A New Normal

I have been going to work now with a mask and a shield. No, I did not become Captain America, nor did I become an Avenger. What I meant is I’m going to work with a medical face mask and a face shield. This has become the new normal for me.

If I am going to do a procedure that is at risk of aerosolizing the virus, like putting an endotracheal tube or doing a bronchoscopy on a known or suspected COVID-19 patient, then I even use my “powered suit.” Not a powered suit like that of Iron Man, but it is a battery powered air-purifying respirator or also known as PAPR.

I rarely take my temperature before. Now, it is taken at least once a day and sometimes more. This daily temperature probe is not to determine if I’m ovulating or not, for the last time I checked I am a male. For your information, the “temperature method” is a family planning method that takes the woman’s daily basal temperature to determine if she is in her fertile or infertile periods of the menstrual cycle.

I am having my temperature taken whenever I enter the hospital, with additional screening questions of “Do you have fever, cough or shortness of breath?” If from the hospital I would go to the outpatient clinic building, I would get my temperature checked again and have the same screening questions, with an additional inquiry of “Were you exposed to a person with known COVID-19?” The last question is tricky to answer, for if I say yes, then they might not let me enter the building. But how else could I answer that question if I have just seen patients with confirmed corona virus in the hospital? Lie, if we must.

Photo by Ketut Subiyanto on Pexels.com

I don’t know if we have flattened the curve in our community. I am not talking about the bulge around the waist, for that has definitely ballooned more in many people with the stay-at-home order and the uncontrolled eating, plus with the gyms being closed. I guess a mask can help with this, as it is impossible to eat when you’re wearing a mask. But I digress.

We still have lots of COVID-19 patients in the hospital, though it maybe less compared to two weeks ago. Yet I still saw 15 COVID patients in the ICU this weekend, and many of them were on ventilators. I say it’s less, for at one point we had more than 20 COVID patients in the ICU and had a steady admission of 1 to 3 more a day. Good thing was many recovered fast, although some also died. There was also a time that we registered close to 50 admitted COVID patients in our hospital, both in the ICU and wards. So are we really flattening the curve?

Even though it is terrifying, we as physicians, have gained lots of knowledge and experience taking care of the critically ill COVID-19 patients. One thing we learned is that not all COVID patients with severe hypoxia needed to be on ventilators. Placing them on humidified high flow (pressurized) oxygen via nasal cannula can prevent intubation, and in fact they have faster recovery and less complications with this. Of course there are still patients that would require ventilator as a last resort, but we probably avoided more than half of our COVID patients from getting on a machine. Our experience in our hospital was extremely good that it was even featured in the local news. We might be publishing a paper on a medical journal about this experience in the near future.

Our hospital has also gained so much experience in placing patients on prone position if their oxygenation is failing. Never have I seen so many ICU patients on their belly. If the patient is awake and not on mechanical ventilator, we instruct them to lay not on their back if able. If they are sedated and on ventilator, we avail a team to flip them on their belly. And based on our experience, this really improves their respiratory status – belly down prevents them from going “belly-up.”

Photo by Miguel Á. Padriñán on Pexels.com

There are also interventions that have rapidly fallen out of favor, at least from our experience. Like giving hydroxychloroquine, the anti-malaria medicine, which we initially give to all our infected patients at the onset of the pandemic, but stop doing so. I don’t want to be political, but there is currently no robust data supporting it. We are also part of the on-going study of giving convalescent plasma to our patients, that is transfusing blood from a person that has recovered from COVID-19 and thus has presumed antibodies. We are also giving other drugs like Remdesivir and Tocilizumab, agents that are still under investigation. We are even conducting our own small trials using other novel drugs. At this time, no one really knows which medicine works. It might turn out that all of these medications are worthless.

As we open our communities more and more, I am anxious that we would see a second wave of infection. Yet I have to accept the fact that we cannot keep the world close indefinitely, for that is not considered living either. We just need to embrace the new reality.

For simple recommendations, first, we need to keep a distance from each other. At least 6 feet they said. But is that distance scientifically sound when we know that a sneeze or a cough particle can travel much farther than that? That is why wearing mask is helpful, for it protects us from each other if we cannot keep a safe distance.

So another new normal is that we need to wear a mask when going out. I know it is a barrier for communication as we cannot see the facial expressions when we talk to people. It is really bad for the deaf or for those who read lips. Probably good for people with bad breath, for they can be accepted back to the society. And perhaps sad for many, as we cannot see anymore each other’s beautiful smile.

Photo by cottonbro on Pexels.com

Lastly, no more handshakes. This act of shaking hands evolved from an era when nobody was trusting anyone, that people have to approach each other with an open hand to show that they were not holding a dagger as they meet. This developed into the custom of a handshake. Maybe now we need to greet each other with a bow, like some Asian cultures do. Or maybe a curtsy. That would be cute. Or perhaps some kind of a salute. Just not the “Italian salute.”

Stay safe everyone.

Fearless

I am fearless. But that’s not true. It’s not that I’m scared of spiders or cockroaches. It’s more than that.

I think we all know that we are in a middle of a war. The casualties from this COVID-19 pandemic continues to rise and it is devastating. More devastating are the news that healthcare frontliners are becoming casualties themselves. The news of doctors – from China, Italy, France, Indonesia, Philippines and more – dying from getting infected with the novel corona virus from patients they are trying to save, sends shivers to my spine.

I know there are risks from my chosen profession. From being overworked and being sleep deprived to being cursed by patients and being sued, that goes with the territory of our duties. I can live with that. But to risk your own life from contracting a possible deadly disease and even worse, to endanger your own family from passing on the illness at home makes me afraid. Very afraid.

For those people who are not taking this pandemic seriously and continues to party or not follow the recommended social distancing and community quarantine, or for those who think they are strong and invincible, please think again. If it’s not you who would be severely affected, it may be someone that you love that could suffer, because of your foolish actions.

Today, I came face to face with only my mask in between, with this deadly disease in our ICU. As I place an endotracheal tube to the patient’s passageways to hook her to a ventilator, I can only pray that my personal protective gear will be enough shield from this invisible enemy. Though I pray even more that heaven’s hand will be my shield.

I know this is only the beginning of my daily battle and confrontation with this foe. And it is expected that the worse is yet to come.

Fearless or not, I swore an oath to do this job. So help me God.

(*photo taken at Jardin du Palais Royal)

Rx: Sleep

This year is quite hectic for me. Besides the load at work and other responsibilities, I also have to renew 2 of my 3 board certifications. That means I have to study and pass my board exams to keep my certifications.

The governing bodies of Medicine wants all the practicing physicians to be updated and competent in their field of expertise. After all the discipline of science and medicine is ever evolving and what may be true some years ago, may not be applicable today. That’s why doctors have to take regular scheduled exams to maintain their qualifications.

Most of the medical specialties need re-certifications every 7 to 10 years. But now, they are introducing an option of taking the test every 2 or 3 years. More frequent test, oh fun!

The first exam I had to re-certify for this year is for my Pulmonary boards. I am relieved to say that it is past and done. I took my re-certification exam last May, and for 4 months before the boards, I devoted at least 30 minutes a day for review. It must have been worth the efforts for I’m proud to say that I passed it. I’m good for another few years on this sub-specialty.

The next exam to tackle is this coming November. It is for my Sleep Medicine boards.

I took a break in studying the month of June. But this July I’m back to the books again. I’m allotting half an hour (or more) every day for study.

Come to think of it, this might eat up some of my time for training for the annual half-marathon that I do in October. Should I just skip the half-marathon this year? Though I think I should still do my regular 2 to 3-mile run to keep me from getting too flabby.

Should I take a break from blogging too? Nah! Blogging is actually my relaxation.

I was on 24-hour duty the other day, and it was a busy call. It was not until 2 o’clock in the morning that I went to bed in our hospital call room, only to be called several more times during the remainder of the night, or should I say early morning. One particular ICU patient that I admitted around midnight was so sick, that he died 6 hours later despite our best efforts to keep him alive.

By the way, my other sub-specialty is Critical Care (ICU Medicine) and my Critical Care boards re-certification is due next year. That means I will be studying again for next year. Who said you’re done taking test after you graduate from school?

Anyway, I was off the next day after my 24-hour call. I decided to do some “light” reading to prepare for my Sleep Boards. My brain may be half-awake, but I was resolute to stick to my schedule. But do you know that according to research, dolphins can have half of their brain asleep while the other half awake? Maybe I was trying to be a dolphin.

It so happened that when I opened my reviewer, the chapter I was about to read was about sleep deprivation and its ill effects on our health. Wasn’t it so ironic? I was studying about the bad effects of sleep deprivation, and I myself was sleep deprived!

I stopped reading. I put down the book and did the best thing. I went to sleep.

(*photo from the web)

Doctor’s Books

Last year we added two new partners to our group. It is good that our practice is growing and there’s now ten of us Pulmonary and Critical Care doctors in our team.

The downside to this growth is that our limited office space can barely accommodate our expansion. Storage spaces and closets have been turned into patient’s examination rooms.  The other thing that has to give is our personal spaces. Before each one of us have an office room, but now it was converted into one large room that we share together. Though we still have our own desk and a corner or side of the room where we hang our diplomas and personal photos or mementos.

We now also have a common book shelf that we share where we placed our valued textbooks even though they are outdated. As you know, a medical textbook is only good for a couple of years, like our smartphones, as new and revised version comes out every so often with updates of the latest studies and findings.

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Many of the books here in the shelf were published more than a decade ago, and thus they are obsolete and are only good for showcase. Note how thick and heavy many of these books. I can’t avow though that we read them from cover to cover. But perhaps just displaying them make us feel confident and smart.

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From “Medical Dictionary,” to basic science “Lung Cell Biology,” and to our specialty’s bible “Textbook of Respiratory Medicine,” I can say that at some point in time I referred to these books.

But there’s one book in the shelf that caught my attention recently, as it may be out-of-place. It is not my book, and I dare not ask whose book it is among my partners.

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Did you spot the book?

In case you still not sure what book I’m referring to, I pulled it off the book shelf and here it is:

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Perhaps it’s a book of one of the young children of my partners. Perhaps a partner of mine reads this book for relaxation. Or perhaps this book is an inspiration or has a special meaning for one of them. After all, considering where we came from and where we are now in our state of life, it is a realization of “Oh, the Places You’ll Go!” And as a transplant from a foreign land, this really rings true for me.

Here’s an excerpt from the book:

You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And YOU are the one who’ll decide where to go.

Maybe it really belongs to this shelf among other medical books. Besides, this book is also authored by some famous doctor. Dr. Seuss, that is.

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Post Note: “Oh the Places You’ll Go” was first published in 1990, and the last book published by the author in his lifetime. Even though Dr. Seuss is well-known as children’s book author and illustrator, this particular book is a popular gift for students graduating from high school and even college.

(*photos 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.

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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.

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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)

Weight on My Shoulder

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

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

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

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

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

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

Like what the Beatles’ song say:

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

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

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

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

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

I really have nothing to complain about.

 

I’m Free

I was on-call last weekend, and it was busy. The ICU was full. Our patients list was quite long. I only got about 8 hours of sleep from Friday to Sunday, that by the end of my 58 hours shift, I was really exhausted. I felt deflated and defeated.

Days like those, I even wonder, “Why am I doing this?”

After having Monday off, I came to the office the next morning and found this on my table:

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flowers and a memorial service program

The flowers came from a patient, or should I say from his relatives. My patient passed away. I should be the one sending flowers. But in this occasion, it was the dead and the grieving who gave the flowers.

I guess the family was just grateful and appreciative of the care I gave their loved one. Even if the end result was death.

Day like this, reaffirms why I am doing this.

I have taken care of this patient for almost 10 years. And over the years I saw his constant struggle to breathe, and his progressive decline. By the past year or so I have been seeing him so often in the clinic or in the hospital, that I have come to know him very well. Yet, despite our efforts he continued to get worse.

At the end I knew I have nothing left to offer him, and so we have agreed to place him under hospice care.

He had Chronic Obstructive Pulmonary Disease or COPD.

Damn cigarettes! If there’s any young people here reading this article and are smoking and feels that you’re indestructible, I am pleading to you, please stop smoking. I am a constant witness of the destructive effects of cigarettes and the utter suffering they cause. Whatever pleasure smoking gives, it is not worth it.

Though I would admit, some of the nicest people I came to know were smokers. And that includes my patient. They are just slaves of a bad habit that may not be their own doing.

In the funeral program of my patient that they also sent to me, was a poem by Ann Davidson, printed on it. A poem so apt for my patient. It was entitled “I’m Free.”

Free from the pain. Free from suffering. Free from the disease that tormented him. He was indeed free.

I’m Free

Don’t grieve for me, for now I’m free

I’m following the path God laid for me.

I took His hand when I heard Him call

I turned my back and left it all.

I could not stay another day

To laugh, to love, to work or play.

Tasks left undone must stay that way.

I’ve found that peace at the close of the day.

If my parting has left a void

Then fill it with remembered joy.

A friendship shared, a laugh, a kiss,

Ah, yes, these things I too will miss.

Be not burdened with times of sorrow

I wish you the sunshine of tomorrow,

My life’s been full, I’ve savored much

Good friends, good times, my loved one’s touch.

Perhaps my time seemed all too brief

Don’t lengthen it now with undue grief.

Lift up your heart and share with me.

God wanted me now; He set me free!

Are Resident Doctors Really Doctors?

No, they are not.

According to a recent article (read here) that appeared in Mindanao Times, here are the new essential qualifications for a real doctor.

1. Wears a uniform. Preferably white, and in impeccable condition. One that does not get hot nor dirty even when you’re rushing and answering to all calls, especially in the Emergency Room.

2. Speaks English. It does not matter whether you’re in Manila, or Ilocos, or Cebu, or anywhere in the Philippines (or world) for that matter. It does not matter if the patient you’re attending to speaks Tagalog, or Ilocano, or Ilonggo. You must talk to them in English. That’s how you discern one from an impostor.

3. Knows the “problem” of the patient, even if the patient does not tell them anything about what ills them. They must master the art of foretelling the disease, even without taking history and doing physical exam. In other words, can read crystal balls. Nurses should possess this power too.

4. Must be courteous at all times. Never rude. Even when faced with arrogant yet idiotic patients. If you’re not courteous, that means you are a fake doctor.

5. Must see a demanding patient, right away. Now na! It does not matter if you’re attending to a sicker patient. It does not matter if you’re running a code or doing the CPR itself, or assisting in surgery, or doing a procedure. Your doctor’s license expires within an hour of not seeing the patient.

The following standard eligibility on becoming a real doctor are not needed anymore:

1. Four years of undergraduate degree. Forget it!

2. Another four years of medical (graduate) school. Forget it!

3. One year of post-graduate internship. Forget it!

4. Pass the Philippine (or other country’s) Medical Board Exam. Forget it!

5.  Lastly, no need to do three to seven years (depending on specialty) of Residency after passing the board exam. Remember when you’re a “Resident” doctor, you are a fake doctor.

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(This post is in response to an article with the same title, that was published 7/20/15, in the Opinion section of Mindanao Times, written by Fely V. Sicam)

Blast from the Past

Change. That is the only constant thing in this ever-changing world.

Not too long ago, we cannot get by our daily lives without the typewriter, mimeograph machine, telephone booth (not just Superman), cassette tape recorder, floppy disc, and film negatives. Do you even know what they are?

When was the last time you placed a 35 mm roll of film in the film cartridge of your camera? Or when was the last time you held a real printed photograph instead of viewing it on a computer monitor or from a smart phone?

In the world of medical radiographic images, the same is true. In our practice, rarely do we see a real printed x-ray film nowadays. Instead, everything is now digital or electronic.

Gone are the days when we have to wait for several minutes for an x-ray technician to develop the film in a dark room. Then wait for it to dry. Then hand you the film. And then you have to find an x-ray view box to hang it so you can read it.

Today, we view radiographic images digitally through PACS (Picture Archiving and Communication System), which is a network of computers used by radiology department, that we can access through our desktop, laptop, tablet, or even our smart phone. And if a referred patient comes with an x-ray taken by a radiology department not in our network, he brings in his x-ray images in a CD that we can load and view.

However the other day, a new patient referred to us came in with a real copy of her chest x-ray film. A real film!

I have not held one of these for a while. I missed the feel of its smooth texture on my fingers. The crisp sound of the film as you pull it out of the envelope and wave it softly in the air. Its peculiar slight acidic scent (from the x-ray developer and fixer chemical solution). The unmistakable exotic taste of its…..ah, er……. no, I have not done that.

Who knew that a plain x-ray film will bring me such nostalgia?

As I hold the x-ray film in my hand, I looked around for a viewbox (negatoscope is the technical term), but can’t find one. I guess they don’t install them anymore. I was in one of our newly constructed multi-specialty satellite clinic, and they don’t have a negatoscope in the whole building. None. Zilch. Nada.

So how did I view the x-ray?

I held the film against the bright window and squint my eyes a little, just like the “old” days.

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Right after graduating from medical school, almost twenty-five years ago, I worked in a small (and I mean really small) rural hospital in Plaridel Bulacan, in the Philippines. There whenever I ordered an x-ray, I even helped with shooting and developing it. That’s why I cannot forget the aroma of the freshly developed x-ray film. And while the film was still wet, I would hold it against the light, squint my eyes, and read it.

That was just like yesterday. Yet so much have changed.

As I looked at the film of my current patient, I also peered through the window and looked outside at the present world I’m in, while I relived and reminisced the past through the window of my mind.

(*photo taken with an i-Phone; and in case you’re asking, the chest x-ray was normal)

Life’s Worries

A couple of weeks ago, I took care of a patient who was admitted in the hospital for shortness of breath. She has COPD (CDOP if you’re obsessive-compulsive), a disease due to smoking, and went into acute respiratory failure.

The patient was really struggling to breathe thus the Emergency Room doctor placed her on a non-invasive positive pressure ventilator (NIPPV), a device similar to CPAP used by people with sleep apnea, to provide assistance in her respiration. She was then transferred to our ICU.

On the first day that I rounded on her she was still on the NIPPV and unable to talk much, as it was almost impossible to talk with that mask on, for it’s like having a blower in your face. I would not be able to hear her clearly anyway even if she wants to speak. Though I examined her thoroughly, I limited my history-taking to questions she can answer by yes or no.

The next day she was much better and we have weaned her off the NIPPV. She was sitting in a chair, breathing much easier and looking comfortable.

I pulled up a chair and sat beside her and talked. She admits she has been diagnosed with COPD for years, and has even been on oxygen at home. But sadly to say she continues to smoke. Damn cigarettes! I guess old habit never die.

I told her that it was vital that she quit smoking. Yet in the back of my mind, she has done quite good despite of her bad habits, for she was 84 years old after all, and she still lives independently, all by herself.

Then when I asked her how can I help her quit smoking, she relayed to me that she smoke because she was stressed out.

What? She was eighty-four years old and still stressed out? She should be relaxing and enjoying life, or whatever is left of it, at this age.

That was when she told me that she has not gotten over the death of her husband, whom she was married for sixty-one years. He died three years ago. I suppose the heartbreak never heals when you lose somebody you love and lived with, for that long.

If we only peel off our prejudgment and peer behind the puff of cigarette smoke, we will learn that these people are hurting inside.

Then she said that she was also worried about somebody she knew longer than her husband. She was worried about her mother.

Her mother? What?!!!

Wait a minute, was my patient confused? Too much medications maybe? Was she having ICU delirium? Or does she have the beginning of dementia perhaps?

But as I talked to her more, I ascertained that she was very lucid and of clear mind. She was indeed worried and stressed out about her mother, who has been in and out of the hospital for the past several months.

Her mother was 103 years old!

I came out of the ICU room with a smile. I was ever so determined to help my patient get well. And maybe if I can get her to relax and convince her to quit smoking, she will live more than 103.

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view from the hospital’s corridor

(photo taken with an iPhone)