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.

5354f750a2816333f42efbeeacb4e244

(*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.

42281389_1847773448671905_1345897078160621568_n

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.

42210825_1847844961998087_94840389793480704_n

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.

IMG_7199

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.

42101599_1845764435539473_1233798676548157440_n

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.

42196844_1845592728889977_5418741619232866304_n.jpg

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.

IMG_6672

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.

IMG_6674

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.

IMG_6675

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:

IMG_6677

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.

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.

tawas

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)