Help My Unbelief

(I was asked to lead a devotional in a group of Christian doctors. Here is what I shared.)

One man was telling his friend about his doctor. He said, “my doctor guaranteed that I will be walking in just a week after my big surgery.”

The friend remarked, “Wow, that’s impressive.”

The man added, “Yes. I have to walk now because I have to sell my car to pay my doctor’s bill.”

Most of the times, we doctors guarantee healing. But our story today is about a failed healing.

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Our story for our devotional today is found in Mark 9: 17 -27

17 A man in the crowd answered, “Teacher, I brought you my son, who is possessed by a spirit that has robbed him of speech.18 Whenever it seizes him, it throws him to the ground. He foams at the mouth, gnashes his teeth and becomes rigid. I asked your disciples to drive out the spirit, but they could not.”

19 “You unbelieving generation,” Jesus replied, “how long shall I stay with you? How long shall I put up with you? Bring the boy to me.”

20 So they brought him. When the spirit saw Jesus, it immediately threw the boy into a convulsion. He fell to the ground and rolled around, foaming at the mouth.

21 Jesus asked the boy’s father, “How long has he been like this?”

“From childhood,” he answered. 22 “It has often thrown him into fire or water to kill him. But if you can do anything, take pity on us and help us.”

23 “‘If you can’?” said Jesus. “Everything is possible for one who believes.”

24 Immediately the boy’s father exclaimed, “I do believe; help me overcome my unbelief!”

25 When Jesus saw that a crowd was running to the scene, he rebuked the impure spirit. “You deaf and mute spirit,” he said, “I command you, come out of him and never enter him again.”

26 The spirit shrieked, convulsed him violently and came out. The boy looked so much like a corpse that many said, “He’s dead.”27 But Jesus took him by the hand and lifted him to his feet, and he stood up.

The background of the story is that Jesus just came down from the mountain where he had his transfiguration. Though it is really uncertain what mountain, traditionally it is believe to be the Mount Tabor. With him were Peter, James and John. When they got down from the mountain he was met with the rest of his disciples and was told that they failed to heal a boy from his illness.

I want us to view this story from a doctor’s or a healthcare provider’s perspective.

Let’s first examine the boy, the patient, in our story. How old was he? I don’t know, but most likely he is in the pediatric age. Since I am an adult medicine doctor, he will be somebody that will not be brought to me.

What is his illness. If we look at the description of what his illness is, we would say that it is epilepsy with the classic tonic-clonic grand-mal convulsions. The seizures seems to be uncontrolled and frequent that it can come any time, as he would fall in the fire or in the water. Being unable to speak, maybe he also has cerebral palsy with speech impediment.

How long has he been sick? According to his father since his childhood. So for a long time this boy has been suffering. One reason why I did not choose to be a pediatrician, besides I hate placing an IV on a baby is that I cannot stand the sight of suffering children. Especially those sick kids that had poor outcome.

Are there any pediatricians here? I admire you, caring for the most vulnerable among us. May God continue to bless your profession and your ministry.

So if this sick boy was brought to you, what will you give him? Keppra? Carbamazepine? Phenytoin? Or perhaps you will request for CT head, EEG and lumbar puncture first.

But something tells us that this is more than physical illness. Rather, it is an spiritual illness, or more specifically demon-possession. As it was told in the story that Jesus drove the deaf and mute spirit out and ordered it not to come back.

I have witnessed demon-possession when I was still in the Philippines. It happened on an evening prayer meeting and this young lady jumped out of her seat and attacked the speaker. Her voice changed and it took several men in the church to hold her down. It required some intense prayers of the church before the demon was driven out.

Let us examine now the father, the other patient. One thing for sure is this father was desperate. If your child is sick for a long time you will be desperate too. He has been disappointed before, perhaps by other healers that he brought his son to and they tried to heal him, including Jesus’ disciples, but all were unsuccessful. Because this father was let down in the past, he was having trust issues. He has become a skeptic. He told Jesus, “IF you can do something,” (emphasis on the IF), but honestly admitted his doubts by telling Jesus, “I believe. Help my unbelief.”

This father is also suffering. It’s not just the boy, but the father as well. Maybe not much physically, but more on emotionally and mentally. Note on verse 22, he did not say “have compassion on my son,” rather he said to Jesus: “have compassion on us and help us.”

He is undergoing mental agony. Perhaps anxiety and depression. Would you give him Prozac? Or maybe a psychotherapy session? But most likely he just needed his son to be healed and he will be healed as well.

Let’s apply the story to our day to day experiences.

First, have you experienced that you were unable to help your patients, even how hard you try, like the disciples did? You probably tried all the medications and procedures known to you, but still your patient was not getting better. I know I have experienced that, all the time. Being a Critical Care doctor, I have lost many patients, which is part of the specialty I chose, especially in this time of COVID pandemic. How frustrating that has been for us. We felt incompetent. Is our training not enough? Is our knowledge and skills not enough? We felt helpless.

But in our story, Jesus said (verse 19), “Bring the boy to me.” Yes my fellow doctors, we can bring our patients to Jesus. We can bring our frustrations, our incompetence and our helplessness to Him. We can bring our problems to the Lord, not just in our patients, but our own personal failures to Him.

Many times though we are also like the child’s father, we suffer with unbelief. As trained scientists and professional clinicians, we believe more in our medications, or in our surgical skills, in our medical science and technology than in God. Have you felt that way sometimes? I know I felt that way, many times!

When I was sick with a flu last year and I felt so awful, I prayed that God will heal me quickly. But I felt I have more faith in the Tylenol that I took to make me feel better than in God who can really take my illness away.

In this story, when the father told Jesus “If you can do something” Jesus used that same words back to him and said “If you can” believe “everything is possible.” May we also pray that father’s prayer, “Lord, help, my unbelief.”

Lastly when the child was taken to Jesus, it appears that he even got worse. The boy had more violent seizures when the evil-spirit saw Jesus. The original text used a term that meant worse than before. The boy went into a grand-mal status epilepticus, worse than he ever had. After the seizure, the people thought that the child was dead (verse 26)! Did Jesus made the situation worse?

Have we experienced something similar? We prayed to God already, and we call on Him to heal our patients, but they seem to be getting worse, not better. Was God not hearing our prayers? Was He not listening to our pleas?

Then when people thought that the boy was dead, (in verse 27) Jesus took him by the hand and lifted him on his feet and he arose. The healing came in God’s way. The healing came in God’s time.

For us today, when we are struggling in our practice, when we are getting discouraged in the outcome of the patients that were placed under our care, we just have to trust in God’s ways, and we have to trust in God’s timing.

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I would like to tell a story that happened to me last year.

It was the height of flu season last year, and this was before COVID, which made this year’s flu season worse. I was working that weekend, and I was in the hospital for 36 hours straight. We had several patients in the hospital that had complications from the flu. There were five on ventilators due to respiratory failure from Influenza A in our ICU. Two of them were on ECMO. 

ECMO is short for extracorporeal membrane oxygen, an extracorporeal life support. It is an intervention to provide adequate amount of gas exchange or perfusion in patients whose heart and lungs have failed to sustain life. It is done by placing a large bore catheter in the patient’s central vein or artery, where the blood was sucked out from the body, then ran through a machine to bathe it with oxygen, then flow it back to the body. We also have used this intervention now for the very severe COVID patients.

Saturday morning, I got a call from another hospital for a woman in her 40’s who had Influenza A and who was rapidly deteriorating. She went into respiratory failure and was placed on ventilator. They want to transfer her to our hospital for possible ECMO.

We rarely have two ECMO patients at the same time in our ICU. Even one patient on ECMO makes us busy, so two was really demanding. But a third one at the same time? That never happened in our hospital before. 

I made some phone calls to verify if we have a machine for a third patient and if we have enough resources and staff to handle a third ECMO. After confirming, I was given the green light to accept the patient.

Additional ICU and ECMO staff were called to come in. I called the interventional cardiologist-on-duty who would assist us to put the Avalon catheter, a dual-lumen catheter half as big as a garden hose that goes from the jugular vein and through the heart. The cardiologist in turn called the cath lab to prepare for the arrival of this patient.

The patient was flown in via helicopter to our hospital and went straight to the cath lab where me, my ICU and ECMO team, as well as the cardiologist and his cath lab team were waiting.

We were ready for the challenge and eager to make it happen. 

While we were doing all this, our patient’s oxygen saturation was only in the 70-80% despite maximum ventilator support, so we knew we needed to work fast.

However problem struck. Working for more than an hour, we had difficulty placing the Avalon catheter in good position. We tried different approaches with different instruments, but cannot get the ECMO flow going.

After deliberation, we decided that we cannot sustain this patient on ECMO. Perhaps it was her vascular anatomy, or perhaps there was a big clot in her vein. Whatever the reason, we could not proceed.

I went out to the cath lab’s waiting room, and gave the sad news to the patient’s family that we couldn’t do the ECMO. All I could say was that we tried and gave our best, but it was unsuccessful.

I felt that we betrayed this patient and her family. After I thought I moved heaven and earth to get this patient to our hospital, only to end up like this was really deflating.

The worse part was, I knew that without ECMO, this patient had little to no chance of surviving and possibly could be dead in a few hours.

We transferred the patient to the ICU, but we left the big neck catheter in place even though it was not hooked to the machine. We have to wait for the heparin we gave when we attempted to start the ECMO, to wear off before we can pull the catheter out.

After about half an hour in the ICU, I was informed that the blood test showed that the heparin had worn off and I can remove the catheter with less risk of bleeding.

When I pulled the Avalon catheter out, I applied direct pressure in the patient’s neck to control the bleeding. I did this for 30 minutes. I was alone in the room with the patient most of that time, with the nurse intermittently coming in and out of the room to adjust the IV pumps or to check on the patient.

All along while I was holding pressure, I was watching the monitor which showed that the patient’s oxygen saturation was staying in the high 70’s to low 80%. I thought death was imminent.

During the time when I was alone with the patient, I felt helpless and defeated. I failed her. We failed her. 

Then a thought came to me: I don’t save lives. It was not up to me. Only a higher power determines who will live or die. That’s when I reached out for the Higher Power.

As a doctor, many times, I put more faith to the medical intervention than God’s healing.

With my hands on the patient’s jugular holding pressure, I turned my thoughts to heaven: “God I am nothing, but an instrument of Your healing hand. I failed. But You never fail. I don’t know this patient personally, but I am personally praying for her. Please heal her in my behalf, and let me witness Your awesome power. Amen.”

After 30 minutes of holding pressure the bleeding stopped. I left the room and went to see other patients, especially the new ICU admission, a young man in his 20’s who had a bad asthma attack, so bad we had to place him on a ventilator.

As I was busy attending to other patients, I was just waiting to be called back to that particular patient if she goes to cardiac arrest or expires.

More than an hour later, I went back to the room of our failed ECMO patient. I looked at the monitor and her oxygen saturation was 100%. I was amazed! The respiratory therapist told me that she even titrated down the oxygen level on the ventilator to almost half as the patient was really doing good.

What happened? I had no other explanation but one: God heard my prayer.

I went down to my call room to be alone. With tears welling in my eyes, I uttered a prayer of thanks. Never would I doubt the power of God again. 

My friends, God healed my unbelief.

May God heal us all with our unbelief, this is my prayer.

Spinning Plates

When I was much younger, I had a fascination for juggling. I learned how to juggle on my own. I could juggle 3 tennis balls, or toy blocks, or even plastic bowling pins. Though I did not and would not try juggling chainsaws.

Juggling is an art. The more dangerous and challenging the feat, the more captivating it is.

Have you seen an act of spinning plates, where the juggler spins several plates on sticks? He goes from plate to plate to keep them spinning or else the plates drop to the floor and break.

plates

Three weeks ago I had one crazy weekend duty. I think it would fall as one of my busiest calls in the ICU in my recent memory. It was so busy that my Friday to Sunday, kind of blended to one very long day with only a few hours of sleep in between.

In one particular stretch of that call, hell broke loose.

I worked on a very sick young man in his 30’s, who was admitted to ICU room 5. I intubated him, placed him on ventilator, placed a large neck catheter for IV access, and started several medication drips on him, all in one rapid succession. I was in the midst of trying to stabilize him when another patient, a lady in room 18, went into cardiac arrest. “Code Blue”* was called.

I have to drop what I was doing on the first patient and ran to room 18. When I got there, the ICU resident was already running the code. After 10 or 15 minutes of CPR and fast paced intervention, we were able to resucitate her back. With her heart rhythm semi-stable, I ran back to room 5, and continued what I was doing.

Not too long after, the patient in room 18 went into cardiac arrest again. I ran back to that room once more. This time I beat my resident to the room and took charge of the Code Blue. My resident who eventually arrived told me that she got hung up in ICU room 16 who was also crashing. I saw another resident who responded to the the Code Blue, but I sent him to room 5, to continue on what I was working there.

After more than 10 minutes of CPR we got our patient in bed 18 going again. It was heartbreaking to see that while the CPR efforts were in progress, the family was just outside the room crying and wailing as we work furiously on their loved one.

After we got the patient’s heart beating again, I gathered her family to a nearby consultation room and discussed with them the dire situation. I told them that there was no guarantee that her heart would not stop again. But given of how sick she was, especially after successive cardiac arrest already, I knew her chances of walking out of the hospital was close to nil, and continuing to do the CPR would be an exercise of futility.

I was talking to the family, when I was called emergently to see room 16 who they were about to call Code Blue. This was the one my resident told me about earlier. We got the patient intubated and hooked to ventilator, started several IV medications and got him stabilized, at least for the time being.

After getting out of room 16, the family of room 18 approached me and told me that they have decided that if her heart stop again, to let her go peacefully.

Less than 30 minutes later, she died.

The patient in room 16 that we attended to also continued to circle down the drain. And despite our efforts, he also succumbed several hours later.

I finally was able to concentrate on room 5 when there was a lull in the chaos we were in. I decided to place him on extracorporeal life support, also known as ECLS** (see previous post about ECLS here), as he would not survive without it. The ECLS team was mobilized, and around 2 o’clock in the morning, the patient was off and running on ECLS.

I have not even mentioned the other 17 ICU patients under my care, but were not actively crashing during that time, nor the other 3 new ICU admissions that came during that span of 4 hours of absolute craziness. I even accepted another patient from an outlying hospital during that period, for whom I ordered our flight crew to fetch. Though the patient did not make it to our hospital, as he was so unstable and our helicopter crew was reluctant to fly him unless they stabilize him more for the flight. I heard he died shortly then.

Spinning plates? Seems like it, right? Sometimes I wonder if I could  keep up with this pace or would I like to continue doing this. Don’t get me wrong I do like my job. But I don’t like the awful stress and the awful reality that comes with it. For it is not just plates that are falling and breaking.

About the patient in room 5? He improved after we placed him on ECLS. He eventually was weaned off ECLS and ventilator after almost 2 weeks in the ICU. He went home from the hospital the other day, walking unassisted and off oxygen.

Success stories like him, though few and far between, keeps us going. After all, I believe it is still worth doing this.

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*Code Blue: an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate resuscitative efforts.

**ECLS: extracorporeal life support (ECLS) is an extracorporeal technique of providing both cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange to sustain life. It is done by siphoning blood out of the body and artificially removing the carbon dioxide and giving oxygen to the blood by running it through a special machine.

Frankenstein Medicine

For this week, I have been spending 8-9 hours a day inside the classroom and in the simulation laboratory trying to learn something new. Never too late to learn a new trick, even for an old dog. Though I admit I was almost half asleep in some of the lectures.

The hospital where I have affiliation with, will have a “new” intervention available as soon as next month. This treatment is called Extracorporeal Life Support (ECLS) or also known as Extracorporeal Membrane Oxygenation (ECMO). So they are training us doctors (critical care specialists, cardiologists and thoracic surgeons), as well as nurses, respiratory therapists and perfusionists, so we can have this life support system off and running.

In a simplistic way, ECLS entails placing large tubes to suck out the blood from the patient. Then having the blood run into a machine where it will be bathed with oxygen and then pumped back into the body. ‘Extra’ means outside, and ‘corporeal’ means relating to body, thus out-of-body life support.

Does this mean the patient will have out-of-body experience?

For patients, whether kids or adults, whose organs have failed for one reason or another, especially the heart or the lungs, can be placed on this life support system to sustain them and keep them alive and buy some time. The use of this intervention is not by all means the first line of treatment but rather of a last-ditch salvo. But it definitely has saved lives, and more and more advanced centers are offering it. Our hospital will be one of the first to provide it in our state.

ecmo

baby on ECLS (photo from the net)

ECLS is not really a new procedure. This has been done for several decades now. Except before, the intervention is only limited to short period of time, like several hours only. The main use of this before was in the operating room during cardiac surgery. They run the blood out of the patient’s body and through this machine, while the surgeon stop the beating heart and tinker on it. I can imagine the heart surgeon singing Sting’s “Be still my beating heart” while he operates. Then the machine is shut off once the heart is beating again.

Now ECLS is also being used outside the operating room, and people are placed on this life support while in the Intensive Care Unit. They can be on this for a few days, a few weeks, or sometimes even months – while their own body and organs recover, or while they wait for a new heart or a new lung, or both, or until “kingdom come.”

Of course the complexity of this intervention is beyond what I can explain here, not to mention the immense cost to the already burdened health care system and the sensitive ethical questions involve, like who to place or who not to place, or when to continue and when to stop. Are we playing God?

While we are doing the training, one of the trainee commented with a sinister smile, “we are Dr. Frankenstein.”

Is this as close as we get to Frankenstein medicine? I don’t think so. We have not created a monster. Yet.