps I can have my own therapy someday.

Back to our ICU 34, the mini-concert though is not done by our hospital’s music therapy team, for we don’t have an official team like that as of yet. The music is being performed by the patient’s son and daughter who are both college-age and are both enrolled in music degree.

The son is playing his French horn, and the daughter is singing. The daughter even composed a special song for her mother, our patient, and would sing it for this special occasion.

However, their mother, who is only 44 years of age, is not going to wake up again. Not even with the beautiful music rendition from her children or any music therapy session on earth for that matter. She suffered a devastating head bleed which caused her to be in perpetual comatose with no hope of meaningful recovery. She is just being kept alive by life-sustaining machines.

The whole family agreed, that their mother would not choose to live a life in a vegetative condition like this. So they decided that they will take her off all life support. But only after they perform their mini-concert in her presence. They would like to dedicate their music as a send off, as she passed on beyond this world.

Sometimes music can be a therapy too for the broken-hearted and for those who are left behind.

(*ICU Room number was purposely changed)



Sa isang luxury car show, may mga tao mula sa iba’t ibang lahi ang nagkausap-usap. Habang tinitignan nila ang mga magagarang kotseng naka-display sa show, ay nagsimula silang magbidahan.

Taga-Europa: “Doon sa Europa, ang mga luxury cars, gaya ng Mercedes Benz at BMW ay hindi lang para sa mayayaman. Ordinaryo lang na pinanghaharabas at pinampapasada namin ang mga iyan bilang mga taxi.”

Amerikano: “Naku, walang-wala iyan sa Amerika. Doon sa amin, ang mga mamahaling kotse tulad ng Mercedes, BMW at Corvette, ay binabale-wala at linalaspag lang. Walang patumangga pa naming binabangga at pinapasabog ang mga ito sa mga pelikula.”

Pilipino: “Nakow, taghirap naman pala sa bansa ninyo. Walang panama iyan sa Pilipinas. Doon sa amin, ang mga bagong-bagong luxury cars gaya ng Jaguar, Mercedes, BMW at Corvette ay hindi ginagamit o sinasakyan! Pinayuyupi lang ng aming Presidente para ang bakal ay gawing tansan!”



(*photo from

Question and Answer: Hindi Maubos na Ubo

May kanta ang Eraserheads na nagsasabi: “Hanggang sa dulo ng mundo, hanggang maubos ang ubo.” Pero ang tanong na tatalakayin natin ngayon ay ang hindi maubos na ubo.


Good AM po. Ako po ay may ubo, matagal na po pero hindi pa rin naaalis. Akala ko dahil sa sumugod ako sa ulan kaya po ako inubo. Sumasakit na din po minsan ang aking likod pag ako umuubo, tas noong isang araw may bahid po ng dugo plema ko.

Hindi naman po ako nilalagngat. Sabi ng asawa ko pumapayat po raw ako, pero baka kulang daw ako sa bitamina. Ano pong dapat kong gawin? Sana po matulungan ninyo ako.


Dear Toto,

Maraming dahilan kung bakit tayo inuubo. Una sa lahat ang ubo ay hindi mismo sakit. Ito ay palatandaan o sintomas lamang na maaring tayo ay may sakit.

Ang ubo, ay isang reflex o protective response ng ating katawan sa isang bagay na maaring magdulot ng pinsala sa ating sistema. Tulad nang kapag ikaw ay nasamid, ibig sabihin, maaring may butil ng pagkain, o tubig, o laway o anumang foreign body ang nag-trespassing sa ating trachea or windpipe. Tayo ay uubo upang matangal ang anumang nakabara sa daluyan ng ating hangin.

May mga taong hindi makaubo o kaya’y mahina ang kanilang cough reflex, tulad ng mga na-stroke, o kaya’y mga nawalan ng malay, gaya nang sa sobrang kalasingan. Sila ay maaring mag-develop ng aspiration pneumonia. Ito ‘yung mga secretions mula sa kanilang bibig ay nakapuslit at naligaw papuntang baga. Dahil hindi sila makaubo ng maayos kaya nalulunod sila sa sarili nilang laway.

Umuubo rin tayo kung maraming plema sa ating daluyang ng hangin at baga. Ang ubo ay paraan upang maalis ang mga plema. Kaya’t hindi maganda kung atin laging pipigilan ang ubo. Kalimitan ang mga gamot na cough suppressants ay hindi kailangan, maliban kung talagang malala na ang ubo na para na tayong asong kumakahol at hindi na tayo makatulog.

the big yawn

Isa sa pinakamalimit na dahilan ng ubo ay infection. Dahil sa inflammation na sanhi ng infection, tumitindi ang mucus production sa ating daluyan ng hangin. Kadalasan ay virus ang sanhi nito, at wala masyadong mabisang gamot sa viral infection. Lilipas lang din naman ito. May mga medisina na maaring magpalabnaw ng plema, lalo na kung malagkit na parang kalamay, upang mas madali natin itong ilabas. Makakatulong din ang pag-inom ng maraming tubig.

Minsan ang infection ay dahil sa bacteria. Ito ang sanhi ng bacterial bronchitis o pneumonia. Dito maaring kailangan na natin ng antibiotics upang labanan ang infection. Pero minsan hindi lang bacteria, pero maaring fungal (amag) o mycobacteria (tulad ng tuberculosis o TB) ang sanhi ng infection. Sa pagkakataong ito, kailangan na talaga ng subaybay ng duktor para malunasan ang mga infection na ito.

May mga sanhi rin ng ubo na ang dahilan ay hindi infection. Tulad ng asthma, allergy, at gastroesophageal reflux disease (GERD). Sa asthma, maaring ang ubo ay katumbas ng bronchospasm o paninikip ng airways. Maari ring mamaga ang daluyan ng hangin dahil sa hika, kaya mayroon ding plema. Inhalers o tinaguriang bomba de hika ang makakapagbigay ginhawa dito.

Sa allergy naman, maaring maraming mucus o sipon galing sa ilong ang tumutulo sa lalamunan (post-nasal drip), at ito ay umiirita sa ating lalamunan. Maaring makatulong ang mga nose sprays at allergy medications.

Sa GERD naman, ang maaasim na asido mula sa stomach ay maaring umakyat papuntang lalamunan at ito ay umirita sa ating daluyan ng hangin. Makakatulong ang mga antacids na gamot para sa pesteng ahem na ito.

Isa pa sa mga dahilan ng ubo ay ang paninigarilyo. Nagrerebelde ang ating airways, at ang ating katawan ay naglalabas ng maraming mucus para protektahan ang sarili sa umaatakeng iritante. Ito ang sanhi ng tinatawag nating “smoker’s cough.” Siyempre maari rin magkaroon ng COPD or emphysema sa paninigarilyo, at hindi lang ubo ang sintomas nito, kundi kasama na pati ang paghingal at maingay na paghinga na parang nakalunok ng pusa.

Maari rin magkaroon ng kanser sa baga dahil sa paninigarilyo. Ang kanser ay isang sanhi ng ubong hindi maubos-ubos, hanggang maubos pati hininga. Sa katunayan, kapag kanser ang sanhi ng ubo, kalimitan ang kanser sa baga ay nasa advanced stage na. Sa ibang salita, mi ultimo ubo.

Balik ako sa kaso mo Toto, sabi mo medyo matagal na ang ubo mo. Ito ba’y ilang linggo na o ilang buwan na? Isa pa, ikaw ba ay naninigarilyo? Nababahala ako sa sabi mong may bahid ng dugo sa iyong plema. Maaring magkaroon ng dugo sa plema sanhi ng infection o iritasyon ng daluyan ng hangin. Pero maaring mas malala rin ang sanhi nito, tulad ng kanser.

Isa pa sa kinababahala ko ay sabi mo, pumapayat ka. Maaring dahil wala ka lang ganang kumain, o dahil na rin sa iyong sakit kaya nahuhulog ang iyong katawan.

Sa aking listahan ng maaring sanhi ng iyong ubo, infection ang isa sa aking hinala, kasama na rito ang TB, dahil medyo palasak pa rin ang TB sa Pilipinas. O kung ikaw ay naninigarilyo, dapat natin isaalang-alang na puwede itong kanser. Hindi sa tinatakot kita, ako’y nagaalala lamang.

Kaya ang payo ko sa iyo, magpatingin ka na sa iyong lokal na duktor kung hindi mo pa ginawa ito. Siguro kailangan mo na rin magpa-chest x-ray. Itigil mo na rin ang sigarilyo kung ikaw man ay naninigarilyo.

Buti pa kanta na lang tayo:

Hanggang sa dulo ng mundo,

Hanggang maubos ang ubo,

Hanggang gumulong ang luha,

Hanggang mahulog ang tala.

(*photo from the web)


Once Upon A Time

Not too long ago while walking at the mall, I was captivated by the music being played. You might ask, on what occasion does mall music captivating? Many times the music is just blaring and quite annoying.

Not in this store. Actually I was in a large department store that you would consider old-school, a holdover from the classic era, if you will. Though it is in the mall, this particular store has a quiet and serene environment. The music is calming and not loud. Most of the time it is provided by a grand piano in the center of the store, near the escalators. And they employ a live pianist to play the piano.

So when I heard the certain song being played, I was drawn to the place where the piano was, to see the musician who was providing the music. Though I was not familiar with the tune, somehow it stroke a nostalgic chord.

When I came down the escalators, I was surprised when I saw the pianist.


He was a bit older than what I was expecting. He was perhaps in his late 70’s or even 80’s. His mobility was not very good anymore, as substantiated by the presence of a walker beside the piano. Yet the dexterity of his fingers were still impeccable. And the emotion in his playing was still very much palpable.

I was enthralled that I had to sit down on one of the sofas near the piano so I can watch him a little longer. He has no notes or music piece that he was reading. He was playing by memory with his eyes closed. Perhaps he has played this song so many times, that he’s performing it all by finger or muscle memory. Yet I can feel the deep sentiments on those fingers as it runs through the piano keys.

Maybe he was reminiscing the good ole days. Maybe he was reliving bygone happy moments. Or maybe he was lamenting a lost Valentine’s.

What was the song? I didn’t know, so I asked him after he finished playing.

He answered, “Once Upon A Time.”

Such an appropriate piece.

(*photo taken with an iPhone)


“Once Upon a Time” is a song composed by Charles Strouse, with lyrics by Lee Adams, from the 1962 musical All American. It has been sung by Bobby Darin, Frank Sinatra, Perry Como, Tony Bennett and Bob Dylan among others.

Here’s a version by Alex Bird (taken from YouTube):


For all the lovers out there, including those who loved and lost, and who loved once upon a time, may you have a memorable Valentine’s.

Lalamunang Butas

Bahagi ng pagiging isang masinop na duktor, ay ang pagkuha ng istorya, o aming tinatawag na history, mula sa pasyente. Dahil kalimitan, maaring ma-diagnose o malaman kung ano ang sakit sa pamamagitan lang ng history. Siyempre kailangan pa rin ng physical exam at mga ancillary testing, para makumpleto ang diagnosis. Pero napaka-importante ng history.

Kaya naman kasama sa aming training o pag-aaral bilang duktor, ay ang kung paano kumuha ng tamang history. Katulad nang kung masakit ang tiyan ng pasyente: aming itatanong kung kailan pa nagsimula, o anong oras ng araw lumilitaw ang sakit, anong klase ng sakit, anong maaring nagpapalubha o nagpapaginhawa sa sakit, kung saan mismo ang sakit, o kung ito ay gumagapang sa ibang bahagi ng katawan, kung kumain ba ng panis na pansit, at kung anu-ano pa.

Huwag ninyo sanang isipin na makulit lang ang inyong duktor dahil napakaraming tanong, na pati pagkain ninyo ng pansit ay inuusisa. Ang mga tanong na ito ay kailangan para malaman ang tamang diagnosis.

Oo nga’t mayroong mga pagkakataon na hindi kami makakuha ng tamang kuwento o history mula sa pasyente. Tulad ng mga pasyenteng tuliro o walang malay na dinala sa hospital. Marami kaming ganyang pasyente sa ICU. O kaya naman ay ibang wika o dialect ang kanilang salita, o kaya’y pipi ang pasyente, kaya’t kailangan pa namin ng interpreter.

Mayroon din namang mga pasyente na hindi makapagbigay ng tama o accurate na history, dahil lito sila, o talagang magulo lang silang kausap. Para silang laging lasing. Kaya naguguluhan tuloy pati ang duktor kung ano talaga ang nangyayari.

Saludo ako sa mga Pediatrician, na kayang malaman kung ano ang iniinda ng mga bata o sanggol nilang pasyente, kahit hindi pa ito nagsasalita. Siyempre nakakatulong din ang history na ibinibigay ng magulang ng mga bata.

Mas saludo ako sa mga Veterinarian, kung paano sila kumuha ng history. Siguro ay naiintindihan nila ang bawat kahol, meow, o huni ng kanilang pasyente. Buti na lang at hindi ako pinag-beterenaryo ng nanay ko, at baka kumakahol na rin ako ngayon.

Isang kuwento mula sa matagal na panahon nang nakalipas ang aking isasaysay sa inyo. Ito’y nangyari nang ako’y intern pa sa Pilipinas.  Isang araw ay sabik na sabik na nagkuwento sa amin ang isa naming co-intern, ng kanyang karanasan mula sa hospital ward.

Sabi niya, may pasyente raw siyang may butas sa lalamunan o tracheostomy. Siguro dahil sa cancer sa larynx, pero hindi niya ito sigurado.  Kaya’t kailangan pa rin niyang kunin ang history ng pasyente.

Kung hindi ninyo alam kung paano ang may tracheostomy, sila ay hindi makapagsalita ng maayos,  dahil lumalabas ang hangin sa kanilang tracheostomy at hindi dumadaan sa vocal cord. Minsan, yung mga may tracheostomy, ay wala na ring vocal cord, at tuluyan na silang hindi makapagsalita.

Gayun pa man, desidido pa rin ang aking co-intern na kunin ang history ng kanyang pasyente.

Intern: Kuya, ano po bang dahilan bakit ka pumunta sa ospital?

Pasyente: Heh, hasi hirahp ahoh humingah.

Intern: Ganoon ba? Eh bakit ka nagka-tracheostomy?

Pasyente: Heh hasi, hanito hiyan. Halahas haho hahihahiho. Hayah haghahooh haho hang hanser sa lahlahmunah.

Intern: Teka, teka kuya. Hindi po kita maintindihan.

Luminga-linga ang aking co-intern at nagbakasakali na may kasama o bantay ang kanyang pasyente. Inisip niya, baka makakatulong ito na magbigay ng kuwento.

Sapak naman at naroon sa may pintuan ang isang kabataang lalaki. Tinanong ng intern kung kilala ba niya o siya ba ang bantay ng pasyente.

Tumango naman ang lalaki. Natuwa ang intern.

Tinanong uli ng intern kung alam ng bantay ang kwento ng pasyente. Tumango ulit ang bantay. Lalong natuwa ang intern.

Intern: Ano ba ang nangyari sa kanya?

Bantay: Ngabi ngiya, malangas naw ngiya mangingangiyo, ngaya ngagngaroon ngiya ngang nganser nga lalamungan.


Sa kabila nito, nakuha pa rin ng intern ang wastong history. Kinailangan lang ng konting tiyaga at pangunawa.


(*Ang kuwentong ito ay tunay na pangyayari, at hindi ko po intensiyon na laitin ang may mga tracheostomy o cleft palate.)


Pahabol na tula:

Mga lalamunang butas,

At ngala-ngalang bukas,

Mga boses na gasgas,

Hirap silang bumigkas.

H’wag batuhin ng pintas,

Bagkus tratuhin ng patas,

‘Pagkat ‘di man sila matatas,

Isip nila’y matalas.

Chasing Sun Dogs

Last time I posted about sun dogs (see earlier post this month), I just borrowed a photo taken by a friend, for I did not witnessed it personally.

Sun dogs are atmospheric phenomenon that consists of a pair of bright spots on either horizontal side of the sun. Most of the time it is part of a luminous ring around the sun known as a 22° halo. These beautiful glowing spots are created by the sunlight refracting off the plate-like ice crystals in the cirrus clouds.

Since it needs ice crystals in the clouds, sun dogs occur when it is harshly cold. My take on this is, even in unpleasant situations, beauty can exist. We just have to open our eyes for it. As in most life’s circumstances.

We are experiencing nice weather in Iowa this weekend, but last week our temperature was below zero Fahrenheit. To make up for the extreme cold, we were delighted with the appearance of sun dogs during one particularly frigid day. That time, I saw them with my own eyes and even able to capture photos of them.

Below are photos of the sun dogs that my wife and I took.






(*my wife and I traveled on separate errands that day, me – an hour and a half drive south, she – two hours north, so we were able to capture sun dogs in different times and locations)