Cold and Dead

Part of the duty of a medical resident in a teaching hospital is to formally pronounce a patient dead. When a patient dies, the nurse would call the resident-on-call to assess and examine the patient and confirm that he or she is indeed dead. Normally this is done in a timely fashion, within several minutes after the patient breathes his/her last breath, and the resident would chart the time the patient was pronounced dead. This would be the official time of death.

I understand that in a non-teaching hospital the attending doctor would be the one to call. If the doctor is not available, a nursing supervisor or a charge nurse can declare the patient dead. 

You may argue that it does not really take a lot of training to determine if a person is dead. Any reasonable person can discern this. Though there are some people you probably know who look like dead, but I’m not talking about that. So why do we need a doctor or an experienced nurse to pronounce a person dead? I think it is more for a medico-legal purpose.

Of course sometimes your judgement that a person is dead can be challenged  by somebody. The following is an actual exchange of questions and answers as recorded in a court documents:

A lawyer was cross-examining a witness, who was a pathologist.

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive, practicing law somewhere.

Several nights ago, we had a very busy night in the ICU. I believe we had 7 admissions to the ICU in a short span of time. This is in addition to the 20 or more critically-ill patients that we already had in our unit. So “busy” may even be an understatement.

One patient that we had that night had been in the hospital for almost 2 months and had been in and out of the ICU a few times. This time around the family had decided that they would transition to comfort cares and the patient would be taken off life support. So death was imminent and expected.

For some reason, whether the medical resident was not called, or he was so busy at that time, or he was called but forgot to do it promptly, but the patient who was taken off life support was not officially pronounced dead right away. Of course everybody knew that the patient expired – the ICU nurses knew, the family members who were gathered in the room knew, and even the morgue and funeral personnel knew.

Perhaps it was assumed the he was already pronounced dead, so the body was taken down to the morgue within an hour or so after the patient died.

It was not after a few hours later that our medical resident learned that the body of our deceased patient was taken to the morgue without him officially examining the patient and pronouncing him dead.

So what would a diligent medical resident do? 

Our conscientious resident went down to the morgue in the wee hours of the morning to search for the body. He pulled out the body from the freezer. He opened the body bag. He identified the deceased patient. Then he examined the body and pronounced it dead. I know, it sounds like a plot of a horror movie. At least he had an interesting story to tell his co-residents the next morning.

A couple of days ago, I received a notice from a funeral parlor to complete and sign a death certificate. Part of the certificate is to write down the official cause of death. Since I had 3 death certificates to complete that day I checked each of the patient’s hospital electronic medical record to be accurate on what I would write. That was when I read our resident’s note on the chart and I could not help but smile: 

Patient examined in morgue. On exam patient did not respond to verbal or physical stimuli. No heart or lung sounds were heard and patient has no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dead at 0336.

Since the patient was only officially pronounced dead after a few hours in the morgue’s freezer, should I write “froze to death” as the cause of death?

Of course I did not.

photo taken with an iPhone

(I meant no disrespect to the dead, nor do I make fun of a rather serious situation. I am just relating a light moment in the otherwise morbid world of ICU I lived in.)

Black Friday

Thanksgiving week is the busiest time for travel in the United States. Students who are in distant colleges and universities, family members who have moved away from their parents, and most people who have wandered far, all journeyed back to the place they call home to be with their family.

For a day the family gathered around the table with a spread of bountiful food and gave thanks. For a day the family was one again. Unless you have no family, or you don’t like your family, or you hate food, it is hard not to like this holiday.

Of course for some people this time is for vacation and some time off work. For some it is about parties. For some it is about parades. For some it is all about watching football. And yet for some they make this holiday time all about shopping – the Black Friday event. But primarily, this time is for families and about giving thanks.

I am in charge of the hospital’s ICU this week. I know there’s no good time to be sick and be admitted in the ICU, but being sick during the holidays is terrible. It is particularly difficult for the families involved.

We have one patient who was admitted in our ICU about 10 days ago. He is in his mid 50’s and he got really ill. He has multi-organ failure. Despite all the efforts, he did not get better. He is on mechanical ventilator, on continuous dialysis, and on several medications to keep his heart pumping and blood pressure up, yet he is sliding away. More concerning still is that he is not waking up.

His family would like us to continue our intensive management until many of his family, especially his children, who are in other states could come and see him and then they would say their goodbyes. For one more Thanksgiving, they gathered, though not in front of a bountiful dinner table, but in an ICU room, as one family again. Then today, Black Friday, they decided to transition to full comfort cares and let their father passed on after a final farewell. It’s kind of hard to give thanks in such circumstances.

Sadly to say, that story is not unique to that family.

In another ICU room, a mother who is only 40 years old, has metastatic breast cancer to the brain. She failed all surgery, chemotherapy and radiation therapy, and is now having frequent seizures. Family would like to keep her in the hospital until Thanksgiving day. Last night they took her home with Hospice to die.

In yet another ICU room, a man who is in his 70’s suffered a large intracranial hemorrhage a week ago. Even after surgery to the brain to evacuate the blood, the patient remains comatose and is in continued vegetative state. The family also would like to have family members from far away places to come on Thanksgiving to see him. Today, they took him off life support.

The saddest of all is in another ICU room. The patient is in his 60’s who had cardiac arrest and prolonged CPR four days ago. We cooled his body down (hypothermia protocol) to try to preserve any brain function. However after we rewarmed his body temperature and discontinue all sedation, he’s not waking up. There is no family members around and we cannot find any one except for a friend that said they don’t know any family of his, and perhaps he is estranged from his family. Both the cardiologist and I felt that continuing life support is medically futile given his significant anoxic brain injury. We let him passed on peacefully, with nobody around him except our ICU staff.

To many, today, Black Friday means bargain sales and wild shopping spree. But in this frantic place, inside these ICU walls, it has a different meaning. It is the solemn color of mourning.

For those of you celebrating this holiday time, may you cherish each moment you have with your family, and commemorate this season in it’s true essence.

(*photo taken with an iPhone)

Bad Night

We’re sleeping in the hospital now. It started this year. Our calls are now in-house as the hospital wanted us to physically man the ICU 24/7. This is besides the resident-on-call who is already in the ICU. Sleeping in a call room of the hospital about once a week, makes me feel like I’m a resident or a doctor-in-training all over again. But I understand, the times are changing, the practice of medicine is changing, and the liability of this profession is changing. We have to adapt.

Few weeks ago, I walked in at 5 in the afternoon to take over the call for the night. The moment I walked in, I was called by my partner who was in charge of the ICU all day, to meet her in the cardiac catheterization lab (cath lab) so she can sign out to me the patients.

When I came down there, I found out that there were two patients currently in the cath lab that were both going to the ICU.

One was a man in his 40’s with severe pancreatitis and was having multi-organ failure, including severe respiratory failure that was not improving even if he’s on mechanical ventilator. So large-bore catheters were being inserted in his neck and groin, so we can place him on Extracorporeal Membrane Oxygenation or ECMO (see previous post about ECMO).

The other patient in the cath lab was a man in his 70’s that had a cardiac arrest. He required prolonged resuscitation. The cardiologist was putting an Impella device in his heart, a device placed inside the left ventricle of the heart to help pump out blood. When that’s done, the patient would be transferred to the ICU. He was already on ventilator as well.

impella

Impella device (photo from Medscape.com)

Then my partner told me that there were two more patients already in the ICU that she was called to evaluate, but did not have the chance to see yet, as she was stuck in the cath lab for the last hour or so, assisting in this patient that require ECMO.

One patient in the ICU was a transfer from another hospital, he had fever with very low blood pressure. He also has advanced esophageal cancer and on chemotherapy. He has no immune system to fight the infection. After the initial work-up, he turned up to have Influenza A.

The other patient in the ICU to see was a trauma patient, who was in a vehicular accident. He had several broken ribs and a collapsed lung. The Trauma Team has admitted the patient, but they were having difficulty oxygenating him despite being on a ventilator, thus they were consulting us for assistance.

She also told me that we have 21 other patients in the ICU that were relatively stable at the moment, but can turn volatile anytime, besides the four new ones that needed my immediate attention.

Lastly, she said that she declared the patient in room 15 as clinically brain-dead, hence, legally dead. Patient was a young lady in her 20’s who overdosed on drugs, and unfortunately was not found immediately. When she was brought to the hospital, she was too far gone. The patient’s family agreed to have her organs donated, so she’s still on life support until they can harvest her organs. The Transplant Team wants us to do a bronchoscopy to assess if the lungs and airways were normal and appropriate for harvest.

Hearing the long laundry list, I thought to myself, this would be a long night. That’s not even considering more new patients that may come.

Shortly thereafter, I got a call from the Transplant Team asking me when could I do the bronchoscopy in room 15. I told them that I would take care of some more pressing issues, and when I get free, I’ll do it, but I already contacted the endoscopy nurse to come and set up for the scope. I thought, let me take care of the living first, before I deal with the dead. But I didn’t tell them that.

When I came up to the ICU, the patient from the cath lab who had a cardiac arrest and got the Impella device, also arrived in the ICU. I evaluated the patient, and it was obvious he was doing poorly. He was requiring 3 IV drips (1 drip is a poor sign already, let alone 3!) to keep his blood pressure up. This was despite the device in his heart to pump blood. He already looked dusky and gray.

I sat down with the patient’s family, and told them that the odds were not in our favor. I don’t believe he would survive the night. I also told the cardiologist that I felt bad for him as well, as all his efforts may be all for nought.

The patient died less than 2 hours after he came up from the cath lab.

While I was working on this patient, I got a call from the Emergency Department about a new patient that needed to come to the ICU. The patient was in her 80’s, with advanced dementia, and was from a nursing home. She was septic, perhaps from a urinary tract infection. I may think that she was not the best candidate to spend my limited time and resources at that time, but who am I to say who lives and who should not. A life is still a life. So I sent my resident to evaluate and admit the patient.

When the ECMO patient came up to the ICU from the cath lab, that was where I spent most of my time and effort. We even consulted Nephrology to start the patient on dialysis too. However, despite all intervention, with ECMO, dialysis, mechanical ventilator, and several IV medication drips, the patient continued to deteriorate. I felt like we’re just spinning our wheels without gaining any traction. I noticed that the patient’s heart rate and blood pressure were drifting down. Definitely an ominous sign.

I gathered the patient’s family and brought them at bedside to the patient. I honestly told them, there’s nothing else we could do.

The patient died 5 hours after he was hooked up on ECMO. I felt defeated and deflated with these events.

In between the deaths of my 2 patients, I was able to squeeze time to do the bronchoscopy on room 15. It looked healthy, so I relayed to the Transplant Team, they can perform their harvest.

After midnight my night quiet down a bit. I caught up and was able to see all the patients I needed to see. When I had some down time, I reflected on what I accomplished and those I failed to accomplish.

At least I was able to stabilize the elderly patient from the nursing home, right? She will get better from the infection, then she’ll go back to the nursing home in a few days, and spend the rest of  her existence in bed with very poor quality of life due to her advanced dementia. How about the patient with metastatic esophageal cancer? He’ll get better from the influenza. But he still have to deal with his cancer and more chemotherapy with bleak hope of a cure. And the sad list just goes on and on.

Nights like this, make me question if it’s really worth doing this. I got several more pages through the night, but I survived to see the morning.

IMG_6345

A couple of weeks after that disheartening night-call, I received a letter. It was from the Organ Donor Network. They were thanking me for my effort in assisting to obtain donor organs for transplant. Because of this, they informed me that a young man was given a new lease in life as he received new lungs. There were other patients too that received “gifts of life” with their transplanted heart, kidneys, cornea and so on.

I then realized that even in patients who died under our care, we can make a difference. It still worth it after all.

(*photo of dawn, taken with an iPhone)

Concert in the ICU

Inside ICU room 34* of our hospital, there is an ongoing musical performance. One young man is playing an instrument and another young woman is singing.

Music therapy is a burgeoning field of science. We have known since the history of man, that music has a healing property. During Biblical times, young David was summoned to play his harp whenever King Saul of Israel was stressed and troubled. Pythagoras, Plato and Aristotle all wrote about how music affects health and behavior.

Now, modern science and current medical studies back this up. In Harvard’s Health Blog, one article mentioned that music therapy can aid pain relief, reduces side effects of cancer therapy, restores lost speech in people who suffered stroke, and improves quality of life for dementia patients among other benefits.

One study from Austria conducted in General Hospital of Salzburg, has found that patients who are recovering from back surgery had increased rates of healing and reported to have less pain when music was incorporated into their rehabilitation process. I consider Austria a leading authority in music science, after all that’s the country where great classical composers like Mozart, Strauss, Schubert, Czerny and Haydn all came from.

Several years ago, when I was doing my Critical Care Medicine training in New York City, we had a music therapy team that plays to our patients in the ICU. The team, composed of a flutist, a violinist and a cellist, would go from room to room in the ICU and would play for about 5 to 10 minutes in each room. Even if the patient was medically sedated or comatose, they would do it anyway. It was soothing for us medical staff as well, when they come, as we got to listen to their music.

Music-Therapy-1

ICU music therapy (image from wakingtimes.com)

Since music therapy is the in-thing right now, I even told my daughter to look into a career in this field, that is if she would be interested, since she is pursuing a music degree. Perhaps I can have my own therapy someday.

Back to our ICU 34, the mini-concert though is not done by our hospital’s music therapy team, for we don’t have an official team like that as of yet. The music is being performed by the patient’s son and daughter who are both college-age and are both enrolled in music degree.

The son is playing his French horn, and the daughter is singing. The daughter even composed a special song for her mother, our patient, and would sing it for this special occasion.

However, their mother, who is only 44 years of age, is not going to wake up again. Not even with the beautiful music rendition from her children or any music therapy session on earth for that matter. She suffered a devastating head bleed which caused her to be in perpetual comatose with no hope of meaningful recovery. She is just being kept alive by life-sustaining machines.

The whole family agreed, that their mother would not choose to live a life in a vegetative condition like this. So they decided that they will take her off all life support. But only after they perform their mini-concert in her presence. They would like to dedicate their music as a send off, as she passed on beyond this world.

Sometimes music can be a therapy too for the broken-hearted and for those who are left behind.

(*ICU Room number was purposely changed)

 

Old Friend

Hello friend.

First of all, I know it is your birthday tomorrow. Don’t be impressed that I remember that after all these years. It is just because you shared the same birthdate with my father, that’s why I cannot forget.

I know we have not seen each other in person for several years. But it is not a reason that we have not stayed in touch as friends. After all, we’ve known each other since our “uhugin” days of childhood. We even had that matching yellow shirt that we would often wear at the same time when we were kids, as if we were twins.

We played together. We ate together. We even got lost once together in a farm. We were so small then and cannot see beyond the tall plantation. But you told me that we should kneel down and pray right there in the rice field. After that, we eventually found our way back.

Remember how we played those tau-tauhan or toy soldiers? We would stand them up in the dirt while we were on our hands and knees on the ground, and we’ll hit them with marbles as if it was a war. I think I could hit more than you. And I’ll rub it in, mas asintado ako sa iyo.

Our lives were intertwined, as our families were good friends. We would go to parks and other places together. Remember how we would fit our two families in our “Ford Cortina” – all 4 adults and 6 young kids in one car? Who cares about seatbelts? Those were the good ole days.

Then your family decided to migrate to Papua New Guinea. I was sad that you were leaving us, but happy for you and your family that you would be going to a new country and pursuing a “better” life.

Yet you still came back a couple of times to the Philippines for a visit. You told me about your experience riding that big airplane and crossing the ocean. I was so envious! You told me how excited you were in going down the stairs of the plane that you slipped and almost fell down the tarmac.

Then after a few more years I heard that your family would be migrating to the US from Papua New Guinea. Again I was happy for you and your family for another new adventure. Though I honestly was saddened, as the chances that you would come back to live in the Philippines and we’ll be together again was nil.

But tadhana smiled again and our path crossed once more. Several years later I was given the chance to go to the US too. I remember how you and your family welcomed me with open arms. I even stayed in your place for a short time. You showed me around California in your new Toyota Camry. Your family toured me to Disneyland. And you even took me shopping for some muffler and gloves, as you learned I was going to New York City in the dead of winter to have an interview.

Then I too was able to chase my American dream.

One day you called and told me that you are quitting your job. Your stable, high-paying job. And that you were going to South America with your family as missionaries. I was surprised. But more so, I was so impressed with your admirable faith. I know it’s not easy to give up the comforts and luxuries of life, and leave everything behind, in the name of God’s higher calling. I don’t know if I can do the same.

I understand it took you some time getting used to the change. You told me how remote your location was in South America. That you live almost like in a jungle, and your home was like living in a big tree house. And how it would take you a couple of days to travel to the nearest city. Yet you never forget to call me once in a while when you have the chance. I know you can only make that overseas call whenever you’re in the city.

I heard you say that even though how meager your resources were and how simple your life was, you told me, that you love working in God’s mission. What a remarkable dedication. I have nothing but respect for you.

Then more than a couple of years ago, I learned that you and your family came back to the US. Though I understand, you were still live-in volunteers in a small Christian academy. At least you don’t have to fight anymore, those pesky mosquitoes and poisonous snakes that sneak inside your home.

Once in a while we’ll talk about our families over the phone. And how we would open up about our “little” problems raising our family, just like any parents have. I called you few weeks ago, and I told you that I would be praying for you and your family. I also got your “thank you” card about two weeks ago.

Then I got a phone call from your sister yesterday. What an awful news! A heartbreaking news. That you had a tragic car accident. And in an instant, you were gone.

I don’t know what to think. My finite mind cannot rationalize it. I don’t know why God called you home too soon. But I just have to trust Him. As you always did.

I cannot imagine how your family and children are taking this. I am praying for them. I would continue to support them in whatever way I can, just like I promised you the last time we talked.

I guess I will never hear your voice again. We will never have that heart to heart talk again. At least not here on earth. But hoping someday, somewhere, beyond this earth…….

Goodbye my old friend.

IMG_5013

(*in loving memory of Boying)

(**photo 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.

1234

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.

 

********

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.

IMG_3659

Destined Rest Stop

Returning home one evening after dropping off my daughter to her university, I came to this rest area. Since I was still several miles away from home, and needed to take a leak, so I use the rest stop.

img_3630

Rest Stop where I stopped

For the weary road traveler, rest stops are such an inviting place. Especially if they are beautiful, clean, and well maintained, like the one I used above. For people with hyperactive bladder, like me, rest stops are life-savers.

Many times we just stop to take a bathroom break. Though sometimes we take a rest for several minutes to stretch our legs or take a walk. While some take a longer break and even sleep for a few hours in their car or truck, before continuing on their long journey.

Not to brag, and since I have driven from America’s coast to coast, I believe rest stops here in Iowa are among the cleanest and well-maintained facilities. Of course I’ve also been to ones that are not worth a stop at all.

The world’s largest rest stop or truck stop is found here in Iowa along I-80. This stop has pretty much anything a road warrior needs. In addition to plenty of fast food restaurants, there is a movie theater, a laundromat, showers, a trucking museum, and a church that have service on Sundays.

Though rest stops are not meant to be our final destination. They are mere transient stops along the way. They are just there to provide us a respite from the weariness of our long travel. And that’s should be true as well in our life’s journey.

Few days ago, I learned from our batch that two of our classmates from medical school passed away. One died from a “lengthy illness” according to his obituary. While the other died suddenly from a ruptured brain aneurysm while he’s on a trip.

Of all circumstances, dying while on a break or a vacation, to me is just not right. Perhaps some will say, at least your last memories are of a happy occasion. But then again, is there really even a “good” time to die?

I am deeply saddened by these news. I guess me and my classmates and contemporaries are now in that age that we can get seriously ill and die. Though I would say, they were still too young to die.

The one who died suddenly from a ruptured aneurysm was a classmate of mine not just in medical school in the Philippines, but even since we were in pre-med. Besides being in the same classroom together since our teen years, we also played a few basketball games together, went to some outings together, and much more.

Then when we were both doing our post-graduate training here in the US, when I was applying for my subspecialty training, I even stayed in his home for a couple of days when I had an interview in Chicago, where he was still living at that time.

He worked in the US for several years, but he left a lucrative cardiology practice here, and went back to the Philippines last year, to practice back home and serve our own people. Perhaps he’s more nationalistic than I am. Or perhaps he just wanted to go home.

In one level or another, he did go home.

The last time I saw him was in Manila during our 25th graduation anniversary from University of Santo Tomas (UST) medical school, earlier this year. At one time, after a whole day event in UST, we, together with other friends went to a restaurant near Ortigas for a night-cap. Even though the place was probably less than 10 miles from the school, it took us almost 2 hours to get there due to horrible traffic. Who needs a rest stop, when we were already stopped all the time?

As I was riding with him in his car and we were stuck in Manila’s traffic, at least this gave us more time to catch up with each other’s lives. Never did I imagined, that will be the last time we’ll spend time together, and that will be our last shared trip.

Our life’s journey is so unpredictable. We plan for a long haul, but at times our travel is shortened. Way too shortened. Some of us will arrive at a rest stop. And it’s a permanent rest stop.

Rest in peace, my friends.

Guardians of the Galaxy: A Reminiscence

This is not a film review.

I know anybody can be a critic. Everybody has an opinion and everybody is entitled to one. You don’t have to be an expert to critique a movie. There are movies that we watched and discerned that they are good movies. Then there are those that we watched, and we felt duped and wanted our money back.

But there are films that we remember or even cherished, not because of the film itself, but because of the memories tied into them.

Maybe it was that animated movie that your whole family saw when you were young. Or maybe that romantic comedy that you saw with your crush on a date. Or perhaps that stupid action movie that you and your classmates cut class just to see it. Or maybe it was that boring drama that you watched after your girlfriend/boyfriend dumped you.

The film that I fondly remember as of recent is the “Guardians of the Galaxy.” (Spoiler alert, if you have not seen it yet.) I know a sequel is in the works and will be out by the middle of next year.

The reason I like the “Guardians of the Galaxy” was the personal events surrounding it.

guardians-of-the-galaxy

It was August 2014. I went home to the Philippines emergently to see my mother who got sick and was hospitalized. My sister sent me a message and told me that mom was gravely ill, and to come immediately if I want to see her alive.

Three days after I got the message, and after more than 24 hours of traveling, and about 8000 miles of airflight, and a ton of apprehension and jet lag, I got home.

When I came to the hospital, UERM university hospital in Quezon City, my mom came out of coma and actually was doing better. Maybe because she learned that I was coming home to see her. At least, that’s what I wanted to believe.

However, after few more days and more tests were done, it was found that her cancer from the colon, which was removed through surgery five years earlier, had come back. Now it had spread to her lungs and perhaps to other organs as well.

After evaluating all our options, we discussed with my mother asking her what she wanted to do. She firmly stated that she does not want to do any more therapy – no more surgery, chemotherapy, or radiation. She decided to just wait for the inevitable to come, and she wanted to go home. “Home,” has different meanings in so many levels.

So that day we decided that as soon as she is stronger, hopefully in a couple of days, we will take her home and set up a kind of hospice-like arrangement until her days here on earth is through. It was a sad day of reckoning.

I was the bantay (watcher or guardian) that day of my mother. I know in the Philippines, it is a common practice that patients in the hospital have a bantay, to assist in every need, may it be a glass of water or help with the bedpan. Unlike in the US, a patient is mostly left alone in his/her room with just a call light to summon for help.

When my older sister came that evening to relieve me as the bantay, I really don’t want to go home, but I don’t want to stay in the hospital either, for I need to clear my head.

So I went to SM Sta. Mesa (Centerpoint) which was just a block away from UERM, to pass the time. I just want to escape from the sad reality that was happening right before my eyes.

After wandering for a while, I decided to watch a movie. The movie I watched was the “Guardians of the Galaxy.” If there would be a movie about the hospital bantays would they entitle it “Guardians of the Bedpan?”

I like sci-fi movies. So its not a surpirse that I chose to see the “Guardians.” Besides I don’t remember the other movies that were showing that time. Definitely I would not watch a drama or a depressing movie given the circumstances I was in.

I thought the concept and setting of the “Guardians” was so out of this world, that it was hardly believable. But then again, at that time and what I was going through, the farther from the reality, the better for me.

I like the featured songs of the 1970’s in that movie, music that I grew up with. I also like some of the characters of the movie. Especially Groot, the man-tree who has very unique powers, even though he can only say one line: “I am Groot!” And of course the star of the movie, Peter Quill, an unorthodox hero, who calls himself Star Lord.

But maybe it was background of the story that has a soft spot in my heart. Peter Quill lost his mother, and what remained was only her loving memory and the old songs her mother left him.

On the last scene, Peter reads an old letter from his mother, and then unwraps a gift from his mom, a cassette tape of oldies songs. As he listens to the nostalgic music, it puts him on a kind of trance. It placed me on a kind of trance as well, realizing the similarity to my own state of affairs.

I thought I was escaping, but somehow the painful reality sneaked in.

Last week was my mother’s death 2nd anniversary. It so happen that the movie the “Guardians of the Galaxy” was being shown on TV that night. I couldn’t help it. I had to watch it again.

Sure enough, it brought back memories.

(*photo taken from the web)

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.

********

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