Son’s Regret

In our church this weekend, the pastor asked the congregation how many still have their fathers with them. Several hands rose up. He then told them that they are very fortunate, for there are many people in this world who have no more dads or never knew their dads. He further admonished us, as he slightly choked-up in tears, to appreciate our dads while we still can. I don’t know what our pastors’ regret, but I also did choked up in tears in my seat as I listened to him.

Do not get me wrong, my father and I had a good relationship. We spent much time together as a family. And I love my father very much. But I regret, that I have not been much expressive in letting him know that, or letting him hear my appreciation of him, while he was still living.

Men, more so than women, usually are not good in expressing their feelings. We don’t let our loved ones know our appreciation of them, at least in words.

When my father got sick, and after he underwent a second brain surgery for a deep-seated brain tumor, he never recovered to speak again. And in one of his last nights in the hospital, I stood there by his bedside, and I struggled to tell him how much I am grateful and appreciative of him. But it was a monologue…….for my father was almost comatose.

Shortly after my father died, a song by Mike and the Mechanics, titled “The Living Years” became popular. And this song up to this day, bring tears to my eyes, as it expressed my regret exactly:

I wasn’t there that morning

When my father passed away,

I didn’t get to tell him

All the things I had to say.

I think I caught his spirit

Later that same year,

I’m sure I heard his echo

In my baby’s newborn tears

I just wish I could have told him in the living years.

Say it loud, say it clear

You can listen as well as you hear

It’s too late when we die

To admit we don’t see eye to eye.

I know I have written a few articles as a tribute to my father, and I hope my life is a living tribute to his legacy. But I still wish I could have told him that I really love him, in his living years.

For all of you who still have your fathers with you, tell him how you appreciate him………. while you still can.

Happy Father’s Day.

Behind the Puff of Smoke

Marion was sitting in the examining table. He looked cachectic and debilitated. He was stooping forward, leaning on his arms like a tripod. His lips were pursed as he breath, and was using his neck muscles to assist his respiration. A small tank of oxygen was at the foot of the table and it was connected to a long tube and into a nasal cannula that was hooked to his nostrils. He was obviously struggling, but he managed to flash a smile when I entered the room.

I have known Marion for more than 5 years, and he went through a lot over the years. I have treated him for severe COPD (Chronic Obstructive Pulmonary Disease) and repeated exacerbation, lung mass, bouts of pneumonia, respiratory failure requiring mechanical ventilation, lung collapse requiring chest tubes, and multiple hospitalizations. He had gone weaker and weaker, and is wasting away with every labored breath. It is painful just to see him breathe. He was a heavy smoker, but had quit a few years ago, albeit a little too late. He is paying for all the years he had puffed away with those damning cigarettes.

I hate cigarettes! No, I have no personal vendetta against the tobacco companies. In fact, if there is a career that cigarettes made to flourish, it is mine. I partly owe my profession to cigarettes. Because of so many people who smoke, I have a lot of pulmonary patients, and that I can send my kids to college. And even if smoking will be banned starting today, we will still see the effects of smoking for many more years to come, that my practice will be secure until I retire. But I am witness to the tragic effects of smoking every single day, that it is plainly heartbreaking. I just wish people will stop smoking. Besides, there will be other lung patients aside from smokers, that I can survive with.

It is amazing that even with the known cold hard facts regarding the ill effects of tobacco, people still continue to smoke. And more astounding is the fact, that young people who are well-informed, still start and pick up the habit of smoking. I know it is hard to quit once you have formed the habit, but still it is difficult for me to fully understand why people would continue to smoke even if they are literally dying from it.

Many years ago,during my training in Memorial Sloan-Kettering Cancer Center, I have seen patients who have lost their voice box due to throat cancer, still smoking thru their tracheostomy tube, in front of the hospital, while they lean on their IV poles. I have even seen patients who had caught ablaze and suffered facial burns, as they tried to smoke with their oxygen on. I guess they wanted to go out blazing into the night.

Nowadays most of the hospitals have adopted a smoke-free campus. Nobody can smoke in the hospital grounds, so smokers have to get out of campus to lit-up. Here in Iowa, there is a state-wide ban in smoking in all public places, like restaurants and malls. The only public place that smoking is still allowed here, are in the casinos, but that may change soon too. For some reason smoking and gambling goes together. If you think about it, smoking is really gambling, with your own life at stake.

I strongly advise all my patients to quit smoking. We even provide support, counseling and prescription to help them quit. But still quite a number of them still do smoke and this get me really frustrated. Are they just a bunch of non-compliant morons?

Before I pass that judgement, I should distinguish my aversion between smoking and smokers. I should definitely abhor smoking, but not necessarily smokers. For it is ironic, that many of the good and kind people I come to know, are smokers. Behind that annoying puffs of cigarette smoke, is a person like you and me. A person who may be suffering, a person who needs help, and a person who needs love and understanding in spite of who they are.

After I examined Marion, he told me that I need to keep him going until June. I asked him what’s going on in June. “It will be my 50th wedding anniversary”, as he answered with a smile, “and I would not like to miss it for all the world.” I felt a lump in my throat. I know he is on borrowed time. But I prayed that his wish would be granted.


Post Note (4/14/12): Marion made it through his 50th wedding anniversary. He passed away a year after this article was posted.

Good Night, Sleep Tight

(The following article was written for our local church newsletter.)

“Indeed, He who watches over Israel will neither slumber nor sleep.” Psalms 121:4

That statement of the psalmist pertains to God. However, humans in this modern age also try not to sleep nor slumber. With our 24-hour-a-day schedule, and with a society that makes the night the frontier of the next day, people deprived themselves of sleep. And that is not good for our health.

God created men to work, to play, AND to sleep. Though some creatures only require less hours of sleep, like the giraffe who sleeps less than 2 hours a day. But for an adult human, we need an average of 7-8 hours of sleep to stay healthy and to function properly. (Babies and kids need more.) Even though we still not fully understand the science behind it, we know that sleep is needed to regenerate certain parts of our body, especially our brain. Somehow sleep resets our brain to work optimally.

Sleep deprivation has become one of the most prevalent public health problems of our time. It is estimated that in our modern culture we sleep an hour and a half less than people did a century ago. Of course, they don’t have televisions that have programs like “Late, Late Night Show” or computers and internet that is basically 24/7, a century ago.

Rx for sleep deprivation is more sleep, not more coffee.

Our society’s lack of sleep is evident on many mishaps that we had. The 3-Mile Island, space shuttle Challenger and Exxon Valdez accidents were partly blamed on human errors caused by operators who were sleep deprived. The American Academy of Sleep Medicine reports that 1 out of 5 serious injuries from traffic accidents is related to a tired and sleepy driver.

When we lack sleep, it impairs our cognitive function, judgement, reflexes and reaction time. In studies, people who were awake for 17-19 hours and drove, they performed as bad as people who were drunk with an alcohol level of 0.5 percent. That means if you are awake since 6 AM and driving at past midnight, you are as good as drunk! Now what if you even had a real drink too? That will be really bad.

Some people who are always tired and sleepy may have real sleep disorders, like sleep apnea, restless leg syndrome or narcolepsy. They need to see their doctors or better yet referred to a sleep clinic. But many of us who are sleep deprived, are because of our own choosing not to sleep.

If you cannot sleep because of many worries and anxiety, which is by the way the most common cause of insomnia, then maybe you can find comfort in this text: “I will both lay me down in peace, and sleep: for thou, Lord, only makest me dwell in safety.” Psalms 4:8.

Good night. Sleep tight.

Crash and Burn(out)

For the past month or so, I have been reviewing for my Critical Care re-certification Board Exam. In the US, they want us to re-certify every 10 years for our (sub)specialty Boards. So between certifying and re-certifying in Internal Medicine, Pulmonary Medicine, Critical Care Medicine and Sleep Medicine, it seems like I’m taking exams every year or so.

Few days ago, in my reviewer book, I came upon this practice question which made me think. I have never read this topic in any textbook nor heard it in any lectures or review course before. But after a minute of deliberation, I guessed the answer right.

Here’s the  review question:

Which is most commonly associated with burnout among critical care professionals?

A. Conflicts with patients and their families.

B. Conflicts with coworkers.

C. Severity of patient’s illness.

D. Increasing age of clinician.

So what’s your answer? Believe it or not, among the stressors that contribute to burnout among critical care professionals, conflict with coworkers is the most common (choice B is correct). In a survey of almost 7,500 ICU physicians and nurses, conflicts were perceived by 71.6%, with nurses-physician conflicts being the most common. It is also interesting to know that younger intensivists with less experience had higher levels of burnout than their older counterparts. (Source: ACCP-SEEK vol.XX)

I know that working in a critical care environment has a high burnout rate. And I am glad that I have no problems with my co-workers: fellow physicians, nurses, and other medical ancillary workers. This gives me more reason to love, appreciate and always try to get along with my co-workers – not only for the sake of the health of our patients but it is good for my health too.

Being in this line of work for more than 10 years, makes me old, but that is reassuring to know that being experienced makes me less prone to burnout. So there’s actually an advantage of getting old!

If I would give advice or create a practice question, here’s what I will draft:

What will be the best way to prevent burnout in your work?

A. Change career into a less stressful one. (Like, ah…. er….. a professional clown? On second thought, I don’t think a rodeo-clown is less stressful!)

B. Quit your job, and live in a remote place out of civilization, like a hermit.

C. Party every night after work, as if there’s no tomorrow, to release your stress. (Make your motto: eat, drink and be merry, for tomorrow you die!)

D. Start and learn a new hobby……….like blogging!

I guess you know what answer I highly recommend.

I Don’t Know. But That’s Alright.

Not too long ago, I diagnosed a patient with sarcoidosis. She asked me what was the cause of her disease and I offered her that I have two versions of the answer: a short one and a long one. She requested for the short one, which I said “I don’t know”. I went ahead and gave the long answer too, as I can read in her face that she was not satisfied with my short version.

I told her that sarcoidosis results from a specific type of inflammation involving lymphocyte and mononuclear cells forming caseating granuloma, which in some theories said could be triggered by occupational or environmental exposures, while other theories implicate infectious agents, some think it is an auto-immune disease, and some believe it has genetic association — but all theories are not proven, so we really don’t know. I think I made her more confused after that, but she was satisfied with my answer.

There are so many things in this world that we still don’t understand and we don’t have answers to. Of course there are more things that have answers, but you and I, as an individual, may have not just learned it yet. And I think there’s nothing wrong to admit if we don’t know them.

I have been asked by patients questions that I don’t know the answer, and I tell them so, but promised to looked them up and study to provide an explanation for them. I also have been asked by my medical residents and students during hospital rounds, questions that I don’t know the answer and I admit to it. So I tell them I’ll read up on it, or better still, I tell them to research on it, and give us an informal report the next day, so they could learn it better (we tend to retain information better when we read it ourselves rather than hearing it from somebody else) and so I could learn from them too (students can teach their teachers more ways than one, you know).

I remember our Principal during my high school days saying: when we finish high school, we think we know everything; when we graduate from college, we find out that we know something but not everything; after graduate school, we realize we really know very little, but so does everybody else. I find that statement very true, for the more knowledge we gain, the more we discern how little we really know.

Einstein explaining how to draw circles and squares?

I don’t think we show our weakness when we admit that we don’t know. But we show our strength when we do something about what we don’t know. We show our true ignorance when we don’t admit that we don’t know, and worse if we don’t do anything about it, or even pretend that we know.

So what is that theory of relativity again? I don’t know. But I’ll look it up (though it does not guarantee I’ll understand it!).

Lesson From A Limping Deer

It was a lazy weekend afternoon. I was just relaxing sitting by the window, and my thoughts were wandering beyond the confines of my dwelling. In fact, one of my favorite form of relaxation (aside from blogging), is just staring blankly beyond the blue. It’s transcendental daydreaming.

My quiet musing was disrupted by the sight of familiar visitors intruding and frolicking in my yard. Even though I’m used to seeing deers in my lawn, something was quite different this time.

As I observed them more closely, I noticed that one of the deer was limping. I hurriedly grabbed our camera, and zoomed in to see closer.

I was surprised that one of the hind legs of the limping deer was rotated backward. It appeared that it was dislocated from the hip or fractured above the knee. (Maybe I’ll have a career in veterinary orthopedics.) Perhaps she had a close encounter with a speeding car: got mesmerized with its headlights and did not move out of the way quickly enough. But she lived and did not become a roadkill. And she had the evidence to show of that tragic encounter.

My first reaction was I felt sorry for the deer. That must be a painful experience. And perhaps more painful to struggle with everyday existence with her injury.

Deers are agile animals. They are fast runners and strong leapers. Thanks to their powerful hind legs. But with only one good hind leg, this deer was in a great disadvantage. How could she survive in this cruel world?

I thought of giving her food by bringing it out in my porch. However, something stopped me. First, I may just scare them away when they see me go out. Second, my wife would probably get mad at me, as I know she really hate those deers, for they massacre her flowers. And besides, by providing food for that deer, would I help her situation or just make it worse?

That deer did not asked for my pity. What she asked for is time and chance, to show me and the other creatures, that she is fine and that she can rise above this tragedy and survive on her own (three) feet.

How about us? Do we gripe that life is unfair and cruel? Or maybe we already had been wounded and injured. Do we give up and wallow in self-pity? Do we continue to parade our open wounds so people would show us mercy? Or do we lick our wounds and rise to the occasion and overcome the adversities that life had dealt us with?

I noticed that the deer was moving with ease and had no apparent distress despite of her injury, telling me somehow that her accident was quite a while back already. As she scurry and bounced away gracefully, albeit with a limp, somehow she showed me, that she had learned to adapt to her condition and that she had already conquered her disability. She had three good legs left, and that’s all she need to survive.

Slow Place, Quick Opinion

I drove to southern Iowa a few days ago to my new outreach clinic, which is about 70 miles (1 hour and 15 minutes drive) from Des Moines. After seeing all my patients there in the morning, I headed then to my other outreach clinic (still in southern Iowa) for the afternoon, which is about 30 minutes away from the first one. I visit these satellite clinics, outside of Des Moines, once every other month. (Most specialty clinics from bigger cities in Iowa reach out to many surrounding small towns to provide services.)

On the way to my afternoon clinic, since it was lunch time, I decided to get food. I passed a small rural town (estimated population: a couple of thousand people) and searched for a place to eat. I looked for something familiar and a restaurant that I knew would be accepting credit card, as I had only a few dollars in cash. Come to think of it, I rarely carry more than $20 in my wallet, as I exist by the swipe of the card.

small Iowa town (photo from New York Times)

I saw a Subway franchise restaurant and stopped there for lunch. The place is quite small and I thought to myself, since it was a small town, it must be a “slow” place. I wondered how can this franchise survive in this “remote” place. Sure enough, when I entered, there was no body sitting in the tables, though there were 2 people in the counter placing their order to-go, ahead of me. That would be OK, I would be eating in my lonesome, but at least a quiet meal.

After I got my order, I sat by the window in an empty restaurant all by myself.  However, I soon observed that one after another, cars started pulling up in the parking lot. A wave of people came trickling in non-stop. In a short period of time, the restaurant was bustling and full of people, and I felt like I was in a crowded downtown joint. Must be a popular place to eat. What did they do, invite the whole community for a lunch party?

As I left the place, there were several people seated in the tables, and there were 42 people (yes, I counted them!) in line, waiting to make their order. A “slow” place huh?

How many times do we quickly form our opinion and judgement on many things, just based on our first impression? And many times it turns out to be wrong.

Treasure in the Junk Mail

buried in junk mail

Few days ago, my wife cleared out all the letters, and junk mail in our table. As we received a lot of materials in the mail, most of them junk mail, they just piled up in our counter. Most of the time, I will separate the bills from the rest of the mail, and put it to my important mail pile. (Yes, all I am searching for in the mail are bills!) How funny that the only “important” letters we receive nowadays are bills.

As there are some personal information on the letters and even in the junk mail, my wife decided to shred them before she toss them away. As she was sorting the pile of papers and envelopes, she found an envelope with a check inside that amounts to more than $1,500 named to us. Yes, more than $1500! The check was sent to us more than 4 months ago. It was from our previous bank lender and it was given back to us, when we refinance our home to a new lender. We have mistakenly stacked it in the junk mail pile.

I cringe at the thought that we almost shred  and throw away  a nice sum of money. We have never thought that there’s something precious buried in that pile of junk letters. And we never even knew that we had it.

Sad to say, there are also other precious things in our homes that we are not aware of, or worse, pay no attention to. Treasures that are buried in the clutter of our busy lives. Valuable moments that are stacked upon by our preoccupation and distraction to “junk mails.” Constant deadlines, overtime at work, games and amusements, TV, computers, and other forms of entertainments heap over and bury this simple treasures.

A quiet family meal time together, a moment reading with your child, tutoring them with their homework, or time just playing with your children — these are the treasures I am talking about.

My son just entered the room with a chessboard in hand. I think I should finish this piece and heed my own advice.

Failed New Year’s Resolutions

Today is already the end of the first month of the new year. We blink and time will pass us by.

How long does a new year’s resolution last? A lifetime? The whole year? How about a few days to a few weeks.

Yesterday, I went to the gym. It was notable how different a couple of weeks made. It was not as crowded as it was a few weeks ago as I wrote in a blog before. Does that mean the people with resolutions to go to the gym and exercise, fizzled out already?

This is a classic example of human endeavor. We just cannot sustain our initial enthusiasm, nor can we finish what we started. Are we doomed to fail? Maybe this is the very reason why some people (that may include me) don’t make new year’s resolution at all: the fear of failing.

However, if we don’t at least make an effort to commit ourselves to change or make resolutions, then I believe that it is more dangerous, for we will not care at all. For me, it is better to make a resolution and fail, than not make one, or not care to change at all. I know no one can claim that he/she has no more room for improvement. For we all do.

Go ahead, try to quit smoking for the thousandth time. Try to exercise more regularly instead of once a year. Try to live more healthy. Try to stop chewing your fingernails. Try to blog everyday (I’m still working on this). Try to take a bath everyday or at least once a week (you have to, for the sake of the people around you). Try to be more patient and loving. Try to make more time for your family. Or just try to be a better person.

If we fail? There’s always the next year. We only really fail, if we completely quit trying.

By the way, who said you can only make resolutions during new year? Start one today.

Walk Fast, Live Long

(The original article is written for a local church newsletter.)

Fish were created to swim, birds were created to fly, and men were created to walk (although some are born to run). Even though most of the land creatures crawl or walk in all fours, human beings stand upright and walk on their two feet. From the dawn of history – from evading our predators, to the present – to strutting on the catwalk, moving on our feet is key to our survival.

We may not think of it much, but there is a lot of science, physics and physiology in standing and walking upright. How a creature can remain vertically steady against gravity without tipping over is already a marvel. And to move by shifting our weight from one foot to the other like an inverted pendulum and remaining perfectly balanced and straight up while walking is really amazing. Sometimes this equilibrium malfunction, like people who suffered stroke, and walking becomes a challenge. Indeed, we are fearfully and wonderfully made.

The most physiologic way of going from point A to point B for humans is by walking (not Segway). It is estimated that an average human being will walk 65,000 to more than 100,000 miles in his lifetime depending on his level of activity. (65,000 miles is almost 3 times the distance around the world.) The thing is the more we walk, the better. Unlike cars, humans last longer with higher mileage.

Studies have showed that the more active we are, the healthier we become, and the longer we live. In one study, researcher analyzed more than four decades of data from the Framingham Heart Study. They found that life expectancy at age 50 for people with medium activity was 1.5 years longer than those with low activity, while the high activity people live 3.5 years longer.

For most people, the optimum walking speed, that is the speed where our kinetic energy  is balanced with our potential energy, is around 3 miles per hour. We may not consciously think on how fast we walk, but our walking speed can be a simple reflection of how healthy we are, or how well our body systems are doing.

In a recent study that was published in Journal of American Medical Association this year, it stated that walking speed predicts life span and health. It was a meta-analysis of 9 separate studies of individuals 65 years or older. The study measured the walking speed of more than 34,000 seniors. They found that for every one-tenth of one meter per second increase in walking speed, survival rates for additional years increased exponentially.

Thus walking faster just not make you reach your destination earlier, or just make you appear that you are a man with a mission. It is also an indication of your longevity.

Let’s walk. And a little bit faster please.

Ang taong naglalakad ng matulin, (kung matinik malalim)………..buhay nama’y mahaba ang aabutin.