A New Normal

I have been going to work now with a mask and a shield. No, I did not become Captain America, nor did I become an Avenger. What I meant is I’m going to work with a medical face mask and a face shield. This has become the new normal for me.

If I am going to do a procedure that is at risk of aerosolizing the virus, like putting an endotracheal tube or doing a bronchoscopy on a known or suspected COVID-19 patient, then I even use my “powered suit.” Not a powered suit like that of Iron Man, but it is a battery powered air-purifying respirator or also known as PAPR.

I rarely take my temperature before. Now, it is taken at least once a day and sometimes more. This daily temperature probe is not to determine if I’m ovulating or not, for the last time I checked I am a male. For your information, the “temperature method” is a family planning method that takes the woman’s daily basal temperature to determine if she is in her fertile or infertile periods of the menstrual cycle.

I am having my temperature taken whenever I enter the hospital, with additional screening questions of “Do you have fever, cough or shortness of breath?” If from the hospital I would go to the outpatient clinic building, I would get my temperature checked again and have the same screening questions, with an additional inquiry of “Were you exposed to a person with known COVID-19?” The last question is tricky to answer, for if I say yes, then they might not let me enter the building. But how else could I answer that question if I have just seen patients with confirmed corona virus in the hospital? Lie, if we must.

Photo by Ketut Subiyanto on Pexels.com

I don’t know if we have flattened the curve in our community. I am not talking about the bulge around the waist, for that has definitely ballooned more in many people with the stay-at-home order and the uncontrolled eating, plus with the gyms being closed. I guess a mask can help with this, as it is impossible to eat when you’re wearing a mask. But I digress.

We still have lots of COVID-19 patients in the hospital, though it maybe less compared to two weeks ago. Yet I still saw 15 COVID patients in the ICU this weekend, and many of them were on ventilators. I say it’s less, for at one point we had more than 20 COVID patients in the ICU and had a steady admission of 1 to 3 more a day. Good thing was many recovered fast, although some also died. There was also a time that we registered close to 50 admitted COVID patients in our hospital, both in the ICU and wards. So are we really flattening the curve?

Even though it is terrifying, we as physicians, have gained lots of knowledge and experience taking care of the critically ill COVID-19 patients. One thing we learned is that not all COVID patients with severe hypoxia needed to be on ventilators. Placing them on humidified high flow (pressurized) oxygen via nasal cannula can prevent intubation, and in fact they have faster recovery and less complications with this. Of course there are still patients that would require ventilator as a last resort, but we probably avoided more than half of our COVID patients from getting on a machine. Our experience in our hospital was extremely good that it was even featured in the local news. We might be publishing a paper on a medical journal about this experience in the near future.

Our hospital has also gained so much experience in placing patients on prone position if their oxygenation is failing. Never have I seen so many ICU patients on their belly. If the patient is awake and not on mechanical ventilator, we instruct them to lay not on their back if able. If they are sedated and on ventilator, we avail a team to flip them on their belly. And based on our experience, this really improves their respiratory status – belly down prevents them from going “belly-up.”

Photo by Miguel Á. Padriñán on Pexels.com

There are also interventions that have rapidly fallen out of favor, at least from our experience. Like giving hydroxychloroquine, the anti-malaria medicine, which we initially give to all our infected patients at the onset of the pandemic, but stop doing so. I don’t want to be political, but there is currently no robust data supporting it. We are also part of the on-going study of giving convalescent plasma to our patients, that is transfusing blood from a person that has recovered from COVID-19 and thus has presumed antibodies. We are also giving other drugs like Remdesivir and Tocilizumab, agents that are still under investigation. We are even conducting our own small trials using other novel drugs. At this time, no one really knows which medicine works. It might turn out that all of these medications are worthless.

As we open our communities more and more, I am anxious that we would see a second wave of infection. Yet I have to accept the fact that we cannot keep the world close indefinitely, for that is not considered living either. We just need to embrace the new reality.

For simple recommendations, first, we need to keep a distance from each other. At least 6 feet they said. But is that distance scientifically sound when we know that a sneeze or a cough particle can travel much farther than that? That is why wearing mask is helpful, for it protects us from each other if we cannot keep a safe distance.

So another new normal is that we need to wear a mask when going out. I know it is a barrier for communication as we cannot see the facial expressions when we talk to people. It is really bad for the deaf or for those who read lips. Probably good for people with bad breath, for they can be accepted back to the society. And perhaps sad for many, as we cannot see anymore each other’s beautiful smile.

Photo by cottonbro on Pexels.com

Lastly, no more handshakes. This act of shaking hands evolved from an era when nobody was trusting anyone, that people have to approach each other with an open hand to show that they were not holding a dagger as they meet. This developed into the custom of a handshake. Maybe now we need to greet each other with a bow, like some Asian cultures do. Or maybe a curtsy. That would be cute. Or perhaps some kind of a salute. Just not the “Italian salute.”

Stay safe everyone.

A Train Ride to the Alps

I know many parts of the world still have travel restrictions currently and some areas are just coming out of lockdown from this COVID-19 pandemic. We don’t know if world travel would ever be the same again, however I just wanted to feature a long overdue post about a trip that we made some time ago. In fact, we made this trip exactly a year past already, in May of 2019.

We rode the Bernina Express. This is touted as one of the most scenic train rides in the world and it runs on the highest railway accross the Alps. We boarded the train at Tirano, Italy and traveled to St. Moritz, Switzerland.

By the way, in this time of pandemic and limited travel, I saw that there are virtual train rides around the world that you can experience (see this link) right now. Bernina Express is one of them.

Tirano, Italy

The Bernina Express travels through the UNESCO World Heritage site via the Rhaetian Railway. When we say World Heritage Site, it is a landmark or area, that is selected by the United Nations Educational, Scientific and Cultural Organization (UNESCO) for having cultural, historical, scientific or other form of significance, and that it is legally protected by international treaties.

And off we go….

The train has comfortable seats and is roomy inside. The glass windows are huge and are up to the ceiling, offering uninterrupted views of the breath-taking landscapes.

We passed through bridges and tunnels, mountains and valleys, towns and even lakes. No underwater tunnel though.

Photo below is the Lago di Poschiavo, a natural lake in the Poschiavo valley near Miralago, Switzerland.

The landscape gradually changed as we went higher and higher in altitude. Not too long from then we were coursing through the Alps. We were on top of the world!

After a little more than 2 hours, we finally arrived at St. Moritz, Switzerland where we boarded off the train. We spent only a shortwhile there, perhaps only to take some photos, and then we headed back to Italy.

This is an instance that the journey is as good, maybe even better, than the destination. A wonderful ride indeed.

St. Moritz, Switzerland

Here’s a short video clip of the train ride as we were navigating through the snow and glaziers that it was like the Polar Express:

From the top of the Swiss Alps,

Pinoy Transplant

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(*photos and video taken with an iPhone)

With Great Distinction

My daughter sat hunch over on a bar stool, and her eyes were glued to her MacBook sitting on top of our kitchen center island. She was watching her university’s President give the ceremonial address on-line. At the end of his speech he conferred to all the graduates, who were watching at their homes, their respective batchelor, master, and doctorate degrees.

It was sad that the commencement ceremony end up in this manner. No marching of the students with their cap and gown on a large auditorium. No roll calls announcing the names as they receive their honor and diploma. No adoring family and friends applauding as their graduate walk up the stage.

The ceremony culminating the hard fought four years of college was a letdown, and I felt sorry for my daughter that her graduation rites came to be this way. Damn this corona virus pandemic!

I certainly know the awful feeling of not being able to march for your graduation, for I myself was denied of that opportunty when I finished my medical school. Though the circumstances in mine was totally different and I have only myself to blame. The memory is still painful up to this day, but that’s a different topic for another day.

However, despite the bittersweet turn of events, there is a momentous achievement that cannot be denied.

Seventeen years ago when our daughter started her formal schooling, we had serious fear. This is a girl who did not speak until she was past the age of four that we even consulted a speech pathologist. When she was about to be a kindergarten, she only speaks in words and sometimes phrases, but not sentences. It’s not that she’s unintelligent, at least that was what we want to believe, she was just different.

We knew that if we enrol her to a conventional school she would be labeled by her teachers, and most likely be bullied by her classmates. But most of all we were worried that she may not develop into the fullest potential that we know she is capable of. That was when we decided to homeschool her. And it was one of the best decisions we ever did.

I commend my wife who did the heavy lifting in homeschooling our kids. I know that there were days that it was a struggle. Yet we pressed on. We were always looking for ways to tap their strengths and fortify their weaknesses, especially in our daughter, hoping to unlock her abilities. But more importantly, we asked for heaven’s guidance in all our undertaking.

Math came easy for her, but language and communication was her Waterloo, and constructing even a 2 or 3 sentence essay was a difficult endeavor. Thus we chose a curriculum that was literature heavy and had them read 20 to 30 short story books or classic novels per school year. One bright thing that happened was when we introduced her to music, it became her language and she found her voice.

We homeschooled her until highschool. Besides the education we had at home we also used tutors to prepare her for college. This included lots of music activities as well. And as she entered college, we were again uncertain of how she would adapt to conventional school. Did we educate her enough? Did we train her enough? Did we equip her enough?

Four years of college had gone by. It went so fast like a blink of an eye. Our daughter did not just survived college, she thrived in it. She got scholarship and maintained it throughout. We were relieved and we felt vindicated.

For any of you my readers, who have a child or know of a child who may be struggling in school, I want you to continue to believe in them. I am convinced that there are no dumb kids. They only have different and individual ways of learning, and we as parents and educators just need to discover their potential. Invest in them, including your time, and if you need to take over their education, then do so.

On this occasion of epic magnitude, our joy is magnified. With magnificent pride and with magnanimous love, we present to the world our 2020 graduate. And she even did it with a Latin honor of Magna Cum Laude.

our graduate

We thank all our family and friends who supported us through this journey, and to God be the glory!

(*She missed Summa Cum Laude by a very slim fraction. But we are not complaining. Magna Cum Laude translates as “with great distinction.”)

Tulip Time

Every month of May there is a place in Iowa that turns into a tulip town. And even though there’s still a scare of the pandemic, we went to visit the place. Of course we practiced precautionary measures and social distancing while we were out.

As their landmark says, it is “Tulip Time.” There is supposed to be a parade also during this festival that showcase the town’s Dutch heritage, however due to COVID-19, it was cancelled for this year. But we can still admire the tulips.

Also popular in this town is the famed Dutch bakery where the baked goods are as colorful as the tulips. The most sought after item though is the Dutch Letter, an S-shaped pastry that taste so delicious. S stands for Sinterklass, the Dutch Santa Claus.

Dutch Letters

Here are some more photos that does not necessarily feature tulips, nonetheless, they caught my fancy.

From Pella, Iowa,

Pinoytransplant.

(*photos taken with an iPhone)

Nanay, Tatay, Gusto Kong Tinapay

Noong isang araw ay nag-bake ang aking misis ng home-made pandesal (Filipino bread roll). Siguro isang magandang epekto ng staying-at-home dahil sa COVID-19 pandemic at dahil na rin sa maraming tindahan at establisyimento ang sarado, ay marami tayong sinusubukang gawin sa ating sarili (do-it-yourself) ang mga bagay na dati nating binibili lang o kaya ay ipinapagawa sa iba. Gaya ng paggawa ng tinapay.

Isa pa ay ang pagkukulay o paggugupit ng buhok. Alam kong maraming mga tao ang napipilitang maggupit ng sarili o kaya’y ipagkatiwala sa kanilang nanay, o mga asawa, o anak ang paggupit ng kanilang buhok. Hindi ko po problema ito, dahil matagal nang ako na lamang ang nagtatabas at nag-aahit ng aking buhok.

Alam kong marami pang mga DIY projects tayong sinubukan nitong mga nakaraang linggo o buwan dahil sarado ang mga suki nating negosyo. Pero mahinahong babala lang po na dahil sarado ang mga klinika ng dentista ay huwag sana nating tangkaing bunutin ang ngipin ng ating kapamilya gamit ang pliers, lalo na’t kung hindi tayo dentista.

Balik tayo sa tinapay, naging matagumpay ang eksperimento ng aking maybahay dahil lasang pandesal naman ang kanyang nilutong pandesal. Naging matayog pa nga ang naging proyekto niya dahil maliban sa plain na pandesal, nag-bake din siya ng ube-flavored pandesal.

my wife’s ube pandesal and plain pandesal

Pero pabiro kong sinabi sa aking misis na hindi authentic ang kanyang linutong pandesal. Hindi ito katulad ng mga kinagisnan kong pandesal sa Pilipinas noong ako’y bata. Ang dahilan ay malaman ang pandesal na linuto niya at hindi gaya ng mga pandesal na binibili namin sa panaderya doon sa amin sa Maynila, na kapag kinagat mo ay malutong-lutong ang labas, pero puro hangin sa loob.

Simple lang naman aking panlasa noong ako’y bata. Masaya na ako sa bagong lutong pandesal kahit pa puno ito ng hangin. Hindi pa noon uso ang mga may flavor na pandesal, gaya ng ube-flavored, o pandan-flavored, o malunggay pandesal. Plain pandesal lang ang tipo ko.

Gusto ko rin naman ng pandecoco, monay, kalihim, kababayan at putok. Hindi anghit ang ibig kong sabihin, kundi ‘yung tinapay na putok (star bread). Noong panahon ding iyon ay nauso ang tinapay na nutriban. Sa katunayan nga ay pinamimigay pa ito ng libre sa mga publikong paaralan. Natikman ko rin naman ang nutriban, pero hindi ko ito masyadong gusto.

Naalala ko rin ang laro ng mga bata habang sinasambit nila ang:

Nanay, tatay, gusto kong tinapay,

Ate, kuya, gusto kong kape,

Lahat ng gusto ko ay susundin ninyo,

Ang magkamali ay pipingutin ko.

Isang araw noong kami’y bata pa ay nag-uwi ang aking tatay ng isang mahaba at matigas na tinapay. French bread daw iyon at baguette ang tawag doon sabi ng aming tatay. Binili niya ito sa Buenos Aires. Teka, kung French bread, hindi ba dapat sa Paris at hindi Beunos Aires, Argentina? Eh kasi iyong panaderya ay nasa kalye ng Buenos Aires sa may Santa Mesa Manila, at hindi ito galing sa ibang bansa.

Sabi pa ng aming tatay ay gusto lamang niya kaming ma-expose sa mga ibang klaseng pagkain at para hindi raw kami ignorante. Pero nang amin nang kainin ang baguette – eh tinamaan ng lintik, matigas pa sa bato ang tinapay na iyan. Sabi pa namin ay maigi pang gawin itong palu-palo sa paglalaba. O pakikinabangan din ito bilang sandata at puwedeng ihambalos sa mga kaaway.

Bumili rin ng kakaibang keso ang aking tatay para raw din matikman namin ang foreign cheese. Kumbaga ay para bang social studies namin at ma-experience ang ibang kultura. Subalit nang aming tikman ang keso, hindi lang mabaho, lasang bulok pa ito! At least, sangayon sa aming ignoranteng panlasa. Inisip na lang namin na baka may amag na iyong keso.

Sa madaling salita, hindi namin nagustuhan ang baguette at ang dayuhang keso. Iyon na ang huling pagbili ng aking tatay ng French bread. Siguro sa isip isip niya, hayaan na lang niya kaming maging ignoramus.

Lumipas ang maraming taon, hindi ko inakalang ako pala ay makakabisita sa bansa ng mga croissant at baguette. Ilang buwan pa lang ang nakalipas nang aking matikman ang original na baguette. Sa totoo lang, masarap pala ito, lalung-lalo na at bagong luto mula sa isang local French bakery.

our simple French breakfast (baguette, of course!)

Tumikim rin kami ng mga kakaibang klase ng keso habang kami ay nasa dayuhang bansang iyon. Anak ng tinapay, hindi ko pa rin maintindihan ang lasa. At kahit hindi ko man sila tuluyang naibigan ay masasabi na kahit paano sila’y aking natikman.

Tungkol naman muli sa pagluluto ng aking misis, ang kanya raw next baking project ay pandecoco at siopao.

(*photos taken with an iPhone)

It is Spring! Not.

The temperature in our part of the world is warming up. In fact last week, there’s a couple of days that it felt like summer as we topped 80 degrees Fahrenheit. The leaves and flower buds are appearing. The grass has turned green and growing. Many of our neighbors have already started mowing their lawn. But not us, we’re not that anxious to start mowing.

Just as you thought spring has fully sprung, then we are hit with this……..

Mid-April snow!

The snow did not stopped me from going out for my morning run. It is after all a balmy 32 degree Fahrenheit (0º Celsius), and the ground is not slippery nor icy.

This lonely goose does not seem to mind the snow as well.

This is crazy Iowa weather. People who grew up here told us when we moved here, “if you don’t like the weather, just wait several minutes, it will change.”

(*photos taken with an iPhone)

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Post Note: Below is what the first photo looked like in the afternoon of that same day with all the snow gone. Crazy weather indeed!

A 2020 Vision

(I was asked to contribute a page for a high school students’ yearbook. My son was one of the co-editors. Their theme was Vision 2020. Here’s the message I wrote.)

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Vision is a precious gift from God. It is one of our senses that we use to interact with the outside world. With our vision we can see a cloudless summer sky, the intricate details of a flower, the changing colors of the autumn leaves, and so much more.

The term 20/20 vision means that one can see a specifically sized target at a distance of 20 feet. 20/100 vision means one can only see the target at 20 feet what another person with 20/20 vision can see at 100 feet. The bigger the bottom number, like 20/200, the poorer the vision.

So important is vision that if we are deprived of this faculty it is considered a disability. But there is a graver condition than having no sight. According to Helen Keller, “The only thing worse than being blind is having sight but no vision.” What an interesting insight from a blind person.

Vision is not just the state of being able to see, but it is the ability to think about and wisely plan for the future with imagination, optimism, and most of all faith to the One who holds our tomorrow. I believe that this is a far more important gift we are given. 

To the graduating class of 2020, we extend to you our sincerest congratulations.

“Where there is no vision, the people perish.” Proverbs 29:18

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Post Note:

Who could have envisioned that the year 2020 will be this unsettling? And we are only a quarter through it. I feel sad for senior students, including my daughter who is supposed to graduate from college next month. She still would graduate, but there will be no commencement ceremonies due to the Covid-19 pandemic. With or without graduation ceremony, should not lessen the momentousness of their accomplishments.

(*The photo above was from a few years back, taken at Nevada’s Highway 50, the loneliest road in America, a perfect place for social and physical distancing.)

A Beautiful Night

I did two overnight in-hospital ICU call in a span of three days lately. This has obviously derailed my circadian rhythm. Normally in our group of intensivists, a doctor only do 24-hour duty once a week or less. But this is not normal times.

So on the day I was off after my back to back calls, I woke up in the middle of the night and cannot sleep anymore. My body was fatigued yet my mind was awake. Instead of tossing and turning in bed, I got up and went to another room so not to disturb my wife who was fast asleep.

I pulled up a chair and sat by the side of the window and stared outside. The night was still and the moon was halfway through the horizon in the sky. The warm glow of the moonlight bathes the whole surrounding and it was quite enchanting. It was after all the super pink moon – the biggest and brightest full moon of this year 2020.

Ah, year 2020. Who could have predicted that this year would be this challenging? At my work we have more than 30 ICU beds, but with the predicted patients surge from COVID-19, our hospital has a contingency plan that we could convert other parts of the hospital into temporary ICUs and that we could potentially take care of 90 critically-ill patients on ventilators. The good thing is we have not seen that kind of surge like what is happening in New York City and New Orleans. At least not yet. I hope we never will.

We do have several confirmed COVID-19 patients on ventilators though, and they are pretty sick. But they are getting better, and the truth is many of them are getting off ventilators after a few days. Even our first ever confirmed COVID-19 patient that ended up on mechanical ventilator improved and got off of it after almost three weeks.

There were deaths though from this virus, even in our ICU and we cannot deny that. In fact the other night that I was on call, there was one patient that was a COVID-19 suspect and I placed him on a ventilator that night. Of course I had my full protective gear when I intubated him. Yet despite of our best efforts he died. But testing came back later that it was not the novel corona virus, but he had positive blood culture for a bacteria and he died from an overwhelming sepsis. People die from other causes as well, not just COVID-19.

As I gazed outside the window, I uttered a prayer for strength and protection not just for me, but for all the healthcare workers that continue to fight this battle. I also prayed for my family and all the families of frontliners who are at continued risk of contracting this disease from us when we come home. More importantly I prayed for the patients and their families that are going through such a woeful and difficult time.

The saddest part of this pandemic is that patients in hospitals are going through their ordeal alone, as family and friends are not allowed to visit them. And for those people who succumbed from this COVID-19, they die alone with nobody to hold their hands even in their last dying breath. It is really heartbreaking.

I looked at the radiant full moon and it was glorious. I observed that the light of the moon cast long shadows on the lawn from the trees. I was unaware on how the trees around us had gone so big and tall now. The evergreens that stayed lush and strong through the cold months and had survived many bitter winters. The deciduous trees that were currently barren but the leaf buds were beginning to appear for it is spring time after all, reminding us that life begins again. I also noticed that there were faint stars in the sky, though their light were subdued by the bright moon, yet they were twinkling whether we see them or not.

All in all, it was a beautiful night.

Photo by David Besh on Pexels.com

Then a thought came to me as if God was answering me. Even if we are going through the night, if we don’t dwell on the shadows and focus on the light, there is still beauty around us. Many times darkness heightens our senses to appreciate the light and other lovely things that we may have taken for granted. Yet the most reassuring thought is that even how dark the night is, morning is surely coming and a new day will emerge.

Yes, we may have lost many in the night and we should remember them, but for most of us, we are going to be alright. Have a blessed and meaningful Easter everyone.

Coming to the Dark Side

Because of this COVID-19 pandemic, as a defense it is now advised that everybody wears a mask when going out. However, there is a shortage of masks available and other personal protective equiptment in many hospitals. Dark times indeed.

Thus, I’m wearing my own respirator mask to work.

“You are unwise to lower your defenses.” – Darth Vader

(*Warning: not a true protective mask. Rest assured for I am donning an officially prescribed PPE when dealing with patients.)