Out of Shape

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

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

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

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cardiopulmonary exercise test (image from BMJ journal)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sleep(less) in Boston

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

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

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

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theme poster of the convention

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

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

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

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

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opening session

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

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

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

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

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

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

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

From Boston,

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Boston Common (central public park in downtown Boston)

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(*photos taken with an iPhone)

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.

 

Weight on My Shoulder

Ever since I have chosen this career, I have this feeling of weight on my shoulder every time I am at work. There’s always something around my neck.

It’s not that I feel like Atlas, the Titan in Greek mythology who was condemned to hold up the sky for eternity. No, nothing like carrying the world on my shoulder.

I know this profession can be stressful. And in fact it is always in the top 10 of most stressful jobs in the world. Though it may not be as much stress as police officers, fire fighters, and enlisted military personnel.

On the other hand, at least our profession is handsomely compensated. I agree though that the salary for police officers, fire fighters and the military should be increased, for the services they provide and the risks they take just to perform their duties.

But this weight on my shoulder and this feeling of something hanging around my neck could be a badge of pride as well. A symbol of our profession if you will.

Come to think of it, there may be other ways to bear this, but this is the easiest way to carry this load. That is around our neck. Thus I would always carry this weight on my shoulder, perhaps until I change career or until I retire.

Like what the Beatles’ song say:

Boy, you gotta carry that weight,
Carry that weight a long time,
Boy, you gonna carry that weight,
Carry that weight a long time.

If you’re wondering what is this weight on my shoulder?

I am just pertaining to the stethoscope that I always carry around my neck when I am working.

Were you thinking of the load of responsibility that we are burdened with? Well, that too. Especially when we’re in charge of the ICU.

By the way a stethoscope only weighs 6 ounces, which is not even half a pound. Unlike the taho vendor in the Philippines who has to carry that enormous weight on their shoulders as they go through streets after streets, just to make a living.

I really have nothing to complain about.

 

The End Of A Miracle

(I am reposting an article from December 26, 2010, “My Christmas Calling.” I wrote it after being on-duty on Christmas day.)

Christmas morning. Freshly fallen snow was on the ground. It was a White Christmas after all.

Bah, humbug!

I forced myself to get up from bed. My throat was sore. It felt like somebody stuck a fork in my throat and scraped it raw. My body aches like I just ran a marathon. I caught a Christmas bug, you know. No, not the “joyful feeling” of the holidays. A real bug.

I don’t want to go to work, emotionally and physically. But I have to. I am on-duty for Christmas. Our patients in the hospital, especially in the ICU, needs my care. (But who will care for me?) On days like this, I just have to suck it in, take a couple (or make it a handful!) of Tylenol and will myself to go.

I left home with the kids still sleeping and the gifts under the tree unopened. Maybe I would be able to come home early and we can open the gifts together.

In the hospital I greeted people with perfunctory “Merry Christmas,” though I was not feeling the “merry” part. In fact was in a Scrooge-mood.

It was a busy day: 32 total hospitalized patients I rounded upon, 2 hospitals I went to, 19 ICU patients, 12 ventilator-dependent, 2 carbon monoxide poisoning that needed hyperbaric oxygen treatment, 1 chest tube insertion, 1 endotracheal intubation, 1 arterial catheter placement, 2 central venous catheter placement……. and a partridge in a pear tree.

As I dealt with the very critically ill patients and talked with their families, I knew that I was not the bearer of good tidings and joy, but rather of grim news most of the times. As the families broke down into tears and came to term to the gravity of the condition of their loved ones, I thought that these people were experiencing far worse Christmas than me. At least I am going home tonight. My patients will not. Some of them will not come home, ever. And for these families, Christmas will never be the same.

Slowly my “Grinchy” attitude peeled off and was replaced with a sympathetic spirit. I then realized my purpose for this holiday: that is to give my compassionate care for these unfortunate people, in this supposed to be joyful occasion.

The last patient I admitted to the ICU on Christmas came late afternoon. He was 32 years old. When he was 7, he received a life-giving gift, when he became a recipient of a heart transplant. His “miracle” heart had kept him alive for all these 25 years. However, for the past few years, his existence was less than joyful. Complications after complications have developed, and one by one his organs started failing. Including his borrowed heart.

Today he was brought to the Emergency Department barely alive. After transferring him to our ICU – placing him on a mechanical ventilator, putting tubes and catheters in his body, and flooding his system with medicines – his condition did not really improve much.

I spoke with her mother in the ICU’s waiting room. She quietly, but boldly stated, in between sobs, that she was ready to let go of her son who have suffered enough. She indicated to me that she just wanted his “boy” to go gently into the night.

Somehow, the ‘miracle’ heart will be resting this Christmas night.

Did the miracle ended?

I don’t think so. For the miracle of love persists. Love that is shown here by letting go. Letting go in some occasion, is more selfless than holding on.

There is another 7-year old boy who is waiting for his gift. That boy is my son waiting at home. He may be anxious to open his gifts. Or maybe he’s anxious just to see me come home.

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Debunking Folks’ Medical Advice: Part 6

Here’s another installment on this series, which are among the popular posts in this blog.

1. Eat carrots, for it will improve your eyesight.

I am sure many of you have heard this from your parents and your grandparents. They even said that it is especially true for improving night vision. Or maybe you’re advising your kids this too, telling them this will prevent them from needing eyeglasses. The scientific proof? Have you ever seen a rabbit wearing glasses?

Although this sounds like just another way for parents to get their children to eat vegetables, there’s actually some truth to this advice. Whether or not eating carrots will stop the need for ever wearing glasses is not accurate though.

Carrots contain a massive amount of beta-carotene, a precursor of vitamin A. Sweet potatoes, squash, and green leafy vegetables are also good sources of beta-carotene. Vitamin A is needed to form the protein rhodopsin, a light-sensitive pigment found in the retina of our eyes.

Vitamin A is not only key for good vision, it is also essential in healthy immune system and cell growth. Though poor nutrition may be one cause, there are many other reasons that can results to eyesight impairment that may need correctional glasses.

The tale for eating carrots was propagated during World War II,  when the British claims that their pilot’s success in gunning down German aircrafts even at night is due to their carrot-enrich night vision, and thus encourage civilians to eat locally grown vegetables. They made up this propaganda to cover-up their recently adopted radar technology, and kept this invention a secret.

2. Wound from a rusty nail will cause tetanus.

Folks say that stepping on a rusty nail or any rusty object, can cause rust to enter the body, and lead to tetanus. This could include eating food cooked in a pot that has some rust on it. These are half-truths. Though I would not recommend using rusty pots nor stepping on rusty nails.

I remember our old car in the Philippines with some rust on it, that some friends jokingly told me that they might get tetanus from scraping into our car.

Tetanus is an infection cause by the bacteria Clostridium tetani. These bacteria or its spores are usually found in the soil or dirt. This bacteria can enter the body through breaks in the skin like cuts or puncture wounds, but it’s not the rust itself is the problem, but from whatever dirt with the bacteria or spores that may be hanging on to the rusty item.

Once tetanus infection sets in, this results in severe uncontrollable muscle spasms, like lock jaw or whole body stiffening. The bacteria produce a toxin that affects the nerve synapses that cause muscles to continuously contract or go into spasm. The disease unless treated can be deadly.

Vaccine against tetanus is universally recommended and is widely available. It’s part of the childhood immunization in the DPT (Diptheria, Pertussis, Tetanus) vaccine.

So you can still develop tetanus from stepping on a non-rusty stainless nail, if contaminated with dirt. Unless you’re adequately vaccinated against tetanus.

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Muscular spasms in a patient with tetanus. Painting by Sir Charles Bell, 1809

 

3. Don’t sit too close to the TV, it can damage your eyes, or harm you.

I was told this by my parents when I was little. I just thought that we were not supposed to sit too close from the television as something might come out suddenly from the TV screen.

I know my parents meant well. However this warning is kind of outdated now. It’s not really an old wives’ tale, but rather as an old technology’s tale.

The old television set before the 1950-60’s emitted levels of radiation, that after repeated and prolonged exposure to them, can cause some harm. But with later models of television that were built with proper shielding, the levels of radiation exposure is negligible.

Now that the TV sets that use cathode ray tubes (those bulky sets we have those days) are obsolete, we really don’t have to worry about emitted radiation from TV anymore. LCD and plasma TV don’t emit x-radiation at all.

Too much TV watching can still cause eyestrain though. Plus for young kids, there’s more fun things to do than watch TV.

4. Don’t crack or pop your knuckles, for this will cause arthritis.

According to one report, 20-50% of people, crack their knuckles. Many do it as a nervous habit. If you’re one of them, you probably have heard somebody warned you to stop, or else you will develop arthritis.

However there is no medical truth to this. And it’s not that it has not been studied. In one study, researchers look into more than 200 people, 20% of whom cracked their knuckles regularly. Of those knuckle crackers, 18.1% of them developed arthritis in their hands, compared to 21.5% of the study participants who did not crack their knuckles. So this study showed that development of arthritis is about the same, whether you crack your joints or not.

By the way, are you wondering what cause the popping sound?

When a finger or joint is extended like in an act of cracking your knuckles, the pressure inside the joint is lowered and the gases that are present in the synovial fluid, such as carbon dioxide, are released in the form of a bubble. This rapid implosion, collapse, or bursting of the gas bubbles creates an audible popping sound.

Even though knuckle-cracking has not been proven to cause arthritis, studies have shown that it’s not good either. In at least one study, chronic joint popping was shown to cause inflammation and weakened grip in the hands.

5. Don’t swallow chewing gum, for it can stick the insides of your intestines.

You probably heard this warning when you’re a child, or you told your kids this warning as well. Folklore suggests that it takes seven years for the gum to pass through the digestive system. However, there is no truth to this.

Certainly I have swallowed a few gum before, mostly not intentional but accidental. And obviously, nothing bad happened to me.

Though it’s true that the gum is indigestible, it’s not true that it will stick your insides, for it will pass through, with your stools within days, not years.

However there are rare reported cases of large amount of swallowed gum, combined with constipation, that caused blocked intestines in children. So I would still not advise to swallow your chewing gum. But if you accidentally swallow one, don’t sweat, it’s not that harmful.

Don’t scare your kids either that if they swallowed a watermelon seed, it will grow into a watermelon inside their stomach. Though if they are too young to understand how pregnancy happens, they might believe you that that’s from swallowing watermelon seed.

A Somber Celebration

Last week, we had a patient in the ICU who was unwell. Unwell, is perhaps an understatement.

He was of an advanced age though, as he was in his 80’s, and maybe has already lived a full life. Yet he was still active, lives independently with his wife, and was in relatively good health, until he got sick and got admitted to the hospital.

He came down with a bad bout of pneumonia. So bad that he went into respiratory failure and had to be placed on mechanical ventilator. This was complicated as well, as he suffered a mild heart attack too. Furthermore, he also developed brisk bleeding in his stomach, but fortunately we were able to stop that bleeding, when we did the gastroscopy.

After several days of intensive support, surprisingly he got better. He got better enough that we were able to take him off the ventilator. He was going to pull through this. So we thought.

But less than 24 hours later, he was placed back on mechanical ventilator. His blood pressure dropped as results of overwhelming infection. He went into congestive heart failure. His kidneys also started to fail. His condition got worse than ever.

We sat down with the patient’s family and discussed with them the dire situation. They decided that they would like to continue the aggressive support and hang on for two more days. I thought it was kind of odd to have so specific timeline in their request.

Why two days?

Two days later, as we’re going through our morning rounds, I was told by my staff that we will be having a party later that day. A birthday celebration right there, in the ICU.

I learned that the family of our elderly patient have called all the family members that can come, to be there and visit the patient. They brought balloons and a large birthday cake. They even brought in the patient’s dog to the ICU! But of course they have to get a permit and confirm all the vaccination records of the dog.

I also learned that the family was planning to take him off life support that same day. They would like to transition to full comfort care, and let nature take its course.

The ICU staff got a birthday card that they passed around and asked us all to sign it. Honestly, I was stumped on what to write on the card.

Do I write “Happy Birthday,” knowing that it may not be really a happy event? Or do I write “May you have more birthdays to come,” which I know would not be true at all? Or should I write “Have a good last birthday?” But that sounds morbid! Or do I write “May you have peace on your birthday,” which I think is very appropriate, but it is as if I’m foretelling death before it actually happen?

Never did I have so much difficulty in writing a simple greeting on a birthday card before.

When the family were ready, we lightened the sedation and have the patient wake up, so he will at least have the chance to witness his own birthday celebration.

The ICU staff came and crowded inside his room and sang “Happy Birthday.” Though I guess, many of us we’re feeling rather sad than happy while singing that song.

We then extubated the patient and took him off the ventilator. He was able to speak after that, though very weakly. The family gave him a piece of his birthday cake which he tasted, even if it was just the frosting.

After a while, he started to show signs of discomfort. He was obviously struggling even just to take a breath. So after the final embraces from the family and a pat to his dog, we gave him medications to relax him and made him more comfortable. He slept the rest of his birthday celebration.

He later slept on into the eternal night.

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P.S. I wrote on his birthday card, “May you have a meaningful birthday.”

 

Smoking Ban

I read in the news that President Duterte is planning to sign a law that will ban smoking in all public places nationwide. My response to this is that: it’s about time!

I don’t think in this day and age, that anybody in this world have not heard or read the damning facts that smoking is harmful to our health. As a lung specialist, and an advocate of no-smoking, I laud this plan to ban smoking in public places.

duterte-no-smoking

I am a witness to all the grim and devastating effects of smoking. I see them everyday.

Though quite honestly, I partly owe it to the smokers, of why I have work today. But in the same token, I don’t want people to continue to smoke.

According to World Health Organization, lung cancer is the most common cancer worldwide. It is also the leading cause of all cancer deaths in the world, accounting to 1.37 million deaths annually. The number of deaths every year from lung cancer alone is more than the number of deaths from breast, colorectal and prostate cancer (other leading cancers) all combined.

In the Philippines, lung cancer is also the most common type of cancer, and is the leading cause of cancer deaths. And we have 17.3 million tobacco consumers, which makes the Philippines the number one in most number of smokers in Southeast Asia. I am not sure if we should be proud of being number one in that category.

More than 90% of lung cancers are linked to smoking. Other causes are occupational carcinogen exposure, radon and pollution. Though lung cancer can arise from people who never smoke, like the late Senator Miriam Santiago, but this is relatively rare.

Besides lung cancer, smoking also causes other diseases. COPD, heart disease, mouth and throat cancer, esophageal cancer, and vascular diseases to name a few.

I know there will be some that will complain and protest that this plan is unlawful. And surely some would say that this is unfair for the smokers. For definitely people should have the right of choice. Even the right to do stupid thing, like smoking.

But the ordinance is to ban smoking in public places only. This is not taking away your right to kill yourself by smoking. You are just not allowed to kill others too that can inhale your toxic fumes.

I remember my jeepney-riding days, where someone would be blowing cigarrette smoke in my face. So between the secondhand cigarrete smoke and the diesel fumes from the buses and jeepneys, no wonder I cannot breathe after sitting for some time in traffic.

Studies have shown that second hand smoke (exposure to others who are smoking) is almost as harmful as firsthand smoke. I pity the children who have parents who smoke in their presence. Where is their right for non-toxic air?

Several places in the world have already this smoking ban in public places being enforced for quite some time now. And I’m glad that the Philippines is catching up with the current times.

I am not denying the fact that it is very hard to quit smoking. There’s even reports that tobacco companies are making cigarrettes nowadays that have higher nicotine content, making it more addictive and making it more difficult to quit.

When I was doing my subspecialty training in Memorial Sloan Kettering Cancer Center in New York City, we have patients who were already dying of lung cancer but still cannot quit smoking. They would go outside the hospital building and smoke. This was almost two decades ago when smokers can still smoke in designated areas in the hospital grounds. I even saw a patient with tracheostomy (a hole in his throat) due to throat cancer, and he was smoking through his tracheostomy! How sad is that?

Nowadays, most hospitals have a total ban of smoking in their entire premises. In the hospital where I work now, smokers would go across the street from the hospital entrance and smoke there. Even when it’s in the middle of winter or even when snowing, where they are exposed to the elements, they would still go outside in the subfreezing temperature and smoke. Why? Because they cannot help it. How really sad is that?

So I get it, it’s hard to quit smoking. But I still support the smoking ban.

Even the cockroaches will be in favor of this.

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(*images from the internet)