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)

The Language of Grief

I was sitting in a consultation room of our ICU. I was having a discussion with the family members of one of our patients in the ICU who was not doing well. Not doing well is an understatement. On the brink of death may be more like it. With me were the cardiologist, our senior ICU resident, and the patient’s nurse.

There were several family members in attendance there in that room. Most of them don’t speak English, or understand very little of it, if at all. We were talking through the patient’s grandniece who speaks English, albeit with a distinct accent.

Our patient was a Cambodian man who collapsed at his home. When the emergency responders arrived he had no pulse and was not breathing. After gallant efforts to resuscitate him, which took them almost 30 minutes, they were able establish a heart rhythm. He was then brought to the hospital and eventually was admitted to our ICU.

We placed him on hypothermia protocol to try to preserve whatever brain function he have. This intervention is used in out-of-hospital cardiac arrest survivors as studies showed that this improves mortality and neurologic outcomes. The intervention entails lowering the patient body core temperature to 33-34 Celsius through cooling blanket and infusion of cold IV fluids.It also involves deeply sedating them and medically paralyzing them, while placing them on life support. This process is an effort to slow the metabolism of the body and thus prevent further ischemic injury especially to the brain. After 24 hours of cooling them, they are rewarmed, and sedation and paralytics are weaned off.

The moment of truth comes after the patient’s body is rewarmed. If the patient will show signs of recovery, they will wake up. If not, they will remain unresponsive or show signs of brain injury from hypoxia(low oxygen supply) stemming from the cardiac arrest. And that will be a very poor prognosis.

Sadly to say, our patient did not wake up. After rewarming, he remained comatose and he was even having seizure-like activity, a tell-tale sign of severe hypoxic brain injury. And that was what brought us to this consultation room. To tell the family the heart-breaking news and help them decide further direction of care.

After we presented the bleak situation to them, the grandniece interpreted for the whole family what we have said. What followed was back and forth discussions among the family members in their native tongue. Some spoke animatedly. Some in whispering tones. No doubt I was lost in their discussion as I have no idea what they were saying.

After anxious moments, one by one the family members started crying, some softly, some more loudly. I don’t have to guess what they were saying anymore. I don’t comprehend their words, but tears is a universal language. I understand it loud and clear.

After more minutes, the grandniece spoke to us, and stated that the family was in agreement, that they just want to have a Buddhist monk come and say a prayer for the patient, and then they will take him off all life support.

Not too long after we left the consultation room, a Buddhist monk garb in a traditional orange robe came. There were about 20 people who came and crammed in that small patient’s room. Usually our ICU regulation only allows 2 to 3 visitors at a time, but this was loosely followed to accommodate family’s needs. I heard incantations and prayers through the closed-door. Then this was followed by sobs and weeping.

Grief. It transcends cultures, religions, and language.

Postscript: The above article was published in Manila Standard Today on July 1, 2012.