He Checked Out

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)

Tortured Soul

She was a tortured soul.

In spite of all the medical interventions and having a supportive family, she still was always extremely depressed. It seems that she cannot get rid of her demons and the tormenting voices in her head. The desire to kill or hurt herself consumed her every day.

She has been on different anti-depressive medications and was regularly being followed by her psychiatrist. She even had several admissions to the inpatient psych unit. Yet nothing really alleviated her condition. For a person who is barely in her 30’s, she already had a fair share of misery.


She has attempted suicide a number of times in the past. Though all of those times it was not serious, resulting no grave medical consequences. It was mostly cries for help.

But this time, it’s different.

Her family found her unresponsive in her room after presumably overdosing on a bunch of different pills. Emergency responders were called and upon their arrival, CPR was performed. They were able to establish a stable heart rhythm and patient was brought to the hospital where she was subsequently admitted to the ICU.

She laid there in our ICU, hooked to several monitors and life support. Her chest would rise and fall as the ventilator bellows air into her lungs.

Three days have passed since her admission, yet she remained unresponsive. In addition she had this intermittent jerking-like activity, which I believe was an ominous sign of severe anoxic brain injury. I called the neurologist to assist in her care.

Then few hours ago, something happened.

Her vital signs became more labile. The continuous EEG monitoring which the neurologist requested showed a significant change. The jerking-like activity have quit. Her pupils were now fixed and dilated.

My suspicion was that she now is brain-dead.

Brain death is a complete and irreversible loss of brain function. Unlike in a vegetative state which could have some autonomic or brain stem functions left, brain dead means cessation of all brain activity.

I updated her family of this recent development. Then I proceeded to do my confirmatory exam for brain death per protocol.

After my evaluation, I determined that all her neurologic functions were gone. I even performed an apnea test, which involves taking the patient off the ventilator for 8 full minutes, while providing oxygen through the endotracheal tube. If there was no respiratory motion for the entire time, and this is associated with an appropriate rise in the blood carbon dioxide level, then this is one verification that someone is indeed brain-dead.

The neurologist independently performed her evaluation as well, and also arrived at the same conclusion.

When one is declared brain-dead, it is an indicator of legal death. Different from a person who is in a continued vegetative state, who can be sustained on life support indefinitely (which is controversial in so many levels), a person who is declared brain-dead is officially dead. All life support should be discontinued. Even if the heart is still beating. No argument. No controversy.

I gathered the family and told them of my findings. They were obviously distraught, but accepted the news without any questions.

I also told them, that based on the patient’s driver’s license, she indicated that she was an organ donor. I asked the family if they would like to honor the patient’s wishes.

The family said, that they totally agree to donate the patient’s organs per her wishes. That despite of the patient’s several mistakes in her life, this may be the best decision she have ever made, according to them. And despite of her cloudy and troubled mind, she have decided on this selfless act.

I called the donor network.

I know that somewhere out there, another person will be set free from the shackles of dialysis as he or she would receive a long-awaited kidney. Another person will be given a new breath of life as he or she would receive a new set of lungs. And another person out there will be given a new lease of life, as he or she would receive a new heart.

All because of the gift of a tortured soul.


I take care of “broken” people. Both broken, physically and emotionally.

Due to the nature of my specialty, I deal regularly with people who overdosed and those who attempted to commit suicide.

This past week, we have a lot of them. Every single night we have at least 2 admissions to our ICU of attempted suicide by drug overdose. There’s one that even slashed her wrist besides taking medications. It was full moon after all.

I am not superstitious, but I believe there is a real science behind the connection of the cyclical phases of the moon and human’s crazy behavior. Just like the gravitational pull of the moon affects the ocean tide, maybe it can influence our mind too. The human’s brain is 75% water anyway.

Most of the times our drug overdose admissions are “trivial” overdoses. They took a handful of pain or sleep medications as a cry for help, with the so familiar line of “I just want to escape from my problems” or “I just want to take a long sleep.” Though many will also claim, “I just want to end it all.”

Most of these overdoses just needed to be closely monitored for several hours in the ICU as they sleep off the effects of the drugs they took. When they sober up, we call the psychiatrist to evaluate them whether they are clear for discharge or transfer to the Psych unit.

However there are some who are “serious” with their attempts, that they overdosed with an awful amount of drugs or took highly toxic substances that they present to our ICU half dead. They have multi-organ failures, and would require infusion of medical antidotes if there’s any, be placed on life support, including mechanical ventilator, cardiac and circulatory support, and even dialysis, if the medication or poison they took can be dialysed out. Few of these gravely ill patients would slip through our fingers and die despite of our best efforts.


Taking care of overdoses and attempted suicide patients is my least favorite in the line of my job. Why?

First of all, as I mentioned above, most of them don’t really need ICU care, as they just require time to sleep it off. But I guess they needed to be in a highly monitored bed in case something goes wrong. So many times it just add to the burden of the ICU staff who are already overloaded in caring other critically ill patients.

Secondly, for those who are “serious” in their suicide attempt and comes to us almost dead, after we work our tails off saving them, they are not even grateful to us when they recover. They are even bitter. Why? For the obvious reason that we prevented them from getting to their ultimate goal, which is to die. It is a thankless job.

Over the years that I have been an ICU physician, I have observed that our admission of drug overdoses and suicide attempts seems to be increasing. Has our society gone so cold and uncaring that many among us feel so lost and so unloved, that they are willing to do foolish things just to get the care and attention they hunger for? Maybe it is the world that is broken. Maybe it is all of us.

As a health care professional, it is my duty and my obligation to care for these people when they come to our ICU, irregardless of how “stupid” their acts seems to be. I’ll listen to their stories. I’ll reassure them. And if care and attention is what they want, deserving or not, I’ll give it to them.

Even though these “broken” people think that the world is so indifferent and no one seems to care, but when they leave our ICU, I can honestly say to them, I cared for you.


(*image from emaze.com)