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 her 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 her 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.

IMG_5491

(*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.

heartjnl-2007-October-93-10-1285-F1.large

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!

IMG_5069

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)

Death Snatchers

During our ICU morning rounds, the medical residents were presenting the patients’ cases to me as I was taking over care from another attending physician.

One of the patients came in with fever and worsening shortness of breath. After work-up he was diagnosed with Legionnaire’s disease, a severe infection by a water-borne bacteria . He had complications with multi-organ failure, requiring mechanical ventilator and dialysis, among other life-sustaining support. After more than a week, he improved.

So as the resident was presenting his case with such bravado, he concluded with the statement, “we snatched him from the jaws of death,” with matching clawing action, like the arcade game of claw crane.

I kind of smiled with his presentation. I know he was half-joking, just to lift the morale of the ICU team. Taking care of very sick patients in the ICU where mortality is quite high despite of all the efforts, can be depressing.

I know this resident is a smart guy. In fact he is finishing his Internal Medicine residency with us in another month, and will be continuing his training in Hematology-Oncology Fellowship at Mayo Clinic this July. Maybe he’ll be “snatching” more patients from the jaws of death.

But there may be some truth in his statement, as we are literally snatching people out of the jaws of death. But are we really? Or are we just kidding ourselves?

That afternoon, there was a Code Blue (medical emergency) that was called overhead and my ICU team ran to respond to that call, which was a little ways out, as it was in the annexing building at the outpatient Cancer Center. The Intern (1st year resident), the most “inexperienced” of my team was the first one to arrive at the scene. He immediately took helm and directed the resuscitation efforts. Of course he was more than able and certified to do so.

By the way, even though some may say that residents (doctors-in-training) can be inexperienced, in a recent study published last month in the Journal of the American Medical Association, it reported that patients’ mortality rate is lower in teaching hospitals, than non-teaching hospitals.

Back to my ICU team, after more than half an hour of furious CPR, a stable heart rhythm was finally attained. The patient was then admitted to our ICU. I commended the Intern for doing a great job with such poise and calm, even in the midst of chaos during the Code Blue. Borrowing the words of my other resident, I told him in a jest that he “snatch” one out from the jaws of death.

I know from my experience, that even though CPR was “successful,” it was only temporary. Given the fact that this particular patient has advanced cancer, and was receiving chemotherapy when she had the cardiac arrest, tells me that the prognosis was poor.

I spoke with the patient’s son and explained to him the situation, that even though we were successful in reviving her mother, still the odds of her surviving through this was slim. But the son wanted “everything” done including doing more CPR if in case her heart stops again and does not want to hear about the poor outcome. But I understand, it is hard to let go.

The next morning, I learned that our cardiac arrest patient died. She died a few hours after I left for the night. So much of snatching people from the jaws of death.

Before we can start our ICU rounds that morning, my ICU team was called to the Emergency Department (ED) for a CPR in progress.

When I came to the resuscitation room in the ED, I saw a patient with the Lucas device on him (a machine that do the automated cardiac compression). I was told by the ED physician, that they were trying to resuscitate the man for about an hour now. He would temporary regain a heart beat, only to lose it again.

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Lucas device (photo from web)

They called me to assess if we should place the patient on Extra-Corporeal Life Support (ECLS), a “heart and lung” machine, as a temporizing measure to save him (see previous post). I suggested we call the cardiologist too.

Shortly thereafter the cardiologist arrived, and as soon as he walked in, the patient regained a stable heart rhythm again. So the Lucas device was shut off temporarily. After a brief conference with the cardiologist, we decided that the he would take the patient to the Cath Lab and see if he can open any blocked coronaries. Then we’ll decide if we need to hook the patient on ECLS.

Less than 10 minutes after we hashed our plan and as we were preparing to take the patient to the Cath Lab, the patient’s heart stopped again. We turned on the Lucas device once more. Our resuscitative efforts was now close to an hour and a half.

That’s when we all agreed, the cardiologist, the ED physician, and me, to call off the code. This patient was too far along from being snatched from the jaws of death.

We turned off the Lucas device, unhook him off the ventilator, and stopped all the intravenous medical drips that were keeping him “alive.” The ED physician then went out of the room to speak with the patient’s family, while me and my ICU team went to start our morning rounds and take care of our ICU patients.

It was grim start of our morning. Definitely my team was feeling down again.

Two hours later, I got a call from the ED. On the other line was the cardiologist, and I cannot believe what I was hearing. He was asking me to admit to the ICU the patient whom we pronounced dead earlier that morning!

Apparently after we unhooked the patient from all life-sustaining device, he regained a stable heart beat, and he started breathing spontaneously. They were waiting for him to die for the past two hours but he did not.

When I told my team that we were admitting “Lazarus,” which was what I called the patient, they thought I was just joking to lighten the mood. It took me a little more convincing for them to realize that I was telling them the truth.

That tells me enough of this “snatching people from the jaws of death.” Some of them can get out, even if we already dropped them. It just show who is really in charge. Definitely, it’s beyond us.

 

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Post Note: “Lazarus” eventually died 12 hours later.

 

 

Illusive Hope

During my last weekend call, one of the many admissions I had to the ICU was a man in his 70’s, who was found unresponsive in his home. Since he lives alone, he probably have been lying on the floor for a couple of days before he was found.

After work-up in the emergency room, it was determined that he had a large stroke. As he was very sick and unstable, we were consulted to admit him in our ICU.

The next day, after providing supportive measures, his vital signs stabilized and he became more responsive, and even following simple commands. Yet he still has significant neurologic deficits due to the devastating stroke.

The patient’s son who was the power-of-attorney, talked to me and showed me his father’s living will, which specifically detailed that in case he had an “irreversible condition,” he does not want to be on any form of life support including artificial nutrition, like tube feedings or even intravenous fluids.

I assessed that with the severity of the stroke, the likelihood of “good” recovery was doubtful. My projection was that he would never live independently again, would most likely be nursing home-bound, and definitely would not be the same person that they know. In addition, he could even get worse as the swelling of the brain increase. No question, I painted a grim scenario.

After hearing my assessment, the patient’s son and family, were ready to call hospice and just make the patient comfort cares. The son told me that his father, for sure would not like to live a life with such a poor quality as I have projected. Though I told them, that the neurologist whom I consulted have not seen the patient yet, and perhaps they should wait on what he has to say.

Not long after, the neurologist came. He extensively reviewed the CT scan of the head, and he made a careful and detailed neurological examination of the patient, as he tried to evoke even obscure reflexes that I can only read in the medical textbook. After his evaluation, the neurologist, the patient’s son, and me, went in a room for a conference.

The neurologist explained that with his estimation, even though the stroke was large, since it involved the non-dominant side of the brain and mostly the frontal lobe, he believes that the patient can still have a “meaningful” recovery. In addition, since the acute stroke was a few days ago, he thinks that the swelling was on its way down, and perhaps we were already past the worst phase. He backed this with his expert knowledge of brain anatomy and function.

Thus the neurologist believed that at best, though it may take months of rehabilitation, the patient can talk – though with a funny accent, walk – but with a limp that he even demonstrated, and maybe could even live independently later on. He definitely painted a more rosy picture than the gray picture that I have painted.

Hearing the neurologist’s opinion, it was obvious we have a “slight” difference of opinion. Perhaps slight was an understatement.

After considering the neurologist’s evaluation, the son and the family changed their mind and decided to defer calling hospice and instead support the patient as much as possible, including tube feedings and all.

To be honest, I was a bit perturbed that I gave such a bleak prognosis than what the other doctor gave. Have I given up on that patient too soon? Have I killed the embers of hope prematurely? Perhaps I have become so pessimistic in my view of things. Perhaps I have seen so many prolonged sufferings and bad outcomes despite our best intentions and efforts in my ICU experience. Perhaps I was just saving the family from the heartaches of clinging to unrealistic optimism. Or perhaps I become more cynical and have lost my faith in hope.

In my defense, maybe I just see the front end and the acute catastrophic courses of patients in the ICU, and have limited exposure to the success stories of patients’ wonderful recovery after prolonged and extensive rehabilitation.

But even though I felt betrayed by my negativism, I felt relieved that I have heard a differing opinion, and perhaps gave a chance to a life that we almost gave up on too soon. Even though I felt embarrassed and almost apologetic for my opinion, I was thankful that we gave hope a chance. Everybody deserves that chance.

The following day, when I rounded on our stroke patient, he was more obtunded and unresponsive. He now have labored breathing and had to be placed on a ventilator. I then requested a repeat CT scan of the head.

The CT scan showed what I was afraid would happen: a further extension of the stroke and more swelling, displacing the structures of the brain beyond the midline and even herniating down the brainstem. This was unquestionably a grave condition, and most likely fatal. No more differing opinions.

The family decided to transition to comfort cares, and the patient expired a day later.

I did not kill hope. It died.

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Constipated Teaching

Since I am practicing in a teaching hospital, besides treating patients, part of my duty is educating and training residents (doctors-in-training) and medical students. In fact the state university even gave me an academic title. My official title is: Adjunct Clinical Associate Professor. Adjunct, means extra or accessory. In other words, not that major. Maybe “A Junk” Professor is more appropriate. In my native language, saling-pusa.

Anyway, most of the time when I am seeing patients in the hospital, I am accompanied by medical residents or medical students. In the ICU though, my entourage could be quite large, composing of 2 to 3 residents, a medical student, a pharmacist, 1 to 2 pharmacy students, a respiratory therapist, and respiratory therapy students. Then when we round on a specific ICU patient, the nurse taking care of that patient will join our discussion too.

Having a group shadow me on my rounds has its perks, as many of the scut work the team could already accomplish in my behalf. Plus the bigger the entourage, the bigger the likelihood that people think you are important (not mere “a junk”), just don’t let that get into your head. But it has its disadvantages too. For one, I have to ask permission to break rounds, every time I needed to go to the restroom.

In our rounds, besides talking about the patients’ cases and our plan of treatment for each one of them, we also discuss about snippets of medical teachings, current trends of practice, new drugs and even latest research that support our plan of management. Thus I really needed to be updated on the most recent guidelines and studies.

Few weeks ago, as I was conducting my ICU rounds, we have been dealing with some very difficult cases as well as some unfortunate patients in our ICU whose chances of surviving were slim. As we went through consecutive depressing cases, I could sense the sadness and stress rubbing in into my team. I could feel the morale of the team was low, for taking care of these sad cases of patients.

As the captain of the team, besides making sure that the right management is given to each of our patient and assuring proper education and adequate training for my residents and students, I feel that it is my duty as well to keep a high spirit in my team.

One particular patient that we have was having a bad case of constipation that was made worse by his requirement for pain medications, on top of all his other life threatening conditions. We then discussed causes of constipation and its management in general. One complication of using opioid pain medication is constipation, as it can slow down the intestinal movement. So we decided to give our patient the relatively new injectable medicine for constipation that blocks the opioid receptors in the gastrointestinal tract without decreasing the pain relieving ability of the opioids.

Then I asked the team, “Have you heard of the long-awaited big study on constipation?”

They all looked at me shaking their heads as they have not heard of it, and anticipating more words of wisdom from me.

To this I said: “It has not come out yet.”

Realizing that I made a joke, and not to be outdone, our knowledgeable pharmacist chimed in, “But I heard of the recent study that said that diarrhea is hereditary.”

The team was smiling now, and seems to be in a better mood , waiting for the punchline.

The witty pharmacist concluded, “Because it runs in jeans (genes).” Eeeww!

With that we moved on into our next ICU patient.

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Pahabol na hugot: Constipation ka ba? Kasi I cannot get moving since you dumped me.