More than Tylenol

It was the height of flu season. 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 or also known as ECLS, 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.

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 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.

Avalon catheter in correct position (image from web)

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% (below 90% is perilous) 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.

I called my other partners over the phone and I probably disturbed their quiet Saturday afternoon off, but I needed some opinion of what else we could do.

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 (anticoagualant) 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 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 fervently prayed.

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.”

How many times have we prayed for a sick loved one? But do we really believe God would heal them? Do we add the phrase, “if it is Thy will,” so we wouldn’t get disappointed?

As a doctor, sometimes, I put more faith to the medical intervention than God’s healing. Like when I was bedridden earlier this year due to a bad viral infection, it seemed I had more faith in the Tylenol that I took than in God to take away my fever.

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.

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.

He healed my unbelief.

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Mark 9: 23 -24: Jesus said to him, “If you can believe, all things are possible to him who believes.” Immediately the father of the child cried out and said with tears, “Lord, I believe; help my unbelief!”

*Post Note: Our failed ECMO patient survived. She even did better than the two patients we had on ECMO.

Still Water

During our recent trip to Poland I was asked a question that I have never encountered before.

We were in a restaurant when the waiter asked me what I wanted to drink. I then requested for water. To this the waiter further asked:

“Still or gassed?”

I looked at him intently and bid him to repeat the question, and he asked me again, “Still or gassed?”

Is he asking me if I wanted “distilled” water? But what about the gas? Does he know that I am feeling gassy? Will they gassed me or something?

Finally it dawned on me that he was asking if I wanted “regular” water or “carbonated” water! It’s just that I am not familiar with the term “still” or “gassed” water.

Realizing what his question was, I stated confidently, “Still water, please.”

Something I learned in Poland was, first, they don’t offer tap water in restaurants. Water is always bottled so you have to pay for it. Secondly, they like carbonated water, for some reason or another. And thirdly, they really call the carbonated water, “gassed” water. I think technically it is more accurate than the term sparkling water.

During the rest of our stay there, I was requesting for “still water.”

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Polish still water

Perhaps I am not the only one who wants to drink still water. I was reminded of a popular text in the Bible in Psalms 23, “He leadeth me besides the still waters.”

Apparently sheep cannot drink from a rushing water. So the shepherd has to bring them to a spring or brook with quiet water, or he has to make a small dam for the water to be still, and only then can his herd of sheep drink the water.

But maybe it is not only our drinking water that we wanted to be still.

Last summer, in our home trip to the Philippines, we were able to visit Palawan, and we spent a few days beside the ocean. We rode boats when we went island hopping, did some swimming and snorkeling, and enjoyed some time kayaking.

During those water activities, you want the ocean to be still. We would not dare sail in a turbulent sea or when the waves are raging. So we want the water where we are treading, to be still waters, as well.

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photo taken at Sabang, Palawan

However the waters where we tread, are not always still. It can be stormy at times.

Two years ago, the waters near Tacloban, Philippines became turbulent. So turbulent that it caused 15 to 20-foot-high storm surges during the super typhoon Haiyan (local name Yolanda). It caused terrific devastation not just near the coast but even spanning to several kilometers inland.

I witnessed this devastation first hand, and it’s not easy to forget such horrendous tragedy . Sadly to say, thousands of lives were lost, with millions more affected. I can only pray for the continuous healing and recovery of those survivors.

(video taken during one of our helicopter medical tour, Tacloban, November 2013)

We may like to have still waters all the time, but you and I know that angry waters is part of our lives. And I am not only talking about drinking water or sailing water for that matter. I think you know what I mean.

You may have not experienced stormy waters before and I hope you won’t ever go through them. Or you may have gone through some rough waters before, and glad that you’re over it. Or you may be going through raging waters right now, that you are desperately asking when will the waters go still.

My friends, we are not promised that we will only go through still waters. But even when I cross through turbulent waters, God has promised that He will be with me, “yea, even though I walked through the valley of the shadow of death.”

And when the storm clears, He will lead me besides the still waters, and He will restore my soul.

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(*post dedicated to the people of Tacloban, in this 2nd year anniversary of the tragedy brought in by Yolanda)

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)