He Checked Out

It is a lonely world out there.

Yes, we have this modern technology of all the world being connected and wired through broadband networks, internet, Wi-Fi, and all platforms of social media, and yet the proportion of the population suffering from loneliness and depression is on the rise at a rate that we have never seen before.

A couple of weeks ago, a man suffering from Parkinson’s disease presented to the hospital for progressive weakness and failure to thrive. He needed to be placed on a non-invasive ventilator (BiPAP) for respiratory failure. He was admitted to the ICU by my partner the night before.

I went to see the patient the next morning. Before going in to the patient’s room the nurse at the station made a comment to me, “I think he just has no more will to live.”

I examined the patient and I spoke to him. Despite him on the BiPAP mask, he was still able to communicate. After learning more about him, he expressed to me that he wanted to be DNR (Do Not Resuscitate), meaning, to let him go peacefully if his heart stops.

I learned from the patient too that his wife passed away recently. He also had a son that lives in the area but he did not want him contacted. His next of kin that he put on record was his church pastor.

I tried to get him off the non-invasive ventilator but his oxygen saturation dropped so we had to place him back on it. But I told him that we could take him off the BiPAP mask briefly to let him eat, however he said that he had no appetite.

After our initial work-up, his condition was still a conundrum. He was not in congestive heart failure. He had no apparent pneumonia. He had no viral or bacterial infection. He was just unwell.

I think the nurse’s assessment was spot on. The patient simply gave up on living.

That night, a little past midnight, my phone rang. It was one of the ICU nurse telling me that our patient went bradycardic (low heart rate) and then went into PEA (pulseless electrical activity). The nurse commented, “He checked out.” He gave up the ghost and died.

The saddest part as I learned later, was that there were no friends nor family that visited him. There was nobody around, except for our hospital staff, when he died.

I don’t really know what was the story behind this patient. What I know is that he was lonely and that he did not care to live anymore. What if somebody was there for him? Could it have made a difference?

Please take time to show people, specially our loved ones that we care.

(*photo taken from here)

A Warm Lunch

I have been back to work this week after a brief break when I went to California to visit my aunt.

(photo taken when we drove to the airport to fly back home)

I have been seeing patients all day in the hospital for the past few days and it has been hectic. We have already seen the first case of the flu admitted in our hospital this season and we are bracing for a more brutal time ahead as the wintry air have started to blow.

I don’t like to bash hospital food, but if I have a chance to eat somewhere else besides the hospital cafeteria, I would do so. I wish there is something like the Manila Sunset Grille (see previous post) in the hospital grounds for that would be bliss.

But I have a busy schedule, and going out of the hospital to get lunch is much of a hassle plus I don’t have much time to spare. So regularly I just go to the hospital cafeteria to grab something to eat just to avoid hypoglycemia. I don’t care if it tastes like cardboard as long as the food is edible. Usually I would inhale my food and then continue my hospital rounds.

Yesterday I was in the hospital cafeteria to get lunch. It was still not that bad as I still had time for lunch for there were rare times that I don’t. The lines were long when I went there. As I head down to the cashier, I was getting impatient as the line was not moving as fast as I wanted. In front of me was an old frail lady who moves gingerly slow. She was taking a longer time as she dug deeply into her purse. It was like watching the character of the sloth who moves in slow-motion in the Disney movie Zootopia.

After the old lady handed her money to the cashier which felt like an eternity to me, she took a look at me. I was wearing my white doctor’s lab coat with my to-go box on one hand and a bottle of water on the other. Then the old lady softly told the cashier that she wanted to pay for my food, as she appreciates people who works in the hospital.

I felt like ice-cold water was poured on the fiery coals on my head. I was having unpleasant mood and yet this lady showed me goodness. Shame on me!

Since I knew the cashier as I am a regular in the cafeteria, I told her not to let the lady pay for my meal. I thanked the lady though but politely declined her offer. I told her that I should be the one paying for her meal, and that I really appreciate her gesture.

Yes, there is still goodness in this world. This old lady made me believe again in human kindness.

I still quickly gulped down my food. But I leisurely savor the warm affection I was served.

Rx: Sleep

This year is quite hectic for me. Besides the load at work and other responsibilities, I also have to renew 2 of my 3 board certifications. That means I have to study and pass my board exams to keep my certifications.

The governing bodies of Medicine wants all the practicing physicians to be updated and competent in their field of expertise. After all the discipline of science and medicine is ever evolving and what may be true some years ago, may not be applicable today. That’s why doctors have to take regular scheduled exams to maintain their qualifications.

Most of the medical specialties need re-certifications every 7 to 10 years. But now, they are introducing an option of taking the test every 2 or 3 years. More frequent test, oh fun!

The first exam I had to re-certify for this year is for my Pulmonary boards. I am relieved to say that it is past and done. I took my re-certification exam last May, and for 4 months before the boards, I devoted at least 30 minutes a day for review. It must have been worth the efforts for I’m proud to say that I passed it. I’m good for another few years on this sub-specialty.

The next exam to tackle is this coming November. It is for my Sleep Medicine boards.

I took a break in studying the month of June. But this July I’m back to the books again. I’m allotting half an hour (or more) every day for study.

Come to think of it, this might eat up some of my time for training for the annual half-marathon that I do in October. Should I just skip the half-marathon this year? Though I think I should still do my regular 2 to 3-mile run to keep me from getting too flabby.

Should I take a break from blogging too? Nah! Blogging is actually my relaxation.

I was on 24-hour duty the other day, and it was a busy call. It was not until 2 o’clock in the morning that I went to bed in our hospital call room, only to be called several more times during the remainder of the night, or should I say early morning. One particular ICU patient that I admitted around midnight was so sick, that he died 6 hours later despite our best efforts to keep him alive.

By the way, my other sub-specialty is Critical Care (ICU Medicine) and my Critical Care boards re-certification is due next year. That means I will be studying again for next year. Who said you’re done taking test after you graduate from school?

Anyway, I was off the next day after my 24-hour call. I decided to do some “light” reading to prepare for my Sleep Boards. My brain may be half-awake, but I was resolute to stick to my schedule. But do you know that according to research, dolphins can have half of their brain asleep while the other half awake? Maybe I was trying to be a dolphin.

It so happened that when I opened my reviewer, the chapter I was about to read was about sleep deprivation and its ill effects on our health. Wasn’t it so ironic? I was studying about the bad effects of sleep deprivation, and I myself was sleep deprived!

I stopped reading. I put down the book and did the best thing. I went to sleep.

(*photo from the web)

An ICU Love Story: A Reload

I have posted more than 850 articles and stories over the years since this blog’s inception, which in a few months, will be 10 years. It’s quite a popular practice in the media to have reruns or replays. Even social media have their “throwbacks.”

I would like to repost a throwback story/article once in a while, not that I am running out of ideas or stories, for as a matter of fact, I have more than 30 unfinished articles in my draft bin. But sometimes, I just want to relive a bygone moment, or perhaps give a new breath to a favorite story from the past.

Here’s a reload of a love story that I witnessed a few years ago:

Making Things Right

“I just want to make things right.”

That was what my patient told me. Wanting to make things right. Don’t we all? Here is his story.

He was in his 50’s, and he presented to the hospital with leg swelling and worsening shortness of breath. After initial work-up in the Emergency Room, he was diagnosed with blood clots in the legs and lungs (veno-thromboembolism). A serious condition.

His chest CT scan also showed a lung mass. After further work-up, which includes a biopsy, it was found to be cancer. Cancer in itself is a risk for developing blood clots. A bad prognosis.

After more work-up, it was determined that the lung cancer was far advanced. It has spread to the bones, liver, and lymph nodes. A grim outlook.

During his hospital stay, his condition deteriorated and was transferred to the ICU.

I approached him as he lay in his ICU bed. Knowing the severity of his condition, I asked him about his “code status.” That is, what he wants us to do if in case he cannot breathe on his own, does he wants us to place a tube down his throat and have a machine breathe for him? Or if his heart stops, does he wants us to shock his heart or pound on his chest to try to resuscitate him? Or does he wants us to just let him go peacefully?

There was a long pause before he replied, as he breathed heavily under the oxygen mask. “I want everything done,” he finally answered. “I want everything done, until I have done one thing. I want to get married.”

Get married? Did I hear him right? Was he of a sound mind or was he confused and hallucinating?

As he continued talking, I ascertained that he was very alert and not confused at all. I did not ask why he wanted to get married, but he explained to me the reason why. Perhaps he saw the quizzical look on my face.

“I just want to make things right,” was his reason. Apparently, he was living-in with his girlfriend for twelve long years. He wanted to make their union legal. This would make her girlfriend the legal decision-maker for him if he becomes incompetent. And she would also inherit his estate without questions, when he dies. But more so, he just wanted to show her how he loved her over the years, but did not quite made it to the altar. Now, he was “making things right.”

Two days later, there was a wedding ceremony in our ICU room. A bride, a groom, a chaplain, and a couple of witnesses. That was all you need for a wedding. Of course there was a gown too. But it was the groom who wore it, for I’m not pertaining to a wedding gown, but rather a patient’s hospital gown.

There was many well-wishers too, courtesy of the ICU staff.

The patient’s son was also present. I believe he was his son from a previous relationship, and he came from out-of-state to visit his very ill father. He was probably expecting to attend a funeral, but was surprised that he was attending a wedding instead.

A few days after the wedding, our patient’s condition improved that he was able to be transferred out of the ICU to the Oncology floor. Perhaps, getting married gave him hope and a different outlook in life, and willed himself to get better.

He was started on combined regimen of radiation therapy and chemotherapy. Hope springs eternal.

Two weeks later, his condition started to decline once more. He grew weaker and weaker. His respirations became more and more labored. This time, he told us, he does not want to be resuscitated if his heart stops or if he cannot breathe on his own. I guess, he already accomplished his one wish, and now he was ready.

Then one day, he quietly faded away at the break of dawn. And he left a newly wed bride, a widow.

Cancer stumps hope. A so familiar refrain, sadly to say.

Yet love conquers all.

**********

(*This story was originally published in July of 2011; featured photo was taken a few weeks ago.)

Unburdened

It has been rough going for us in the past few weeks. Our work group is limping with regards to our coverage of clinic duties and hospital calls.

One partner is on maternal leave. There were sickness in our ranks as well for two of my partners went down with flu at the same time and they were incapacitated for a day or so, and we scrambled to cover for them. Then another partner underwent surgery and have limitations on doing procedures that we have to switch around our rotations. And with recent spring break season, there’s always one of us that is out of town for a vacation that has long been scheduled.

But life goes on and we managed.

I am in-charge of the ICU for almost two weeks now. It is awfully busy and I am in a lot of stress to say the least. My wife have noted that I’m in a foul mood in the past few days. Perhaps I’m becoming a grumpy old man. Or perhaps it’s male menopause, if that’s even a thing. I still blog though, partly to de-stress.

Then a couple of days ago I received an e-mail from our group’s Risk Manager forwarding a letter from the hospital’s Guest Relations Office.

When the hospital’s Guest Relations Office is involved, it is mostly to pacify disgruntled patients and families and to hear their grievances. And when Risk Management contacts a doctor, that’s not a good sign, as most of the time it means a patient is complaining or worse yet, filing a lawsuit.

This is at the heels of a recent local news of a patient that sued a doctor and the jury awarded the complainant several million of dollars for damages. The compensation was so steep that most medical doctors could not earn that amount of money even in their whole lifetime. As a physician it bring shivers down my spine. I am not saying that the doctor in that case is not at fault, but this is just the reality of the world we lived in.

The e-mail I received said that the call came from the family of a patient that I took care in the ICU. It was an elderly woman who became severely ill and died under my care. She was one among the recent strings of our hospital fatalities.

I am already under a lot of pressure from the ICU’s workload and I don’t need any more bad news or added stress.

But as I continue to read the letter, my yoke was suddenly lightened. In fact my burden was lifted and turned into joy.

The letter said that the patient’s daughter reached out to the hospital’s Guest Relations Office and recommended that her experience be forwarded to the appropriate leadership body. And it named me specifically.

What the patient’s daughter wanted was that me and two of my residents “be recognized for our hospitality, warmth, and kindness.” She shared, “they were wonderful in explaining my mother’s circumstances. I cannot even find the right words to express what they did for me. It was so heart-warming.”

God knew I badly needed some encouragement. And I am so grateful He provided me one.

(*photo from the web)

More than Tylenol

It was the height of flu season. I was working that weekend, and I was in the hospital for 36 hours straight. We had several patients in the hospital that had complications from the flu. There were five on ventilators due to respiratory failure from Influenza A in our ICU. Two of them were on ECMO.

ECMO is short for extracorporeal membrane oxygen or also known as ECLS, extracorporeal life support. It is an intervention to provide adequate amount of gas exchange or perfusion in patients whose heart and lungs have failed to sustain life. It is done by placing a large bore catheter in the patient’s central vein or artery, where the blood was sucked out from the body, then ran through a machine to bathe it with oxygen, then flow it back to the body.

Saturday morning, I got a call from another hospital for a woman in her 40’s who had Influenza A and who was rapidly deteriorating. She went into respiratory failure and was placed on ventilator. They want to transfer her to our hospital for possible ECMO.

We rarely have two ECMO patients at the same time in our ICU. Even one patient on ECMO makes us busy, so two was really demanding. But a third one at the same time? That never happened before.

I made some phone calls to verify if we have a machine for a third patient and if we have enough resources and staff to handle a third ECMO. After confirming, I was given the green light to accept the patient.

Additional ICU and ECMO staff were called to come in. I called the interventional cardiologist-on-duty who would assist us to put the Avalon catheter, a dual-lumen catheter half as big as a garden hose that goes from the jugular vein and through the heart. The cardiologist in turn called the cath lab to prepare for the arrival of this patient.

Avalon catheter in correct position (image from web)

The patient was flown in via helicopter to our hospital and went straight to the cath lab where me, my ICU and ECMO team, as well as the cardiologist and his cath lab team were waiting.

We were ready for the challenge and eager to make it happen.

While we were doing all this, our patient’s oxygen saturation was only in the 70-80% (below 90% is perilous) despite maximum ventilator support, so we knew we needed to work fast.

However problem struck. Working for more than an hour, we had difficulty placing the Avalon catheter in good position. We tried different approaches with different instruments, but cannot get the ECMO flow going.

I called my other partners over the phone and I probably disturbed their quiet Saturday afternoon off, but I needed some opinion of what else we could do.

After deliberation, we decided that we cannot sustain this patient on ECMO. Perhaps it was her vascular anatomy, or perhaps there was a big clot in her vein. Whatever the reason, we could not proceed.

I went out to the cath lab’s waiting room, and gave the sad news to the patient’s family that we couldn’t do the ECMO. All I could say was that we tried and gave our best, but it was unsuccessful.

I felt that we betrayed this patient and her family. After I thought I moved heaven and earth to get this patient to our hospital, only to end up like this was really deflating.

The worse part was, I knew that without ECMO, this patient had little to no chance of surviving and possibly could be dead in a few hours.

We transferred the patient to the ICU, but we left the big neck catheter in place even though it was not hooked to the machine. We have to wait for the heparin (anticoagualant) we gave when we attempted to start the ECMO, to wear off before we can pull the catheter out.

After about half an hour in the ICU, I was informed that the blood test showed that the heparin had worn off and I can remove the catheter with less risk of bleeding.

When I pulled the Avalon catheter out, I applied direct pressure in the patient’s neck to control the bleeding. I did this for 30 minutes. I was alone in the room with the patient most of that time, with the nurse intermittently coming in and out of the room to adjust the IV pumps or to check on the patient.

All along while I was holding pressure, I was watching the monitor which showed that the patient’s oxygen saturation was staying in the low 80%. I thought death was imminent.

During the time when I was alone with the patient, I felt helpless and defeated. I failed her. We failed her.

Then a thought came to me: I don’t save lives. It was not up to me. Only a higher power determines who will live or die. That’s when I fervently prayed.

With my hands on the patient’s jugular holding pressure, I turned my thoughts to heaven: “God I am nothing, but an instrument of Your healing hand. I failed. But You never fail. I don’t know this patient personally, but I am personally praying for her. Please heal her in my behalf, and let me witness Your awesome power. Amen.”

How many times have we prayed for a sick loved one? But do we really believe God would heal them? Do we add the phrase, “if it is Thy will,” so we wouldn’t get disappointed?

As a doctor, sometimes, I put more faith to the medical intervention than God’s healing. Like when I was bedridden earlier this year due to a bad viral infection, it seemed I had more faith in the Tylenol that I took than in God to take away my fever.

After 30 minutes of holding pressure the bleeding stopped. I left the room and went to see other patients, especially the new ICU admission, a young man in his 20’s who had a bad asthma attack, so bad we had to place him on a ventilator.

As I was busy attending to other patients, I was just waiting to be called back to that particular patient if she goes to cardiac arrest or expires.

More than an hour later, I went back to the room of our failed ECMO patient. I looked at the monitor and her oxygen saturation was 100%. I was amazed! The respiratory therapist told me that she even titrated down the oxygen level on the ventilator to almost half as the patient was really doing good.

I had no other explanation but one: God heard my prayer.

I went down to my call room to be alone. With tears welling in my eyes, I uttered a prayer of thanks. Never would I doubt the power of God again.

He healed my unbelief.

********

Mark 9: 23 -24: Jesus said to him, “If you can believe, all things are possible to him who believes.” Immediately the father of the child cried out and said with tears, “Lord, I believe; help my unbelief!”

*Post Note: Our failed ECMO patient survived. She even did better than the two patients we had on ECMO.

Calendar Boys

I was rounding in the hospital with my team when we came to a room of one of our patients. The patient was a frail woman in her 70’s, who had significant lung disease and was oxygen dependent. She had improved on this hospitalization and we were discharging her home.

When we were heading out of the door, I overheard the patient told one of my team members, “I want a copy of that calendar.”

I have no idea what they were talking about, and not trying to be nosy or maybe little bit, I asked my resident, “What calendar was the patient talking about?” Since it is a new year, perhaps the hospital is giving away new 2019 calendars, I thought.

Then my medical resident sheepishly smiled and told me the whole scoop.

I learned that this patient thought that our team was “hot” and she was calling us the “Dream Team.” I have been in this teaching hospital for 15 years and have rounded with hundreds of medical students and residents that came and went, but I have never heard my team referred as such before. Or maybe it was, but I was just not aware of it.

So this particular patient, the elderly woman, suggested as a jest to my resident, that “we,” or my team should put out a calendar featuring our team members as models. Whether it’s a white lab gown edition or dress suit edition or a swimwear edition of this calendar they were thinking about, I dared not ask!

I then looked at my current team, and agreed that the old lady had a point. My team appears “hot.”

One of my new resident is a blue-eyed gentleman of English decent, clean-cut and handsome. Now that I think about it, he really looked like a much younger version of the actor Mark Harmon.

The other new resident is a young good-looking French guy with well-trimmed mustache and beard, with hair slickly combed back. He always dress very neatly too.

And then there’s the attractive and muscular Asian hunk of a guy. But before you think I was referring to myself as the Asian hunk, I was not. I was talking about the 4th year medical student I have on my team.

Of course I don’t consider myself as chopped liver. I can definitely hold my own. I deserve to be in that calendar too!

We have women medical residents and students as well in this hospital but it just so happened that this month’s rotation, I have all male house staffs.

But seriously, I never consider much the appearance of my residents. When I evaluate them during their rotation in our service, it is mostly based on their performance, their knowledge, their willingness to learn, and their emphathy to our patients. But of course we don’t want them to appear like hoboes or dress like gangsters. They need to look professional too.

I understand that our patients get well mostly due to our comprehensive care stemming from our intelligent decisions, skillful procedures and emphatetic support. But if our good looks help them heal faster, then I am fine with that too.

Would I put out a calendar featuring my team? Don’t count on it.

(photo is from the show Grey’s Anatomy)

A Battle Within

There is a raging war inside of me. The resulting blaze and smoke of this battle is evident while I am shaking and crouching under my blanket.

It all started a few days ago when the enemy gained unwelcome entrance to my domain. Perhaps these intruders escaped from another territory by a sneeze in which they could travel up to 20 feet at 100 miles per hour, and they usually travel as a mob with 40,000 others of their gang.

They got a foothold on my borders through my nasal and airway passageways. It’s really difficult to close all the entryways unless I quit breathing all together. The invaders then broke through my barriers and overwhelmed my sentinels. I should build a border wall and have Mexico pay for it. Hah!

As soon as there was a breach in my initial defenses, my border guards alerted the headquarters and radioed for back-up. They have identified these infiltrators and relayed their profile to the central intelligence.

The headquarters searched the database if I have a pre-fabricated artillery specific for this certain enemy. But lo and behold this “common” enemy is not so common after all, as it probably continues to change its appearance and structure to outwit my defenses. So my system staged an all out war to fight this common cold.

The first to arrive into the battle field are the big boys, called the macrophages. They are the biggest soldiers among my army of white blood cells. These big boys are like Pacmans as they hunt and engulf these viral invaders.

a macrophage in action (image from the web)

But the enemy has hijacked some of my manufacturing plants. They infused their DNA into my own cells and they are replicating themselves using my own factories and resources. The Pacmans cannot eat them all as they are too many now and they continue to multiply. Good thing my defenses have more tricks under their sleeves.

As soon as the macrophages got an exact profile from the captured intruders they send signals to the headquarters, my bone marrow, to have the rest of the cavalry released.

One of the most effective fighters are the B-cell lymphocytes. They are part of a line of my white blood cell army. These cells uses the information of the enemy’s profile and they start building specific missiles, a protein called antibody, to fight these particular intruders. Once these virus-seeking missiles are constructed they are launched into the system to seek and destroy every infiltrators.

antibodies attacking a virus (image from the web)

Some of these specific antibodies are stored into memory cells. So the next time this specific virus intrudes again, my body already has the pre-fabricated missiles ready to launch to fight them back.

Another important battalion of my soldiers are called the T-cell lymphocytes. These are elite fighting machines, like the SWAT or the Navy Seals. They don’t just track and kill the enemy but also destroy cells that harbor them. With some named as “natural killer T-cells” you know that these are badass soldiers.

Go, go, go my army and defend the motherland! And die you infidels!

There are also some foot soldiers that are deployed to the area of the breached wall. They have fortified the defenses there, and as a result the lymph nodes around my throat are swelled up, a sign of an ongoing battle in that area.

Besides the chills and runny nose, so runny I can’t keep up, I also started having this paroxysmal cough. I got out of my bed and went to the bathroom. I hacked up a phlegm into the sink – a nasty purulent and rusty mess. Then I realized that part of that purulent mess are dead bodies of my white blood cell soldiers. They have laid down their lives for the cause.

So before I flush down the purulent mess deep into the sink, I thanked them for their sacrifice, and as a grateful nation I fired up the canons and gave them my 21-cough salute.

After hearing my cough, my wife suggested that I should take some medicine to relieve my symptoms so I can have a better night sleep. Being hard-headed as I am, I said no to the medicine and just trusted that my body will take care of itself as I crawled back under the covers.

The next morning, I don’t feel as awful as the day before. Perhaps my army is winning the war, and they are rounding up the remaining stragglers, and cleaning up the residual wreck and ruins of the hard-fought battle. I guess I will live.

This is another victory for my immune system. But I’m not ready for a victory march and parade as of yet. I think I’ll take it easy and still stay in bed today.

Grateful to see another morning (photo taken with an iPhone)

(*Credits to my immune system and also to the Immunology class in my medical school)

Cold and Dead

Part of the duty of a medical resident in a teaching hospital is to formally pronounce a patient dead. When a patient dies, the nurse would call the resident-on-call to assess and examine the patient and confirm that he or she is indeed dead. Normally this is done in a timely fashion, within several minutes after the patient breathes his/her last breath, and the resident would chart the time the patient was pronounced dead. This would be the official time of death.

I understand that in a non-teaching hospital the attending doctor would be the one to call. If the doctor is not available, a nursing supervisor or a charge nurse can declare the patient dead. 

You may argue that it does not really take a lot of training to determine if a person is dead. Any reasonable person can discern this. Though there are some people you probably know who look like dead, but I’m not talking about that. So why do we need a doctor or an experienced nurse to pronounce a person dead? I think it is more for a medico-legal purpose.

Of course sometimes your judgement that a person is dead can be challenged  by somebody. The following is an actual exchange of questions and answers as recorded in a court documents:

A lawyer was cross-examining a witness, who was a pathologist.

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive, practicing law somewhere.

Several nights ago, we had a very busy night in the ICU. I believe we had 7 admissions to the ICU in a short span of time. This is in addition to the 20 or more critically-ill patients that we already had in our unit. So “busy” may even be an understatement.

One patient that we had that night had been in the hospital for almost 2 months and had been in and out of the ICU a few times. This time around the family had decided that they would transition to comfort cares and the patient would be taken off life support. So death was imminent and expected.

For some reason, whether the medical resident was not called, or he was so busy at that time, or he was called but forgot to do it promptly, but the patient who was taken off life support was not officially pronounced dead right away. Of course everybody knew that the patient expired – the ICU nurses knew, the family members who were gathered in the room knew, and even the morgue and funeral personnel knew.

Perhaps it was assumed the he was already pronounced dead, so the body was taken down to the morgue within an hour or so after the patient died.

It was not after a few hours later that our medical resident learned that the body of our deceased patient was taken to the morgue without him officially examining the patient and pronouncing him dead.

So what would a diligent medical resident do? 

Our conscientious resident went down to the morgue in the wee hours of the morning to search for the body. He pulled out the body from the freezer. He opened the body bag. He identified the deceased patient. Then he examined the body and pronounced it dead. I know, it sounds like a plot of a horror movie. At least he had an interesting story to tell his co-residents the next morning.

A couple of days ago, I received a notice from a funeral parlor to complete and sign a death certificate. Part of the certificate is to write down the official cause of death. Since I had 3 death certificates to complete that day I checked each of the patient’s hospital electronic medical record to be accurate on what I would write. That was when I read our resident’s note on the chart and I could not help but smile: 

Patient examined in morgue. On exam patient did not respond to verbal or physical stimuli. No heart or lung sounds were heard and patient has no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dead at 0336.

Since the patient was only officially pronounced dead after a few hours in the morgue’s freezer, should I write “froze to death” as the cause of death?

Of course I did not.

photo taken with an iPhone

(I meant no disrespect to the dead, nor do I make fun of a rather serious situation. I am just relating a light moment in the otherwise morbid world of ICU I lived in.)

Black Friday

Thanksgiving week is the busiest time for travel in the United States. Students who are in distant colleges and universities, family members who have moved away from their parents, and most people who have wandered far, all journeyed back to the place they call home to be with their family.

For a day the family gathered around the table with a spread of bountiful food and gave thanks. For a day the family was one again. Unless you have no family, or you don’t like your family, or you hate food, it is hard not to like this holiday.

Of course for some people this time is for vacation and some time off work. For some it is about parties. For some it is about parades. For some it is all about watching football. And yet for some they make this holiday time all about shopping – the Black Friday event. But primarily, this time is for families and about giving thanks.

I am in charge of the hospital’s ICU this week. I know there’s no good time to be sick and be admitted in the ICU, but being sick during the holidays is terrible. It is particularly difficult for the families involved.

We have one patient who was admitted in our ICU about 10 days ago. He is in his mid 50’s and he got really ill. He has multi-organ failure. Despite all the efforts, he did not get better. He is on mechanical ventilator, on continuous dialysis, and on several medications to keep his heart pumping and blood pressure up, yet he is sliding away. More concerning still is that he is not waking up.

His family would like us to continue our intensive management until many of his family, especially his children, who are in other states could come and see him and then they would say their goodbyes. For one more Thanksgiving, they gathered, though not in front of a bountiful dinner table, but in an ICU room, as one family again. Then today, Black Friday, they decided to transition to full comfort cares and let their father passed on after a final farewell. It’s kind of hard to give thanks in such circumstances.

Sadly to say, that story is not unique to that family.

In another ICU room, a mother who is only 40 years old, has metastatic breast cancer to the brain. She failed all surgery, chemotherapy and radiation therapy, and is now having frequent seizures. Family would like to keep her in the hospital until Thanksgiving day. Last night they took her home with Hospice to die.

In yet another ICU room, a man who is in his 70’s suffered a large intracranial hemorrhage a week ago. Even after surgery to the brain to evacuate the blood, the patient remains comatose and is in continued vegetative state. The family also would like to have family members from far away places to come on Thanksgiving to see him. Today, they took him off life support.

The saddest of all is in another ICU room. The patient is in his 60’s who had cardiac arrest and prolonged CPR four days ago. We cooled his body down (hypothermia protocol) to try to preserve any brain function. However after we rewarmed his body temperature and discontinue all sedation, he’s not waking up. There is no family members around and we cannot find any one except for a friend that said they don’t know any family of his, and perhaps he is estranged from his family. Both the cardiologist and I felt that continuing life support is medically futile given his significant anoxic brain injury. We let him passed on peacefully, with nobody around him except our ICU staff.

To many, today, Black Friday means bargain sales and wild shopping spree. But in this frantic place, inside these ICU walls, it has a different meaning. It is the solemn color of mourning.

For those of you celebrating this holiday time, may you cherish each moment you have with your family, and commemorate this season in it’s true essence.

(*photo taken with an iPhone)