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

Impella device (photo from Medscape.com)

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.

IMG_6345

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)

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.

Music-Therapy-1

ICU music therapy (image from wakingtimes.com)

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)

 

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.

Doc,

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.

Toto

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)

 

Last Walk of a Fallen Jedi

(It’s Christmas season once again. Also in 10 days the new Star Wars movie will be out. I would like to re-post a story of one of our ICU patients. The original article was posted in December 2015, “When You Wish Upon A Star Wars.”)

I entered the room and stood silently at the foot of his bed, watching him breathe. He was hooked to a small ventilator that is connected to a mask covering his face with straps around his head, that he looked like a jet fighter pilot. Beside the bed was his father and his mother who were obviously distraught, yet trying to hold off tears.

Luke* (not his real name) was one of our ICU patients. Even though he was only in his 20’s, he had his fair share of surgeries and hospitalizations than many patients in a geriatric floor combined.

He had a genetic disorder that prevents the development of various organ system. This affects the skeletal system giving them a peculiar look and stature, that some people coin the term FLK syndrome: Funny-Looking Kid. Though for me, there’s nothing funny at all. This disorder also causes heart defects, and can involve other organs like the lungs, liver, gastrointestinal tract, lymphatic and blood system. Even so some people with this genetic disorder could live to adulthood, some would succumb to this disease early in life.

Luke had a number of surgeries to fix his heart problem, and other procedures too many to recall. He had been treated in well-known hospitals like Mayo Clinic, for his disease. But despite of all the technology and medical interventions, his body continued to betray him.

For the last several months he had been in and out of the hospital, usually staying for several weeks at a time, including ICU stay. I have taken care of him a number of times in the past.

In spite of his illness, Luke tried to live his life as “normal” as possible. His family gave him the opportunities and the best care they could. His mother, who was a patient of mine too, had the genetic disorder as well, albeit with a milder manifestation, thus I knew the family well.

One thing I learned, was that Luke likes Star Wars, even though the first Star Wars movie came out more than a decade before he was born. Perhaps he envisioned himself as a Jedi Knight. Yeah, he was a fan of this movie genre, just like the rest of us, I guess.

In this last hospital admission, Luke came in with a lung infection causing respiratory failure, requiring intubation and mechanical ventilation. He came on Thanksgiving Day.

After several days in our ICU, we were able to extubate (take out the endotracheal tube) him, only to place him on a non-invasive positive pressure ventilator (NIPPV) with a face mask, as he cannot breathe on his own. This is like a CPAP machine. At least he can stay awake and not be sedated on the non-invasive ventilator, and he can speak as well. He can only tolerate a limited time off the NIPPV, and had to be hooked right back on it. He would not survive without it.

As I watched him with his “jet-fighter mask” with his bed as his vessel, what came to mind was that in a cruel twist of fate, this kid who likes Star Wars, now breathes like Darth Vader: whoooh….poooh, whoooh…..poooh, whoooh…..poooh. Every breath, there’s a gush of pressurized air coming out of the ventilator and through his mask.

After one holiday, another one is approaching. Christmas is just around the corner. And Luke remains in the hospital, ventilator-dependent, with no clear sight that he’ll get better. He knows it, and his family knows it. Luke’s days here on earth is numbered.

With wishful thinking, maybe he can linger a little longer to see the new Star Wars movie which he was looking forward to seeing for the longest time. But how? Him in the hospital? On a ventilator?

But wait, isn’t it Christmas season after all?

Wish granted!

After making elaborate arrangements and collaboration, Luke and his family will be going to a movie theater, to be accompanied by some medical staff, for a special private showing of the “Star Wars: The Force Awakens,” when it opens this weekend.

After that trip to the theater, Luke will be going home for Christmas with his family, on hospice care. No more hospitals. No more ventilators. No more pain.

Perhaps he could stay home until Christmas. But if not, Luke could soar into the heavens and once and for all, walk on stars. His final home.

********

Post Note: Luke made it through Christmas. He eventually lost his battle few months later.

Of Hawks and Turkeys

Last Saturday was gray, damp and cold. It was windy too with strong wind gusts all day. It was a dreary day. I hope Thanksgiving would be a better day as it may be hard to be in a thankful spirit when you’re freezing, fighting fierce winds and just trying to hold on to your hat.

As we were going out, I noticed a large bird hovering high above a field. It could be an eagle as we have eagles in Iowa, though rare. But I believe it was a hawk, as they are so many here in our area. Hawks and strong gusts of wind are what we have in abundance here in Iowa, so no wonder our two big State Universities’ sport teams are called Hawkeyes and Cyclones.

I know hawks or even eagles may not be the right bird to talk about during this occasion. We should be discussing turkeys, right? By the way, wild turkeys abound in our area as well. You can spot them just hanging out in the empty corn fields. Perhaps we can skip the grocery and just capture one of them and make it our dinner for the Thanksgiving.

Enough of the turkey, and back to the flying hawk that I saw. Maybe flying was not the right term, for it was barely flapping its wings. It had its wings open, and like a big kite, it was effortlessly gliding in the sky. It did not seem to mind the strong gusts of wind, and may even be thankful for it. For the stronger the wind, the higher it soared.

Sometimes the strong winds in our lives, those gusts that we think will shred our plans, and those storms that can blast our dreams away, may just be helping us soar to higher heights.

Last week, the lady in the gym’s reception desk, the one who greets me cheerily every time I come in, gave me a book. The book was entitled “Praise God for Tattered Dreams.”

I have observed this lady as always upbeat and has a sunny disposition in life, day in and day out. I am impressed on how she remembers all the names of the gym goers, as she greets everyone by name. And I mean everyone.

Few months ago this lady, after greeting me for years since I have been coming to this particular gym, learned that I am an ICU doctor. She then told me that she was a patient many years ago, in the hospital where I work, and even stayed in the ICU. But that was a couple of years before I came to Iowa.

Since then whenever she sees me, she would always try to convince me to write a journal about my experiences as an ICU physician. She said that it may be interesting to share those stories, and I may even make some money from it.

Last week, after coaxing me to write a journal every time we meet, I finally told her, that I was indeed already writing a journal. Well, sort of. I told her about ‘this’ blog. I rarely tell people I know, that I blog. Why? So I could write about them!

After learning that I write, she went to the back, retrieved a book from a drawer and handed it to me. She told me that she wrote and published this book, and it’s about her trying experience. She added that I can borrow and read it, but if I spill coffee on it, then I have to buy it.

She narrated in the book that she was a vibrant mother with two young boys, and with a promising career, when out of the blue, she suffered a near-fatal stroke. It was a large bleed in the head. She was only 33 years old at that time.

She was close to death when she was brought to the hospital. The doctors, including the neurosurgeon, gave her only 10% chance to live.

But she lived!

She was comatose for several days and spent 3 weeks in the ICU, and a total of 3 long months in the hospital. This does not include several more months of rehabilitation after being discharged from the hospital.

She described that half of her body was paralyzed and was unable to speak for a while. In that dark moment of her life, she found God and discovered a new purpose in life. When she felt that her dreams have ended, God showed her that she was only beginning to live a more meaningful life, for which she was very thankful for.

Now she is speaking and walking with almost unnoticeable residual of her stroke. She is happily working in the gym and encouraging people to be healthy and happy. She definitely has a story to tell. From tattered dreams to an inspirational life.

As we gather around our dinner table this Thanksgiving, with our roasted holiday bird, (the turkey, not the hawk), let’s thank God for everything. Including our trials and disappointments. For storms and strong winds can make us soar higher.

Happy Thanksgiving!

IMG_5638(*photo taken with an iPhone)

 

Huwag Kang Puputok

Siguro lahat tayo ay may kakilalang tao na malakas magpaputok. Hindi rebentador o kaya baril ang ibig kong sabihin. Ang tinutukoy kong putok ay iyong nakakainis na amoy mula sa katawan. Sa ibang salita, body odor o B.O.

Kung ikaw ang may putok, sana makatulong sa iyo ang artikulong ito.

Isang senaryo sa Pilipinas: nasa loob ka ng jeepney.  Dahil sa sobrang init at trapik ay tumatagaktak ang pawis ng lahat. Tapos, may mamang sumakay at sumiksik sa tabi mo. Pag-arangkada ng jeep, itinaas ng mama yung kanyang braso para humawak. Sakto naman yung kanyang kili-kili sa mukha mo. Pag-hinga mo, boom! Parang gusto mo nang tumalon sa jeep, o kaya’y ilawit ang iyong ulo sa labas at pipiliin mo pang suminghot ng maiitim na usok ng jeep at bus, kesa mamatay sa putok ng katabi mo. Naka-relate ka ba?

Ano ba ang sanhi ng putok?

Ang medical term sa putok o anghit, ay bromhidrosis. Ito at ang masangsang na amoy dahil sa pawis. Ang pawis ay mula sa sweat glands. Maaring tanungin mo, bakit ba ginawa ng Diyos ang sweat glands kung ang magiging sanhi lang nito ay anghit?

Ang sweat glands ay importante sa kalusugan at mismong buhay ng tao. Ito ay para sa thermoregulation ng ating katawan. Kung hindi tayo papawisan tayo ay mag-o-overheat at maaring mamatay, parang makina ng kotse na kailangan ng tubig sa radiator para hindi pumalya. Kaya’t sa ayaw mo man o gusto, hindi lang si Andres Bonifacio, kundi tayong lahat ay anak-pawis.

Isang klase ng sweat glands ay ang apocrine glands. Maraming apocrine glands sa axillary area (kili-kili) at pubic area. Maliban sa pagse-secrete ng pawis, ito ay nagse-secrete din ng hormone, na ang tawag ay pheromones. Ito ay may kakaibang amoy. Ang pheromones ang siyang naamoy ng mga hayop, para ma-attrack sa kanilang ka-partner. Ito ang dahilan kung kaya kahit sa malayo ay nakakaakit ang paru-paro, baboy-damo, o aso ng kanilang kalaguyo.

Pagnagbinata at nagdalaga na ang tao, dumadami ang apocrine glands at secretion nito. Pero sa ating tao, hindi gaya sa hayop, hindi masyadong kailangan ang pheromones upang humanap ng ka-partner. Kasi may on-line dating site na (aha-ha). Isa pa, mas mabisa siguro ang bulaklak at chocolates kesa pheromones para sa tao.

Balik natin ang usapan sa pawis. Sa katanuyan ang pawis ay walang amoy. Ngunit kapag may mga bacteria sa ating katawan, na nagre-react sa ating pawis o hormone na galing sa ating sweat glands, lalo na sa apocrine glands, sa halip na walang amoy, nagkakaroon ng mababantot na mga chemical. Mga chemical tulad ng ammoniaE-3-methyl-2-hexanoic acid at 3-hydroxy-3-methyl-heaxnoic acid, (konting chemistry lesson lang po). Ito ang isang sanhi ng putok.

Minsan ang ating diet, gamot, mga toxins, metabolic disorders, at ibang sakit, tulad ng liver at kidney failure, ay nagdudulot rin o nagpapalala ng mabahong amoy ng ating katawan.

Ang bromhidrosis ay maaring makaapekto sa kalusugan. At sa kalusugan din ng ibang kawawang taong makakaamoy. Pero maliban sa pisikal na kalusugan, ang taong may bromhidrosis ay maari ring magdusa ng social isolation at low self-esteem. Sino nga bang gustong mag-hang-out sa taong may putok?

Anong dapat gawin, o ano ang mga lunas sa isang taong may bromhidrosis?

1. Maligo ng regular.

Malaki ang nagagawa ng personal hygiene sa putok. Dahil may kinalaman ang bacteria sa masangsang na amoy, mababawasan ang bacteria sa katawan kung maliligo ka nang regular. Hindi ko sinasabing maligo ka nang apat na beses isang araw, pero sikapin kahit minsan sa isang araw. Maari ring makatulong ang pag-gamit ng anti-bacterial soap.

2. Gumamit ng anti-perspirant at deodorant.

Ang anti-perspirant ay nagpapabawas sa pagpapapawis. Ang common ingredient ng mga antiperspirant ay aluminum salt. Ang “tawas” na popular na ginagamit para sa anghit ay hydrated aluminum potassium sulfate, at ito’y mabisang anti-perspirant. Ang deodorant naman ay mga pabangong nagkukubli sa mabahong amoy. Marami sa mga produkto ngayon ay magkasama na ang anti-perspirant at deodorant.

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Kryptonite? No, Tawas Crystal!

3. Hair removal

Dahil ang buhok ay maaring mag-trap sa bacteria, maaring makatulong ang pag-aahit ng buhok sa kili-kili. Kaya pwedeng slogan: May anghit? Mag-ahit!

4. Palitan kaagad ang damit na pinagpawisan.

Panatilihing tuyo ang katawan. Hindi sa dahil ikaw ay mapupulmonya kung matuyo ang pawis. Pero mababawasan ang mabahong amoy-pawis kung huhubarin mo kaagad ang basang damit na pinagpawisan mo. Isa pa, gusto ng bacteria ang mabasa-basang environment.

5. Iwasan ang mga pagkaing may maaamoy na spices.

Siguro naobserbahan mo na rin na may mga pagkaing amoy kili-kili. Hindi ko ikinakaila na masarap ang mga ito. Subalit kung amoy kambing ka na, bawasan mo na siguro ang mga maaamoy na spices tulad ng curry, cumin, sibuyas at bawang. Pero pwedeng rason na OK lang mag-amoy bawang, kasi at least walang aaswang sa iyo.

6. Huwag manigarilyo.

Hindi sa nagpapabawas ng pawis ang hindi paninigarilyo. Pero ang sigarilyo ay isang sanhi ng mabahong amoy. At mabahong hininga. May B.O. ka na nga, may bad breath ka pa, eh kawawa ka nang talaga.

7. Removal of apocrine glands.

Sa malalang bromhidrosis, ay maaring i-offer ng mga duktor ang pagtanggal ng apocrine glands. Maari itong tanggalin sa pamamagitan ng surgical excision, liposuction, o laser therapy. Hindi dahil nabasa mo rito ang laser therapy, huwag mo sanang tangkaing na sunugin ang iyong kili-kili. Please consult your doctor.

Hanggang dito na lang at sana ay may natutunan kayo. At tandaan, hindi lang sa Bagong Taon po bawal magpaputok!

(*photo of tawas from the web)

Death by Chocolate

All she wanted was to taste the chocolate.

All these years she was strongly warned against having chocolates. It’s not that she’ll have pimples or she’ll get fat when she eats them. It is more morbid than that. Her parents said that she is allergic to it. Deathly allergic to it. The last time she tasted chocolate was when she was 5 years old. And that was more than 30 years ago.

But chocolate is irresistible.

Everybody likes chocolates. In fact it is the most popular dessert in the world. Perhaps many will consider it as God’s gift to men. Some pundits would even say that the food Eve fell for was chocolate that was in the Tree of the Knowledge of Good and Evil.

As you probably know, chocolates are made from cacao. Interestingly the Latin name for cacao tree is Theobroma cacao which means “food of the gods.” Theo is god, and broma is food.

Why does eating chocolate so irresistible?

According to scientific facts, chocolates contains several chemicals that can affect our mood. Especially dark chocolates. Caffeine and theobromine are among those substances, which can make us more alert and gives us energy. I’m sure you’re familiar with the “pick-me-up” effect from the caffeine in your morning brew.

Chocolates also contains Anandamide that helps stimulate and open synapses in our brain that allow “feel good” waves to transmit more easily. A similar chemical, tetrahydrocannabinol or THC can have the same effect. THC is from marijuana. And you wonder why you can’t resist your craving for chocolates?

Furthermore, both serotonin and endorphins, neurotransmitters or chemicals in our brains, are released when we eat chocolates, and in turn, this brings on a sense of well-being. Just so you know, exercise also can release those endorphins, that can give you a euphoric mood after a work-out. Many call it as the “runner’s high.”

Lastly, Phenylethylamine is a chemical that our brain releases when we fall in love. It also acts as an anti-depressant by combining with dopamine that is naturally present in our brain. And guess what? Chocolates contains Phenylethylamine.

So go ahead, give chocolates to your loved one. Send chocolates to the one you want to date. Give chocolates on Valentine’s. I know flowers are nice, but can they release Phenylethylamine? Eating the flowers is not suggested.

Chocolate production is a multi-million dollar business. Ghirardelli, Godiva, Lindt, Cadbury and Hershey, to name a few, are big-name companies that are successful in this trade. Though I am still biased to the Filipino Choc-nut.

Besides chocolate bars and candies, there are also several chocolate-flavored desserts. Like cakes, ice cream, mousse, cookies, shakes, drinks, and whatever you can think of. There’s even chocolate-flavored cigarettes! That’s evil.

Then there’s different confectionaries that are called “Death by Chocolate.” I’m not talking about the chocolate-flavored cigarettes, though that is an apt name for that. “Death by Chocolate” is an idiomatic term they use to describe various desserts that feature chocolate.

Death by chocolate IIIBack to our patient, as I stated in the beginning, all she really wanted was to taste chocolate again. So she took a bite of a chocolate cookie. And she liked it! She took another bite, and another. The chocolate tasted so good, she finished the whole cookie.

Not too long after, she felt that her body was getting numb. She got alarmed, she took Benadryl. Four of them. But the symptoms did not get any better. She then started having some shortness of breath. Soon her tongue and lips swelled up. Then she cannot swallow or breathe anymore.

Finally she was brought to the Emergency Room. She was immediately intubated to establish an airway and then was hooked up to a mechanical ventilator. That’s how she ended up in our ICU.

All because of chocolate.

For two days she was on life support. Her blood pressure also dropped to dangerously low levels. These were all due to severe allergic reaction.

But she improved. With intense supportive care and mechanical ventilation, plus IV fluids, steroids and anti-histamines, and some tincture of time, she got better.

On the third day, she was weaned off the ventilator, and was discharged out of the ICU. I then warned her, that in no instance ever, that she should taste chocolates again.

Death by Chocolate? Almost.

(*photo from here)

Barriers

He was always there.

Constantly standing outside the ICU room, that is closed by a sliding glass door. He looked worried. The expression on his face was if he was begging for any news or information to any hospital staff that goes in and out of that room. Except that even when we tried to talk to him, he does not comprehend any word we say.

He does not speak English. Yet I believe he had a sense of what was going on. I think he somehow knew that something very bad was going on. Except nobody can really confirm it to him in a language he can understand.

His wife was inside that ICU glass room. Lying in bed hooked to several monitors and to a life-sustaining machine. Infusing into her veins were several liquid medications in upside down bottles hanging from poles. Coming out of her body were several tubes and catheters – some in natural body orifices, and some in surgically made openings.

The room was a negative air-pressure isolation room. Meaning, that all air droplets were being suck out of that room to a special outlet to prevent from spreading. And all personnel that go into that room needs to don a gown, a mask or a respiratory hood, and gloves.

As he stands outside that glass room looking in, several barriers are separating him from his sick wife, and from the world.

First is the physical barrier of being in an isolation room. This is being done as we suspect she has a highly contagious disease that can spread not just to the other hospital patients, but also to the hospital staff. If only he can be constantly at her bedside. Of course he is free to go inside the room, as long as he wear all those protective gear.

Second is the language barrier. Being a new immigrant to this country and not understanding its language can be very isolating. Not able to communicate even the simplest of questions is already difficult, how much more understanding a very complex situation.

Perhaps he and his wife came to this country to escape hardship or persecution. Perhaps they came here to pursue a dream and to begin a new life. Then, this happened. Which leads me to the biggest barrier of all, the barrier of the unknown tomorrow. What will happen to his wife? To him? To their dreams? And their future?

For the past two days we have been talking to him only through a phone interpreter. Due to the circumstances’ limitation, most of the conversation with him was to explain a procedure or a test that is needed, and to obtain his consent. Consent for blood transfusion. Consent for the CT scan and MRI. For the spinal tap. For chest tube insertion. For percutaneous abdominal drainage catheter. For bronchoscopy. And other more. But sitting down and explaining to him every nitty-gritty details of his wife’s illness and its prognosis, we have not done yet.

Finally, the social worker was able to get an interpreter to come to the hospital. Being an obscure dialect of a certain language, it was hard to get an interpreter in person.

So I sat down with him, and with a live interpreter, explained in as much as I could, the gloomy situation. I explained to him the severity of his wife’s condition: with overwhelming still-to-be-determined infection, plus the ravaging systemic lupus affecting almost every organ including the brain, the odds were plainly against us.

As I converse with him through the interpreter, I learned that he has no relatives and the only family he had here in the US is his wife. I also learned that at night he still goes to work at a meat-packing factory so he can keep his job, and then come and stay in the hospital all day. Somehow he just tries to sneak some naps in the ICU waiting room during the day. No wonder he looked so haggard. Life can be tough at times.

Then he asked me the crucial question, “Would my wife get better?”

I gave him my honest answer, “I don’t know.” I told him that there’s a possibility that his wife may die. Even though she’s only 22 years old.

His face became more saddened. Perhaps that’s an information that he was afraid to learn. Now through the interpreter, he fully grasps the gravity of the state she’s in. Sometimes I think, that not knowing is better. Perhaps not understanding, is bliss.

Two more days passed, and he was there most of the time. Outside the glass door. Looking. Pleading. Hoping. I almost wanted to avoid him, for there’s no comforting words I can say, with or without the interpreter.

But today is different. I cannot wait for the interpreter to arrive so I can talk to him. I needed to tell him the news. I think we have found an answer. I think she is slowly getting better.

I needed to tell him, that I believe she will live.

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(*photo taken with an iPhone)

Out of Shape

The other day, one of my partners requested me to supervise a cardiopulmonary exercise test (CPET) that he ordered on a patient that he saw in our clinic. Since I would be in the hospital all day that particular day, and the exercise test would be done in a lab in the hospital anyway, so I obliged.

CPET is usually a test that we request if the cause of shortness of breath remains unclear even after initial evaluation. Most of the time when we request a CPET, we have already done lung imaging (like a chest x-ray), a pulmonary function test, and basic heart evaluation to rule out gross cardiac problems. Definitely we don’t want a patient having a heart attack and keeling over while we are performing the test.

During CPET, a patients walks/runs on a treadmill or pedals on a stationary bike, while having all these body monitors to measure the heart rate, blood pressure, and oxygen saturation level. Then they also wear a mask, like the super villain Bane in the Batman movie, that is attached to a breath analyzer where we measure not alcohol content, but the volume and gas content (oxygen and carbon dioxide) of the air they inhale and exhale. At the peak of the exercise, we also draw a blood sample to measure the level of oxygen, carbon dioxide, and lactic acid. We may not be experimenting on Captain America, but it is an intense test regardless.

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cardiopulmonary exercise test (image from BMJ journal)

By the way, lactic acid is a byproduct of “overstressed” metabolism. It is produced when there’s not enough oxygen supply to the contracting muscles, so the muscle switched from aerobic to anaerobic metabolism. The build up of lactic acid in the muscles is one of the cause of having pain in your muscles few hours or few days after a viogorous exercise. I hope I am not bringing back bad memories from your high school physiology teacher.

The exercise test is usually ended in several possible ways: a patient cannot exercise anymore due to exhaustion, or we have achieved the maximum target heart rate (which is: 220 minus patient’s age), or we have reached the end of the designed exercise protocol, or the patient developed an alarming symptom, like severe chest pain.

The information we gather in this test help us delineate what is the limiting factor causing the shortness of breath, whether it is a heart problem, a lung problem, a muscle problem, or plain deconditioning. Sometimes elite athletes undergo this test to gain data on how they can improve their performance. I’m sure Gatorade lab performs lots of this.

Perhaps the most common diagnosis we reach considering the group of patients we deal with, is deconditioning, or in simple term, being out of shape. Definitely this is a scientific way, albeit expensive, to say to a patient that he is too lazy or is too fat.

The duration of the CPET is mostly less than 15 minutes, and with our patient population, it rarely last more than 10 minutes. Not a big deal for me to supervise the test, as it is short and quick.

I was busy that day so I was not able to look beforehand at the chart of the patient whose CPET I would supervise. What I just know was the time I needed to show up in the lab, the name of the patient, and his age.

I knew that the patient was in his early 50’s, a couple of years older than me. Even before meeting the patient, I already have a diagnosis in mind, as I was expecting a middle-aged man who is overweight, maybe a couch potato, and perhaps cannot accept the fact that he is way out of shape, and instead blames something is wrong with him, thus we are doing this CPET. Since I have a few half-marathons under my belt, I thought I could show him how to “exercise.”

When I came to the lab, I met our patient who was already sitting on the stationary bike. He looked fairly trim, and to be honest, he looks younger than his age. I introduced myself and explained the test that we will administer.

To get some idea of his condition, I asked him about his symptoms. He told me that he felt this “disproportionate” shortness of breath when he is running.

Sensing that he is a “runner” like me, I asked if the shortness of breath happens early, or during the latter part of his run. He answered that he experienced this shortness of breath relatively “early” in his run. I asked him then to be more specific, like how many minutes after he started his run.

Then he said, “I have this ‘unusual’ shortness of breath after running 20 to 25 miles.”

What?! Who considers 25 miles as early? Most people are not short of breath, but may not be even breathing at that point!

That’s when I learned that he was an ultra-marathoner, and runs 50 to 100 miles or more when he competes. He said that after 25 miles of running, he usually catches his “second wind” and feels good the rest of the way through.

All my preconceived notion flew out the window. Life is never short of surprises. Another lesson learned. Never assume.

I just told the lab staff to commence the exercise, and brace for a long, long test.

Sleep(less) in Boston

It is my third time to visit Boston. This time I came to Boston to catch up on sleep.

No, I’m not saying that Boston is a sleeper city, for it is an exciting place to visit. Nor am I’m saying that it is a place most conducive for sleeping. In fact since we stayed in a hotel in the heart of the city, it was quite noisy, with all the cars honking and with loud police and ambulance sirens wailing. Added to that, we landed past midnight in Boston, contributing to my sleepy predicament.

Why I came to Boston is to attend a conference to catch up with the current studies, trends and technology in the practice of Sleep Medicine. Honestly I nap a little in some of the lectures, so I literally catch up on my sleep too!

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theme poster of the convention

The science behind sleep has fascinated me since I was in high school, so it’s not a surprise that one of the subspecialty I pursued was on this field.

One of the fascinating sleep phenomenon that I wanted to learn more of are the Parasomias, which includes nightmares, night terrors, sleep walking, and more that goes bump in the night.

One Parasomnia is REM Behavior Disorder (RBD), in which people with this disorder reenact their dreams. Normally when we are in REM (Rapid Eye Movement) stage, a sleep stage when dreams usually occur, our muscles are disengaged and we are temporarily paralyzed, so we don’t move and act out our dreams. In people with RBD, for some reasons the muscles are not paralyzed, so they can kick, swing a punch, crawl out of bed, or even perform a complex activity while sleeping. Not only this put the patient in danger, but also the sleep partner.

One interesting fact I heard from one lecturer is that soursop which is a tropical fruit, or also known as guyabano in my home country, the Philippines, can potentially increase the incidence of RBD. I can almost read a headline news: sleeping wife punch husband, after drinking guyabano punch.

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opening session

Besides the medical implications, there’s also societal implications of people having poor sleep. These are also topics discussed during the convention.

Research have shown that birds can sleep, as half of their brain can go to sleep, while on long flights. But not humans. We need all our faculties when we are doing complex task like flying a plane. Though aviator Charles Lindbergh, the first man to cross the Atlantic on solo flight was awake for more than 34 hours when he accomplished that feat, nowadays we have instituted regulations for pilots limiting their hours of flying and assuring they have a sufficient amount of sleep in between flight.

Same principle applies with operating any machinery or driving any motorized vehicle. Studies have shown that a significant number of vehicular accidents are due to driver fatigue and sleepiness. For instance a sleepy driver can have a slower reaction time. A decrease of even 50 milliseconds in reaction time in hitting the brakes means 5 feet more before coming to a stop, and that can mean safely stopping or crashing, or escaping an accident or dying.

For the medical community, especially the ones who are undergoing residency training, there’s now an imposed 16 hour limit for a first year resident for continuous work. Beyond that they should be relieved, for they need to go to sleep. During my residency training in the mid 90’s, the limit for continuous hospital duty was 30 hours. This regulations though are not enforced to doctors after they are done with their training.

We as a community really need to change our opinions. Staying awake all night to study or pulling an all-nighter to finish the job has become a badge of honor. We view sleep as only for slackers. When we should view that those people who get adequate sleep, that is 7-8 hours a night, should be the ones commended. So no more sleepless in Seattle, or Boston, or New York, or Tokyo, or any part of the world for that matter.

Just like when you’re hungry, the solution is to eat. For people who are sleepy the solution is not more coffee or energy drink, but getting adequate amount of sleep. Of course if you have a sleep disorder and not getting a restful sleep then you need to see your doctor.

Sleep is important in so many levels. Not only for health but also for safety and being more productive. In addition, dreams come when we sleep, and life without dreams would be uninspiring.

From Boston,

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Boston Common (central public park in downtown Boston)

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(*photos taken with an iPhone)