(*funeral of my uncle Tom, a fallen Marines)
I was standing in a small countryside cemetery. With me were seven other people, and we were hovering around a newly covered grave. It did not even have a tombstone or a headstone yet, just a temporary marker placed on its foot end.
It was a beautiful, warm summer day. Nice day to be out, though I’m not sure if there’s really a good day to visit a grave site. Near the cemetery was a small country church. Surrounding the graveyard which was on top of a small hill were endless fields of corn whose stalks were swaying gently with the breeze. Once in a while a car or a truck would whiz by the country road where the cemetery was located.
Buried in the grave we were visiting was a work partner of mine. He was a little past the traditional retirement age but chose to continue working, although in a slower pace. Yes, he was working until the time of his sudden death.
Due to this age of COVID pandemic and physical distancing, we were not able to attend his wake nor his funeral, as his funeral was a family-only affair. Visiting his grave was the closest way to say goodbye to him formally.
I know he chose this small country cemetery which was off the beaten path because not too far from here was a farm that he bought. But instead of making it into an agricultural farm he planted trees and turned it into a little forest. He even had his colonies of honey bees in that patch of land. This is were he escaped to, which was about 45 minutes drive from the city, when he was not doing doctor duties.
He had a brilliant mind, and he delved into different interests. Besides being an arboculturist (forestry expert) and a bee keeper, he was also a certified scuba diver. These were among other endeavors that he had dabbled into. But most of all, he was a diligent and dedicated physician. His patients vouched for his passionate work and many of them claimed that they were literally “saved” by him when their lives were on the line. He was a great teacher too. He encouraged me to pursue my certification in Sleep Medicine.
He and I were the only Board-certified sleep experts in our group of 10 Pulmonary and Critical Care doctors. Perhaps we just love to sleep so we were both fascinated with the science of it. Now I am left to carry on.
We are missing him not just because we have become more busy and we’re down one body. It does not help that this COVID-19 is still running amok. In fact a week ago we were in the news as Iowa was the number one hotspot in the whole USA with the highest infection rate. We are missing him for his wisdom and advices from years of experience which we could use in this difficult time.
As I stood in that cemetery, I was thinking of my own mortality. What do I want to be remembered when I am gone? A bungling pianist? A slow but persistent runner? An amateurish writer? Or an OK (just OK) physician? Maybe a good father, I hope? Or a loving husband? Or a trust-worthy friend? How much time do I have to direct this narrative?
When I moved to Iowa and joined this group 16 years ago, I remember my first day at work. I was in the office and I finished early as I don’t have any established patients yet to see. I hang around in the clinic as in the last group I was a part of in Florida, they frown upon and make you feel guilty if you leave early, especially if the senior partner still have patients to see. So most of the time I would not go home until after 6 PM or even later.
But it was different in this new group that I joined. It was only about 2 o’clock in the afternoon, but I have nothing else to do on my first day. That’s when this partner found me still hanging around. He asked me if there’s any other patients I need to see. When I said no, he told me to go home and rest, and that I should spend time with my family.
My departed partner, it is my turn now to tell you that you can go home. Rest, and have a peaceful long night sleep.
(*photo is of a nearby cemetery where I live, not the site where my departed partner was buried)
I am reposting an experience I had several years back. Original piece published December 2013.
I was on-call that New Year’s Eve. As I remember it, even though it was the holiday season and no patient wants to be in the hospital, it was still very busy for us.
It was a time of a bad flu season and our ICU was full. In fact there was even a pandemic that year of a bad strain of influenza A, the H1N1, or otherwise known as “swine flu,” and we had confirmed cases in our hospital. The hog farmers here in Iowa detest the name “swine flu,” as it was detrimental to their trade.
Despite of my toxic duty, I was able to finish my rounds and saw all our hospital patients for the day (took me 12 hours or so), and made it just in time to a gathering of some Filipino friends for the New Year’s party.
I was only warming up with our friends when I was called for a “stat” consult that I have to see right away. Before I left, my friends told me that if I finish the consult and it was still before midnight, then I should come back to the party. It was around 10 o’clock when I drove back to the hospital.
The patient that I came back for was a woman in her 40’s. She had breast cancer and sad to say, despite all the surgery, radiation, and chemotherapy that she underwent, the cancer had spread to the lungs and pleura (covering of the lungs).
The patient was obviously struggling to breathe when I examined her. The chest x-ray that was done that night, which was requested by the oncologist showed hydropneumothorax. That means there was collection of fluid and air in the space surrounding the lungs. And that was the reason I was consulted, to surgically place an additional chest tube (as she already had one in place) to drain the fluid and air.
After reviewing the chest film and comparing it to the previous chest x-rays, I determined that the finding of hydropneumothorax was old. In fact the chest x-ray was unchanged compared to films from few weeks ago.
That meant that the worsening of the patient’s respiratory status was not from the collection of air and fluid primarily. Placing another chest tube would not matter as the lung was trapped and would not expand further. I surmised that her further deterioration was from the advancing cancer itself.
Maybe the patient and her family was hoping against hope that there was still something that can be done. Maybe they were grasping for straws for a possibility that she could see another New Year.
I explained my findings and I then solemnly, but respectfully told them that in my viewpoint, placing another chest tube would not matter, and that would not relieve her breathing difficulty.
Right after hearing my opinion, that was when the patient and her husband made the somber decision that it was time. Time to end it all. Time to let go. Time to transition to comfort measures only. It was time for her to rest.
The patient’s husband went out briefly, maybe to talk with other family members who were outside the room. When he came back, I bid them goodbye and left.
As I went out of the room I saw two girls, both were probably not older than 12 years of age. They were crying, while an older woman was comforting them. I assumed those young girls were the patient’s daughters. I think it would be safe to say that they were not having a “happy” new year’s eve.
I looked at my watch. It was less than an hour to midnight.
By that time the rest of the world was partying while waiting for some fancy ball to drop. At that time most people were celebrating while waiting to welcome the New Year, while another family was also waiting – waiting for suffering to end. Waiting not to welcome, but to say their final goodbyes.
I did not go back to the party. I went straight home to reflect, while the song Auld Lang Syne (translated as Times Gone By) echoed in my head.
Should old acquaintance be forgot,
And never thought upon;
The flames of love extinguished,
And fully past and gone:
Is thy sweet heart now grown so cold,
That loving breast of thine;
That thou canst never once reflect
On auld lang syne.
For us who will be welcoming another new year, may we face it with hope and optimism, and embrace with reverence this precious life we are given.
(*Auld Lang Syne is traditionally sang to celebrate New Year at the stroke of midnight, but it is also sang in graduations and funerals; photo taken at Musée d’ Orsay.)
It is a lonely world out there.
Yes, we have this modern technology of all the world being connected and wired through broadband networks, internet, Wi-Fi, and all platforms of social media, and yet the proportion of the population suffering from loneliness and depression is on the rise at a rate that we have never seen before.
A couple of weeks ago, a man suffering from Parkinson’s disease presented to the hospital for progressive weakness and failure to thrive. He needed to be placed on a non-invasive ventilator (BiPAP) for respiratory failure. He was admitted to the ICU by my partner the night before.
I went to see the patient the next morning. Before going in to the patient’s room the nurse at the station made a comment to me, “I think he just has no more will to live.”
I examined the patient and I spoke to him. Despite him on the BiPAP mask, he was still able to communicate. After learning more about him, he expressed to me that he wanted to be DNR (Do Not Resuscitate), meaning, to let him go peacefully if his heart stops.
I learned from the patient too that his wife passed away recently. He also had a son that lives in the area but he did not want him contacted. His next of kin that he put on record was his church pastor.
I tried to get him off the non-invasive ventilator but his oxygen saturation dropped so we had to place him back on it. But I told him that we could take him off the BiPAP mask briefly to let him eat, however he said that he had no appetite.
After our initial work-up, his condition was still a conundrum. He was not in congestive heart failure. He had no apparent pneumonia. He had no viral or bacterial infection. He was just unwell.
I think the nurse’s assessment was spot on. The patient simply gave up on living.
That night, a little past midnight, my phone rang. It was one of the ICU nurse telling me that our patient went bradycardic (low heart rate) and then went into PEA (pulseless electrical activity). The nurse commented, “He checked out.” He gave up the ghost and died.
The saddest part as I learned later, was that there were no friends nor family that visited him. There was nobody around, except for our hospital staff, when he died.
I don’t really know what was the story behind this patient. What I know is that he was lonely and that he did not care to live anymore. What if somebody was there for him? Could it have made a difference?
Please take time to show people, specially our loved ones that we care.
(*photo taken from here)
(Eksaktong limang taon ngayong araw na ito ang nakalipas nang aking ilathala ang artikulong Paglalakbay sa Alapaap. Isa lamang pong pagbabalik-tanaw……..)
Paglalakbay sa Alapaap
Iyan ang aking nakita, sa pagdungaw ko sa bintana. Muli akong nasa himpapawid. Lumilipad. Naglalakbay. Pabalik sa aking lupang sinilangan.
Isip ko ay lumilipad at naglalakbay din. Ngunit hindi tulad ng eroplanong aking sinasakyan na mapayapang tumatahak sa mga alapaap, ang biyahe ng aking isip ay maligalig at matagtag.
Mula nang ako’y lumisan ng ating bansa, dalampung taon na ang nakalilipas, ay maraming beses na rin naman akong nakapagbalik-bayan. At lagi sa aking pagbabalik ay may bitbit itong galak at pananabik. Galak na muli akong tatapak sa lupang tinubuan. At pananabik na makita muli ang iniwang pamilya’t mga kaibigan.
Kahit nang ako’y umuwi noong nakaraang Nobyembre bilang isang medical volunteer para tumulong sa mga nasalanta ni Yolanda, ang naramdaman ko’y hamon na may kahalo pa ring pananabik. Pananabik na makapagbigay ng lunas at ginhawa sa mga kababayang nasakuna ng bagyo.
Ngunit kaka-iba ang pagkakataong ito ng aking pagbabalik. Walang galak. Walang panananabik. Kundi pagkabahala sa kakaibang bagyo na aming sasagupain.
May katiyakan naman ang aking patutunguhan. May katiyakan rin ang oras ng aking pagdating at paglapag sa Maynila. Ngunit hindi ko tiyak kung ano ang aking daratnan. Hindi ko rin tiyak kung gaanong kaikling panahon pa ang sa amin ay inilaan.
Pero ganyan daw talaga ang buhay. Walang katiyakan.
Hindi ko sasabihing hindi ko batid na darating din ang pagkakataong kagaya nito. Ngunit katulad ninyo, ako’y nagnanais at umaasa na sana ay malayo pa ang takipsilim. Sana ay magtagal pa ang tag-araw. Sana ay hindi pa matapos ang awit. Sana ay mahaba pa ang sayaw. Sana……..
Subalit tanggapin man natin o hindi, ang lahat ay may hangganan at may katapusan.
Maraming bagyo na rin naman ang aming pinagdaanan. At kahit gaano kalupit ang hagupit ng unos, ito ay nakakaya ring bunuin. At kahit dumadapa sa dumadaang delubyo ay muli rin namang nakakabangon.
Hindi lang bagyong kagaya ni Ondoy o Yolanda ang aking tinutukoy.
Ngunit kahit gaano pa kaitim ang mga ulap na kumumubli sa liwanag, at kahit gaano kalakas ang sigwa na yumayanig sa pagod na nating katauhan, at kahit gaano pa kahaba ang gabi, ay ating tatandaan na lagi pa ring may bukang-liwayway sa kabila ng mga alapaap.
Atin na lang ding isipin na sa ibabaw ng mga alapaap ay palaging nakangiti ang araw. Sa ibabaw ng mga alapaap ay laging mapayapa. Sa ibabaw ng mga alapaap ay walang nang bagyo. Walang nang pagkakasakit. Walang nang paghihinagpis. Walang na ring pagtangis.
Malapit nang lumapag ang aking eroplanong linululanan. Malapit na rin akong humalik muli sa inang-lupa na aking sinilangan. Muli rin akong hahalik sa mukha ng aking ina na sa akin ay nagsilang.
Sana ay magkita pa kami. Sana ay abutan ko pa siya………..bago siya maglakbay sa ibabaw ng mga alapaap.
Post Note: Nagpang-abot pa kami ng aking ina. Ngunit iyon na ang aming huling pagkikita, sapagka’t dalawang buwan matapos nito, siya ay nagbiyaheng langit at pumailanglang na.
I have posted more than 850 articles and stories over the years since this blog’s inception, which in a few months, will be 10 years. It’s quite a popular practice in the media to have reruns or replays. Even social media have their “throwbacks.”
I would like to repost a throwback story/article once in a while, not that I am running out of ideas or stories, for as a matter of fact, I have more than 30 unfinished articles in my draft bin. But sometimes, I just want to relive a bygone moment, or perhaps give a new breath to a favorite story from the past.
Here’s a reload of a love story that I witnessed a few years ago:
Making Things Right
“I just want to make things right.”
That was what my patient told me. Wanting to make things right. Don’t we all? Here is his story.
He was in his 50’s, and he presented to the hospital with leg swelling and worsening shortness of breath. After initial work-up in the Emergency Room, he was diagnosed with blood clots in the legs and lungs (veno-thromboembolism). A serious condition.
His chest CT scan also showed a lung mass. After further work-up, which includes a biopsy, it was found to be cancer. Cancer in itself is a risk for developing blood clots. A bad prognosis.
After more work-up, it was determined that the lung cancer was far advanced. It has spread to the bones, liver, and lymph nodes. A grim outlook.
During his hospital stay, his condition deteriorated and was transferred to the ICU.
I approached him as he lay in his ICU bed. Knowing the severity of his condition, I asked him about his “code status.” That is, what he wants us to do if in case he cannot breathe on his own, does he wants us to place a tube down his throat and have a machine breathe for him? Or if his heart stops, does he wants us to shock his heart or pound on his chest to try to resuscitate him? Or does he wants us to just let him go peacefully?
There was a long pause before he replied, as he breathed heavily under the oxygen mask. “I want everything done,” he finally answered. “I want everything done, until I have done one thing. I want to get married.”
Get married? Did I hear him right? Was he of a sound mind or was he confused and hallucinating?
As he continued talking, I ascertained that he was very alert and not confused at all. I did not ask why he wanted to get married, but he explained to me the reason why. Perhaps he saw the quizzical look on my face.
“I just want to make things right,” was his reason. Apparently, he was living-in with his girlfriend for twelve long years. He wanted to make their union legal. This would make her girlfriend the legal decision-maker for him if he becomes incompetent. And she would also inherit his estate without questions, when he dies. But more so, he just wanted to show her how he loved her over the years, but did not quite made it to the altar. Now, he was “making things right.”
Two days later, there was a wedding ceremony in our ICU room. A bride, a groom, a chaplain, and a couple of witnesses. That was all you need for a wedding. Of course there was a gown too. But it was the groom who wore it, for I’m not pertaining to a wedding gown, but rather a patient’s hospital gown.
There was many well-wishers too, courtesy of the ICU staff.
The patient’s son was also present. I believe he was his son from a previous relationship, and he came from out-of-state to visit his very ill father. He was probably expecting to attend a funeral, but was surprised that he was attending a wedding instead.
A few days after the wedding, our patient’s condition improved that he was able to be transferred out of the ICU to the Oncology floor. Perhaps, getting married gave him hope and a different outlook in life, and willed himself to get better.
He was started on combined regimen of radiation therapy and chemotherapy. Hope springs eternal.
Two weeks later, his condition started to decline once more. He grew weaker and weaker. His respirations became more and more labored. This time, he told us, he does not want to be resuscitated if his heart stops or if he cannot breathe on his own. I guess, he already accomplished his one wish, and now he was ready.
Then one day, he quietly faded away at the break of dawn. And he left a newly wed bride, a widow.
Cancer stumps hope. A so familiar refrain, sadly to say.
Yet love conquers all.
(*This story was originally published in July of 2011; featured photo was taken a few weeks ago.)
Part of the duty of a medical resident in a teaching hospital is to formally pronounce a patient dead. When a patient dies, the nurse would call the resident-on-call to assess and examine the patient and confirm that he or she is indeed dead. Normally this is done in a timely fashion, within several minutes after the patient breathes his/her last breath, and the resident would chart the time the patient was pronounced dead. This would be the official time of death.
I understand that in a non-teaching hospital the attending doctor would be the one to call. If the doctor is not available, a nursing supervisor or a charge nurse can declare the patient dead.
You may argue that it does not really take a lot of training to determine if a person is dead. Any reasonable person can discern this. Though there are some people you probably know who look like dead, but I’m not talking about that. So why do we need a doctor or an experienced nurse to pronounce a person dead? I think it is more for a medico-legal purpose.
Of course sometimes your judgement that a person is dead can be challenged by somebody. The following is an actual exchange of questions and answers as recorded in a court documents:
A lawyer was cross-examining a witness, who was a pathologist.
Q: Doctor, before you performed the autopsy, did you check for a pulse?
Q: Did you check for blood pressure?
Q: Did you check for breathing?
Q: So, then it is possible that the patient was alive when you began the autopsy?
Q: How can you be so sure, Doctor?
A: Because his brain was sitting on my desk in a jar.
Q: But could the patient have still been alive, nevertheless?
A: Yes, it is possible that he could have been alive, practicing law somewhere.
Several nights ago, we had a very busy night in the ICU. I believe we had 7 admissions to the ICU in a short span of time. This is in addition to the 20 or more critically-ill patients that we already had in our unit. So “busy” may even be an understatement.
One patient that we had that night had been in the hospital for almost 2 months and had been in and out of the ICU a few times. This time around the family had decided that they would transition to comfort cares and the patient would be taken off life support. So death was imminent and expected.
For some reason, whether the medical resident was not called, or he was so busy at that time, or he was called but forgot to do it promptly, but the patient who was taken off life support was not officially pronounced dead right away. Of course everybody knew that the patient expired – the ICU nurses knew, the family members who were gathered in the room knew, and even the morgue and funeral personnel knew.
Perhaps it was assumed the he was already pronounced dead, so the body was taken down to the morgue within an hour or so after the patient died.
It was not after a few hours later that our medical resident learned that the body of our deceased patient was taken to the morgue without him officially examining the patient and pronouncing him dead.
So what would a diligent medical resident do?
Our conscientious resident went down to the morgue in the wee hours of the morning to search for the body. He pulled out the body from the freezer. He opened the body bag. He identified the deceased patient. Then he examined the body and pronounced it dead. I know, it sounds like a plot of a horror movie. At least he had an interesting story to tell his co-residents the next morning.
A couple of days ago, I received a notice from a funeral parlor to complete and sign a death certificate. Part of the certificate is to write down the official cause of death. Since I had 3 death certificates to complete that day I checked each of the patient’s hospital electronic medical record to be accurate on what I would write. That was when I read our resident’s note on the chart and I could not help but smile:
Patient examined in morgue. On exam patient did not respond to verbal or physical stimuli. No heart or lung sounds were heard and patient has no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dead at 0336.
Since the patient was only officially pronounced dead after a few hours in the morgue’s freezer, should I write “froze to death” as the cause of death?
Of course I did not.
(I meant no disrespect to the dead, nor do I make fun of a rather serious situation. I am just relating a light moment in the otherwise morbid world of ICU I lived in.)
Thanksgiving week is the busiest time for travel in the United States. Students who are in distant colleges and universities, family members who have moved away from their parents, and most people who have wandered far, all journeyed back to the place they call home to be with their family.
For a day the family gathered around the table with a spread of bountiful food and gave thanks. For a day the family was one again. Unless you have no family, or you don’t like your family, or you hate food, it is hard not to like this holiday.
Of course for some people this time is for vacation and some time off work. For some it is about parties. For some it is about parades. For some it is all about watching football. And yet for some they make this holiday time all about shopping – the Black Friday event. But primarily, this time is for families and about giving thanks.
I am in charge of the hospital’s ICU this week. I know there’s no good time to be sick and be admitted in the ICU, but being sick during the holidays is terrible. It is particularly difficult for the families involved.
We have one patient who was admitted in our ICU about 10 days ago. He is in his mid 50’s and he got really ill. He has multi-organ failure. Despite all the efforts, he did not get better. He is on mechanical ventilator, on continuous dialysis, and on several medications to keep his heart pumping and blood pressure up, yet he is sliding away. More concerning still is that he is not waking up.
His family would like us to continue our intensive management until many of his family, especially his children, who are in other states could come and see him and then they would say their goodbyes. For one more Thanksgiving, they gathered, though not in front of a bountiful dinner table, but in an ICU room, as one family again. Then today, Black Friday, they decided to transition to full comfort cares and let their father passed on after a final farewell. It’s kind of hard to give thanks in such circumstances.
Sadly to say, that story is not unique to that family.
In another ICU room, a mother who is only 40 years old, has metastatic breast cancer to the brain. She failed all surgery, chemotherapy and radiation therapy, and is now having frequent seizures. Family would like to keep her in the hospital until Thanksgiving day. Last night they took her home with Hospice to die.
In yet another ICU room, a man who is in his 70’s suffered a large intracranial hemorrhage a week ago. Even after surgery to the brain to evacuate the blood, the patient remains comatose and is in continued vegetative state. The family also would like to have family members from far away places to come on Thanksgiving to see him. Today, they took him off life support.
The saddest of all is in another ICU room. The patient is in his 60’s who had cardiac arrest and prolonged CPR four days ago. We cooled his body down (hypothermia protocol) to try to preserve any brain function. However after we rewarmed his body temperature and discontinue all sedation, he’s not waking up. There is no family members around and we cannot find any one except for a friend that said they don’t know any family of his, and perhaps he is estranged from his family. Both the cardiologist and I felt that continuing life support is medically futile given his significant anoxic brain injury. We let him passed on peacefully, with nobody around him except our ICU staff.
To many, today, Black Friday means bargain sales and wild shopping spree. But in this frantic place, inside these ICU walls, it has a different meaning. It is the solemn color of mourning.
For those of you celebrating this holiday time, may you cherish each moment you have with your family, and commemorate this season in it’s true essence.
(*photo taken with an iPhone)
We’re sleeping in the hospital now. It started this year. Our calls are now in-house as the hospital wanted us to physically man the ICU 24/7. This is besides the resident-on-call who is already in the ICU. Sleeping in a call room of the hospital about once a week, makes me feel like I’m a resident or a doctor-in-training all over again. But I understand, the times are changing, the practice of medicine is changing, and the liability of this profession is changing. We have to adapt.
Few weeks ago, I walked in at 5 in the afternoon to take over the call for the night. The moment I walked in, I was called by my partner who was in charge of the ICU all day, to meet her in the cardiac catheterization lab (cath lab) so she can sign out to me the patients.
When I came down there, I found out that there were two patients currently in the cath lab that were both going to the ICU.
One was a man in his 40’s with severe pancreatitis and was having multi-organ failure, including severe respiratory failure that was not improving even if he’s on mechanical ventilator. So large-bore catheters were being inserted in his neck and groin, so we can place him on Extracorporeal Membrane Oxygenation or ECMO (see previous post about ECMO).
The other patient in the cath lab was a man in his 70’s that had a cardiac arrest. He required prolonged resuscitation. The cardiologist was putting an Impella device in his heart, a device placed inside the left ventricle of the heart to help pump out blood. When that’s done, the patient would be transferred to the ICU. He was already on ventilator as well.
Then my partner told me that there were two more patients already in the ICU that she was called to evaluate, but did not have the chance to see yet, as she was stuck in the cath lab for the last hour or so, assisting in this patient that require ECMO.
One patient in the ICU was a transfer from another hospital, he had fever with very low blood pressure. He also has advanced esophageal cancer and on chemotherapy. He has no immune system to fight the infection. After the initial work-up, he turned up to have Influenza A.
The other patient in the ICU to see was a trauma patient, who was in a vehicular accident. He had several broken ribs and a collapsed lung. The Trauma Team has admitted the patient, but they were having difficulty oxygenating him despite being on a ventilator, thus they were consulting us for assistance.
She also told me that we have 21 other patients in the ICU that were relatively stable at the moment, but can turn volatile anytime, besides the four new ones that needed my immediate attention.
Lastly, she said that she declared the patient in room 15 as clinically brain-dead, hence, legally dead. Patient was a young lady in her 20’s who overdosed on drugs, and unfortunately was not found immediately. When she was brought to the hospital, she was too far gone. The patient’s family agreed to have her organs donated, so she’s still on life support until they can harvest her organs. The Transplant Team wants us to do a bronchoscopy to assess if the lungs and airways were normal and appropriate for harvest.
Hearing the long laundry list, I thought to myself, this would be a long night. That’s not even considering more new patients that may come.
Shortly thereafter, I got a call from the Transplant Team asking me when could I do the bronchoscopy in room 15. I told them that I would take care of some more pressing issues, and when I get free, I’ll do it, but I already contacted the endoscopy nurse to come and set up for the scope. I thought, let me take care of the living first, before I deal with the dead. But I didn’t tell them that.
When I came up to the ICU, the patient from the cath lab who had a cardiac arrest and got the Impella device, also arrived in the ICU. I evaluated the patient, and it was obvious he was doing poorly. He was requiring 3 IV drips (1 drip is a poor sign already, let alone 3!) to keep his blood pressure up. This was despite the device in his heart to pump blood. He already looked dusky and gray.
I sat down with the patient’s family, and told them that the odds were not in our favor. I don’t believe he would survive the night. I also told the cardiologist that I felt bad for him as well, as all his efforts may be all for nought.
The patient died less than 2 hours after he came up from the cath lab.
While I was working on this patient, I got a call from the Emergency Department about a new patient that needed to come to the ICU. The patient was in her 80’s, with advanced dementia, and was from a nursing home. She was septic, perhaps from a urinary tract infection. I may think that she was not the best candidate to spend my limited time and resources at that time, but who am I to say who lives and who should not. A life is still a life. So I sent my resident to evaluate and admit the patient.
When the ECMO patient came up to the ICU from the cath lab, that was where I spent most of my time and effort. We even consulted Nephrology to start the patient on dialysis too. However, despite all intervention, with ECMO, dialysis, mechanical ventilator, and several IV medication drips, the patient continued to deteriorate. I felt like we’re just spinning our wheels without gaining any traction. I noticed that the patient’s heart rate and blood pressure were drifting down. Definitely an ominous sign.
I gathered the patient’s family and brought them at bedside to the patient. I honestly told them, there’s nothing else we could do.
The patient died 5 hours after he was hooked up on ECMO. I felt defeated and deflated with these events.
In between the deaths of my 2 patients, I was able to squeeze time to do the bronchoscopy on room 15. It looked healthy, so I relayed to the Transplant Team, they can perform their harvest.
After midnight my night quiet down a bit. I caught up and was able to see all the patients I needed to see. When I had some down time, I reflected on what I accomplished and those I failed to accomplish.
At least I was able to stabilize the elderly patient from the nursing home, right? She will get better from the infection, then she’ll go back to the nursing home in a few days, and spend the rest of her existence in bed with very poor quality of life due to her advanced dementia. How about the patient with metastatic esophageal cancer? He’ll get better from the influenza. But he still have to deal with his cancer and more chemotherapy with bleak hope of a cure. And the sad list just goes on and on.
Nights like this, make me question if it’s really worth doing this. I got several more pages through the night, but I survived to see the morning.
A couple of weeks after that disheartening night-call, I received a letter. It was from the Organ Donor Network. They were thanking me for my effort in assisting to obtain donor organs for transplant. Because of this, they informed me that a young man was given a new lease in life as he received new lungs. There were other patients too that received “gifts of life” with their transplanted heart, kidneys, cornea and so on.
I then realized that even in patients who died under our care, we can make a difference. It still worth it after all.
(*photo of dawn, taken with an iPhone)
Inside ICU room 34* of our hospital, there is an ongoing musical performance. One young man is playing an instrument and another young woman is singing.
Music therapy is a burgeoning field of science. We have known since the history of man, that music has a healing property. During Biblical times, young David was summoned to play his harp whenever King Saul of Israel was stressed and troubled. Pythagoras, Plato and Aristotle all wrote about how music affects health and behavior.
Now, modern science and current medical studies back this up. In Harvard’s Health Blog, one article mentioned that music therapy can aid pain relief, reduces side effects of cancer therapy, restores lost speech in people who suffered stroke, and improves quality of life for dementia patients among other benefits.
One study from Austria conducted in General Hospital of Salzburg, has found that patients who are recovering from back surgery had increased rates of healing and reported to have less pain when music was incorporated into their rehabilitation process. I consider Austria a leading authority in music science, after all that’s the country where great classical composers like Mozart, Strauss, Schubert, Czerny and Haydn all came from.
Several years ago, when I was doing my Critical Care Medicine training in New York City, we had a music therapy team that plays to our patients in the ICU. The team, composed of a flutist, a violinist and a cellist, would go from room to room in the ICU and would play for about 5 to 10 minutes in each room. Even if the patient was medically sedated or comatose, they would do it anyway. It was soothing for us medical staff as well, when they come, as we got to listen to their music.
Since music therapy is the in-thing right now, I even told my daughter to look into a career in this field, that is if she would be interested, since she is pursuing a music degree. Perhaps I can have my own therapy someday.
Back to our ICU 34, the mini-concert though is not done by our hospital’s music therapy team, for we don’t have an official team like that as of yet. The music is being performed by the patient’s son and daughter who are both college-age and are both enrolled in music degree.
The son is playing his French horn, and the daughter is singing. The daughter even composed a special song for her mother, our patient, and would sing it for this special occasion.
However, their mother, who is only 44 years of age, is not going to wake up again. Not even with the beautiful music rendition from her children or any music therapy session on earth for that matter. She suffered a devastating head bleed which caused her to be in perpetual comatose with no hope of meaningful recovery. She is just being kept alive by life-sustaining machines.
The whole family agreed, that their mother would not choose to live a life in a vegetative condition like this. So they decided that they will take her off all life support. But only after they perform their mini-concert in her presence. They would like to dedicate their music as a send off, as she passed on beyond this world.
Sometimes music can be a therapy too for the broken-hearted and for those who are left behind.
(*ICU Room number was purposely changed)