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)

Where Teddy Bear Dare Not Trod

A child’s Teddy Bear should not witness sad and painful experiences. Yet they do. Here’s a story for you.

I was working that weekend in the hospital for more than 24 hours already, mainly in the ICU, but still had a whole day to contend with. Then came Sunday morning, I was called to the Emergency Department (ED) for a CPR-in-progress. It was a woman in her 40’s who had a cardiac arrest. I was told she was still talking when she was brought by the ambulance. However she became unresponsive and her heart stopped few minutes upon arrival.

When I arrived at the resuscitation room of the ED, a team was furiously doing CPR on the patient, with the ED doctor directing the care. A Lucas device (a robotic contraption) was strapped on the patient’s chest doing the mechanical cardiac compression, while other personnel were hovering around the patient assisting in any way they can.

After about 30 minutes of CPR, which is already an eternity of CPR time, we still could not establish a stable cardiac rhythm. We probed the chest with an ultrasound while the Lucas device was temporarily paused, and it showed that there was no heart motion at all. In simple terms, the patient was dead.

But before we completely pronounce the patient dead, one of the team members suggested that we get the patient’s husband to the room so he can be present. So the CPR continued until the husband can be at the bedside. It is now acceptable to have family members in the room when CPR is in progress.

One study from France that was published in New England Journal of Medicine (a leading medical circulation) in 2013 showed that family members who watched CPR on their loved one have far less post traumatic stress disorder three months later. Similar later studies support this as well, stating that family presence can help ameliorate the pain of the death through the feeling of having helped support the patient during the passage from life to death and of having participated in this important moment.

When the husband came in to the resuscitation room, he was tugging along their son, who was clutching a Teddy Bear. The boy, I believe, was about 8-10 years old. The moment I saw the boy walked into the room, my heart sank. I felt that the boy should have been left outside and should have not witness this traumatic event. But it was too late.

Perhaps whoever spoke to them outside the room did not suggest that it was better for the boy to stay outside. Perhaps there was nobody who can stay with the boy outside the room. Perhaps it was the father’s decision to bring along the son to the room. Perhaps they have no idea of what they would witness. Or perhaps the father was not thinking clearly as he had more serious issues to grapple.

The boy was squirming while his father was holding him, and was shielding his eyes with his Teddy Bear. Finally he was able to escape from his dad’s grasp and he dashed out of the room with his bear. Was the scene too much for the boy or too much for the bear?

The father stayed in the room though until we finally stopped the CPR and pronounced the patient dead.

To lose a mother was already a tragedy. But to lose a mother at such a young age and witnessed it as she die was really heartbreaking.

Many of us feel that we should try to shield children from the painful facts of life. We believe that children should be all fun and play, sugar and spice, and everything nice. Yet for some kids, sooner or later, they have to deal with the ugly realities of this world.

I know Emergency Rooms are not for Teddy Bears. But I do not care about the bear. I care about the boy behind the bear. Besides the comfort from his cuddly companion, I pray that he finds lots of love and reassurance from the remaining family he has.

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(*photo from Pinterest)

Texas Mission

Last week we were down in Texas. I did not attend a medical conference. It was not for a vacation or leisure trip either. I was there for some very serious work.

My family and I volunteered to join Your Best Pathway To Health (YBPTH), a non-profit organization that provides a free mobile mega clinic. There were medical, surgical, optical, and dental services offered, all free of charge to patients. There were also mental health, physical therapy, massage therapy, haircuts, financial planning, and lifestyle counseling among other services provided in that event. (See their Facebook page here.)

It was our first time to join this organization’s humanitarian mission, though they have already served in many other cities in the past, like Los Angeles, San Francisco, San Antonio, and Phoenix. This year it was held in Fort Worth, Texas. The free services were offered to people who could not afford medical care or had no medical insurance.

mobile-hospital-lines-1

photo credit: CBS news

In this event, people started lining up outside the building even the night before the clinic opened. I felt bad for the people who lined up for many hours, only to be told that they have to come back the next day as we were already full for the day.

Though if one clinic was full, for example the dental clinic, which appeared to be the service that most people lined up for, then we suggested to them that they go to the medical or vision clinic instead. Yet, there were still some, that sadly to say, we had to turn away completely, for we just could not accommodate them all. The mere number of people who lined up and were willing to wait several hours in line substantiates that there is a great need for these kind of services.

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photo source: YBPTH Facebook

The event was held at the Will Rogers Auditorium in downtown Fort Worth, which was converted into a mini-hospital, complete with operating suites. Minor surgeries and even cataract surgeries were performed here too.

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photo source: YBPTH Facebook

There were dentists, optometrists, ophthalmologists, internists, family practitioners, pediatricians, OB-GYNs, an ENT, orthopedists, podiatrists, a cardiologist, and a GI doctor present. I was the lone pulmonogist in the team. Below is a photo of my own cubicle.

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Since consultation to the Pulmonary Department was not that overwhelming, I assisted also in the Primary Care Clinic, as they were swamped with many patients there. Afterall, I am an Internist still. I probably have done more breast exams (for patients with breast lump complaints) and rectal exams (for patients with rectal bleeding complaints) in that 3 days alone than what I have done in the past 10 years of my practice now as a lung specialist. I declined to do PAP smears though and referred those patients to Women’s Health, as I have not performed that since I was in residency 20 years ago.

At the end of the event, in my estimation, I was able to see 100 to 120 patients. It was tiring to say the least, yet it was fulfilling.

We knew that there would be no monetary payment when we joined this mission. The only thing we got for free was lunch, which by the way was also provided to all the hundreds of patients seen. We even had to pay for our own airfare and hotel, and use our own vacation time to join this event. But the smile, or the simple “thank you” from the patients, and the satisfaction that we helped somebody was enough for our reward.

Yet to say that I did not receive any payment at all would not be true. There was one patient who gave me a large bar of chocolate as a present, and another one gave me a freshly home-baked loaf of bread. Those simple gifts were more valuable than my professional fee.

My wife was assigned in the Vision Department, assisting in the Optical services, and they were even busier than the medical department. My son, who is 15 years old, was in the Patient Assistance and Transport Department, and he probably was the busiest among us three, as he was walking and accompanying patients into the different clinics the entire duration of the event.

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photo source: YBPTH Facebook

The clinic ran for two and a half days, and at the conclusion of the event, the final report was that we had seen a total of 6,805 patients. That was an impressive number of people served.

Many local news media covered this event, so we were instructed on how to answer questions in case we were interviewed. As you know, health care is a hot political issue in this country, and an overzealous reporter might drag us into answering a touchy subject.

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A doctor being interviewed. (Photo source: YBPTH Facebook)

We were directed that we should avoid any political statements, and that when we were asked why we had volunteered and why we were giving all these medical services for free, our answer should be: Because we wanted to be the hands and feet of our Lord Jesus. Nothing else.

In truth, that was really the very reason we volunteered. To God be the glory!

Sakit sa Balakang: Final Answer

Mula nang aking isulat ang “Question and Answer: Sakit sa Balakang” bilang katugunan sa tanong ng isang reader, ay naging isa ito sa pinakamabenta na entry sa aking blog. Laging mahigit sa isang daan visitors ang sumisilip nito araw-araw.

Mahigit sa dalawampu’t pitong libo (27,000) na ang bumasa ng artikulong ito mula nang aking iakda ito noong Septyembre 29, 2016. Meron na ring mahigit kumulang isang daan (100) na readers ang sumulat sa akin ng katanungan na may kinalaman sa sakit sa likod at balakang simula rin noon.

Base sa mga bilang na ito, ay aking napag-alaman na marami pa ring mga tao ang naliligaw sa aking munting blog. Hindi pa rin naman nilalangaw at may sumusubaybay pa ring mga mambabasa. Marami pong salamat sa patuloy ninyong pagtangkilik.

Akin ring natuklasan na napakarami palang mga Pilipino ang may sakit sa balakang. Bakit kaya? Ano bang pinagkakaabalahan nating mga Pilipino at marami ang may sakit sa balakang?

Sa mga sumulat at nagtanong, wala namang nagsabi na sila ay nagtatanim ng palay. Alam kong maaring sanhi ng sakit sa likod at balakang ang pagtatanim ng palay. Ika nga ng ating folk song:

Magtanim ay ‘di biro, maghapong nakayuko,

Di naman makaupo, ‘di nama makatayo.

Sa lahat ng mga sumulat at nagtanong, ay akin naman po itong sinikap na sagutin sa abot ng aking makakaya, kahit halos magkakatulad naman ang inyong mga katanungan. Siguro kung talagang sumingil ako ng 5 choc-nut sa lahat ng nagtanong, tulad ng aking binaggit sa aking artikulo, ay marahil may ‘sangkatutak na garapon na ako ng choc-nut ngayon.

Ngunit hindi po ito tungkol sa choc-nut, o anumang bayad na aking sinisingil sa mga nagtatanong at kumukunsulta.

Akin pong inilathala ang artikulong “Question and Answer: Sakit sa Balakang” upang magbigay ng pangkalahatang kaalaman tungkol sa sakit na ito. Hindi ko po intensiyon na mag-diagnose ng indibiduwal na sakit ng isang tao, at lalong hindi ko po intensiyon na magbigay lunas sa indibiduwal na tao.

Isa pa, sa aking tingin, ay hindi po ligtas na magbigay ako ng espisipikong opinyon o diagnosis sa isang taong may sakit, lalo na’t hindi ko alam ang buong salaysay ng mga pangyayari, at hindi ko rin naman nakita o na-examen ang pasyente.  Sa halip na makatulong ay maari ko pa kayong mailigaw ng daan.

Dahil po rito, ay hindi ko na po masasagot ang mga magtatanong tungkol sa kanilang espisipikong sakit, o kung ano ang kanilang iniinda, o kung ano ang espisipikong gamot sa inyong sakit. Huwag naman sana ninyong ikagalit kung hindi ko na po sasagutin ang iyong mga tanong. Kahit pa isang buwang supply ng choc-nut po ang ialok ninyo sa akin.

Ang pinamabuting payo kong maibibigay sa inyo sa ngayon ay matapos ninyong basahin ang artikulong “Sakit sa Balakang” at kayo ay mayroong sakit na iniinda, ay magpatingin po kayo sa inyong lokal na duktor, at sila ang magda-diagnose at gagamot sa inyo. Sana po ay inyong maunawaan ang mungkahi kong ito sa inyo.

Maraming salamat po.

*********

PS. Sa mga nagtatanong din kung paano gumawa ng gayuma o ng anting-anting, o kung paano mang-kulam o labanan ang kulam, ay huwag na ninyo akong gambalain pa at hindi ko naman kayo matutulungan tungkol diyan.

 

Doctor’s Books

Last year we added two new partners to our group. It is good that our practice is growing and there’s now ten of us Pulmonary and Critical Care doctors in our team.

The downside to this growth is that our limited office space can barely accommodate our expansion. Storage spaces and closets have been turned into patient’s examination rooms.  The other thing that has to give is our personal spaces. Before each one of us have an office room, but now it was converted into one large room that we share together. Though we still have our own desk and a corner or side of the room where we hang our diplomas and personal photos or mementos.

We now also have a common book shelf that we share where we placed our valued textbooks even though they are outdated. As you know, a medical textbook is only good for a couple of years, like our smartphones, as new and revised version comes out every so often with updates of the latest studies and findings.

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Many of the books here in the shelf were published more than a decade ago, and thus they are obsolete and are only good for showcase. Note how thick and heavy many of these books. I can’t avow though that we read them from cover to cover. But perhaps just displaying them make us feel confident and smart.

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From “Medical Dictionary,” to basic science “Lung Cell Biology,” and to our specialty’s bible “Textbook of Respiratory Medicine,” I can say that at some point in time I referred to these books.

But there’s one book in the shelf that caught my attention recently, as it may be out-of-place. It is not my book, and I dare not ask whose book it is among my partners.

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Did you spot the book?

In case you still not sure what book I’m referring to, I pulled it off the book shelf and here it is:

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Perhaps it’s a book of one of the young children of my partners. Perhaps a partner of mine reads this book for relaxation. Or perhaps this book is an inspiration or has a special meaning for one of them. After all, considering where we came from and where we are now in our state of life, it is a realization of “Oh, the Places You’ll Go!” And as a transplant from a foreign land, this really rings true for me.

Here’s an excerpt from the book:

You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And YOU are the one who’ll decide where to go.

Maybe it really belongs to this shelf among other medical books. Besides, this book is also authored by some famous doctor. Dr. Seuss, that is.

*******

Post Note: “Oh the Places You’ll Go” was first published in 1990, and the last book published by the author in his lifetime. Even though Dr. Seuss is well-known as children’s book author and illustrator, this particular book is a popular gift for students graduating from high school and even college.

(*photos taken with an iPhone)

 

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.

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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.

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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.

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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)