Barriers

He was always there.

Constantly standing outside the ICU room, that is closed by a sliding glass door. He looked worried. The expression on his face was if he was begging for any news or information to any hospital staff that goes in and out of that room. Except that even when we tried to talk to him, he does not comprehend any word we say.

He does not speak English. Yet I believe he had a sense of what was going on. I think he somehow knew that something very bad was going on. Except nobody can really confirm it to him in a language he can understand.

His wife was inside that ICU glass room. Lying in bed hooked to several monitors and to a life-sustaining machine. Infusing into her veins were several liquid medications in upside down bottles hanging from poles. Coming out of her body were several tubes and catheters – some in natural body orifices, and some in surgically made openings.

The room was a negative air-pressure isolation room. Meaning, that all air droplets were being suck out of that room to a special outlet to prevent from spreading. And all personnel that go into that room needs to don a gown, a mask or a respiratory hood, and gloves.

As he stands outside that glass room looking in, several barriers are separating him from his sick wife, and from the world.

First is the physical barrier of being in an isolation room. This is being done as we suspect she has a highly contagious disease that can spread not just to the other hospital patients, but also to the hospital staff. If only he can be constantly at her bedside. Of course he is free to go inside the room, as long as he wear all those protective gear.

Second is the language barrier. Being a new immigrant to this country and not understanding its language can be very isolating. Not able to communicate even the simplest of questions is already difficult, how much more understanding a very complex situation.

Perhaps he and his wife came to this country to escape hardship or persecution. Perhaps they came here to pursue a dream and to begin a new life. Then, this happened. Which leads me to the biggest barrier of all, the barrier of the unknown tomorrow. What will happen to his wife? To him? To their dreams? And their future?

For the past two days we have been talking to him only through a phone interpreter. Due to the circumstances’ limitation, most of the conversation with him was to explain a procedure or a test that is needed, and to obtain his consent. Consent for blood transfusion. Consent for the CT scan and MRI. For the spinal tap. For chest tube insertion. For percutaneous abdominal drainage catheter. For bronchoscopy. And other more. But sitting down and explaining to him every nitty-gritty details of her wife’s illness and its prognosis, we have not done yet.

Finally, the social worker was able to get an interpreter to come to the hospital. Being an obscure dialect of a certain language, it was hard to get an interpreter in person.

So I sat down with him, and with a live interpreter, explained in as much as I could, the gloomy situation. I explained to him the severity of her wife’s condition: with overwhelming still-to-be-determined infection, plus the ravaging systemic lupus affecting almost every organ including the brain, the odds were plainly against us.

As I converse with him through the interpreter, I learned that he has no relatives and the only family he had here in the US is his wife. I also learned that at night he still goes to work at a meat-packing factory so he can keep his job, and then come and stay in the hospital all day. Somehow he just tries to sneak some naps in the ICU waiting room during the day. No wonder he looked so haggard. Life can be tough at times.

Then he asked me the crucial question, “Would my wife get better?”

I gave him my honest answer, “I don’t know.” I told him that there’s a possibility that his wife may die. Even though she’s only 22 years old.

His face became more saddened. Perhaps that’s an information that he was afraid to learn. Now through the interpreter, he fully grasps the gravity of the state she’s in. Sometimes I think, that not knowing is better. Perhaps not understanding, is bliss.

Two more days passed, and he was there most of the time. Outside the glass door. Looking. Pleading. Hoping. I almost wanted to avoid him, for there’s no comforting words I can say, with or without the interpreter.

But today is different. I cannot wait for the interpreter to arrive so I can talk to him. I needed to tell him the news. I think we have found an answer. I think she is slowly getting better.

I needed to tell him, that I believe she will live.

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(*photo taken with an iPhone)

Illusive Hope

During my last weekend call, one of the many admissions I had to the ICU was a man in his 70’s, who was found unresponsive in his home. Since he lives alone, he probably have been lying on the floor for a couple of days before he was found.

After work-up in the emergency room, it was determined that he had a large stroke. As he was very sick and unstable, we were consulted to admit him in our ICU.

The next day, after providing supportive measures, his vital signs stabilized and he became more responsive, and even following simple commands. Yet he still has significant neurologic deficits due to the devastating stroke.

The patient’s son who was the power-of-attorney, talked to me and showed me his father’s living will, which specifically detailed that in case he had an “irreversible condition,” he does not want to be on any form of life support including artificial nutrition, like tube feedings or even intravenous fluids.

I assessed that with the severity of the stroke, the likelihood of “good” recovery was doubtful. My projection was that he would never live independently again, would most likely be nursing home-bound, and definitely would not be the same person that they know. In addition, he could even get worse as the swelling of the brain increase. No question, I painted a grim scenario.

After hearing my assessment, the patient’s son and family, were ready to call hospice and just make the patient comfort cares. The son told me that his father, for sure would not like to live a life with such a poor quality as I have projected. Though I told them, that the neurologist whom I consulted have not seen the patient yet, and perhaps they should wait on what he has to say.

Not long after, the neurologist came. He extensively reviewed the CT scan of the head, and he made a careful and detailed neurological examination of the patient, as he tried to evoke even obscure reflexes that I can only read in the medical textbook. After his evaluation, the neurologist, the patient’s son, and me, went in a room for a conference.

The neurologist explained that with his estimation, even though the stroke was large, since it involved the non-dominant side of the brain and mostly the frontal lobe, he believes that the patient can still have a “meaningful” recovery. In addition, since the acute stroke was a few days ago, he thinks that the swelling was on its way down, and perhaps we were already past the worst phase. He backed this with his expert knowledge of brain anatomy and function.

Thus the neurologist believed that at best, though it may take months of rehabilitation, the patient can talk – though with a funny accent, walk – but with a limp that he even demonstrated, and maybe could even live independently later on. He definitely painted a more rosy picture than the gray picture that I have painted.

Hearing the neurologist’s opinion, it was obvious we have a “slight” difference of opinion. Perhaps slight was an understatement.

After considering the neurologist’s evaluation, the son and the family changed their mind and decided to defer calling hospice and instead support the patient as much as possible, including tube feedings and all.

To be honest, I was a bit perturbed that I gave such a bleak prognosis than what the other doctor gave. Have I given up on that patient too soon? Have I killed the embers of hope prematurely? Perhaps I have become so pessimistic in my view of things. Perhaps I have seen so many prolonged sufferings and bad outcomes despite our best intentions and efforts in my ICU experience. Perhaps I was just saving the family from the heartaches of clinging to unrealistic optimism. Or perhaps I become more cynical and have lost my faith in hope.

In my defense, maybe I just see the front end and the acute catastrophic courses of patients in the ICU, and have limited exposure to the success stories of patients’ wonderful recovery after prolonged and extensive rehabilitation.

But even though I felt betrayed by my negativism, I felt relieved that I have heard a differing opinion, and perhaps gave a chance to a life that we almost gave up on too soon. Even though I felt embarrassed and almost apologetic for my opinion, I was thankful that we gave hope a chance. Everybody deserves that chance.

The following day, when I rounded on our stroke patient, he was more obtunded and unresponsive. He now have labored breathing and had to be placed on a ventilator. I then requested a repeat CT scan of the head.

The CT scan showed what I was afraid would happen: a further extension of the stroke and more swelling, displacing the structures of the brain beyond the midline and even herniating down the brainstem. This was unquestionably a grave condition, and most likely fatal. No more differing opinions.

The family decided to transition to comfort cares, and the patient expired a day later.

I did not kill hope. It died.

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Looking Beyond X-rays

I looked at her chest x-ray, and knew right there and then that she didn’t have a chance. I have seen bad chest x-rays before, but this time, it was different.

I look at chest x-rays and chest CT scans every day. I review 30 or more each day. It is part of what I do for a living. And it is something that I become good at.

Ever since German physicist Wilhelm Roentgen discovered what he dubbed as “x-radiation” in 1895 we have used this technology in analyzing bones, teeth, and other organs in the human body. It also used to detect cracks in metal in the industry. Now we even use them ubiquitously in all airports for luggage inspections. That’s why bag inspectors know you packed in dried fish without opening your luggage.

But do you know that x-rays can also look into the future? It has nothing to do with radiation-emiting crystal balls.

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It was late August of last year when I went back to the Philippines, not for a vacation but for a medical emergency. The attending physician in the hospital, who knew that I am a doctor myself, led me to the radiology department to show me a chest x-ray of the patient.

It was also here in this same hospital, University of the East Ramon Magsaysay (UERM) Hospital, that 27 years ago, where I picked up a CT scan of the brain of another patient. But at that time I just started medical school. In fact I was only in my first month of my first year of medical school then. Yet even in my untrained eye, I knew that the word “tumor” is not good. Especially if it said it is in the brain.

Now I was back in that hospital, looking at a chest x-ray, one morning that August. I have gained more than 20 years of experience now as a physician. And interpreting chest x-rays has become my expertise.

The chest x-ray the doctor showed me revealed a large tumor, the size of a santol (wild mangosteen) fruit. Not just one, but three! A sign that cancer had spread. A sign of impending doom.

Somehow it felt like I was reading the patient’s obituary, way before her death.

The chest x-ray was my mother’s.

And the CT scan of the head that I picked up 27 years ago? That was my father’s. He died 3 months after I peeked on that head scan.

What is this that I was privileged to see the future through an x-ray, as it gave me an insight of what is to come? Is it a blessing, that I could have prepared for it? Or is it a curse, as I started mourning before everybody else did?

When I broke the news to my mother regarding the results of her chest x-ray, she was not surprised. It was as if she knew it already. She was serene and collected.

My mother was diagnosed with colorectal cancer 5 years ago, and underwent surgery for it. We thought we got rid of it. We thought we kick cancer in the butt (no pun intended)!

But we were wrong. It came back. And with a vengeance.

My mother decided to not pursue any further treatment, like chemotherapy or radiation. For there’s no guarantee anyway that it will matter. Somehow she accepted her fate and was at peace with it.

When we took her home from the hospital she even willed herself even though she was weak to accompany me to the airport in Manila when I flew back here to the US. When I embraced her goodbye, I knew it will be our last embrace. Yet she told me, “Anak hindi ako malungkot. Masaya ako dahil nagkita pa uli tayo” (Son, I’m not sad. I’m happy that we saw each other again). She even added that I need not return for her funeral, it was enough that I saw her alive.

A little more than two months after I saw that foretelling chest x-ray, my mother died.

But there are things that the x-ray did not show. It did not show the inner strength and grace that my mother displayed on her last days. It did not show the peace and faith she had even when facing death. It did not show the confidence and hope that she had, that we will see each other again someday, in a glorious place where there’s no more grief and x-rays.

Bloody Sunday

Sunday morning. It was still dark outside, but I forced myself out of bed. Got to go to work.

I was on-call this weekend, and had barely 5 hours of sleep last night. And even those hours of sleep were interrupted by telephone calls. I was so busy yesterday (Saturday) that I left for the hospital before the sunrise and returned home late at night, that I never saw the sun outside. I rounded on 48 patients in the hospital, 21 of them in the ICU. When I came home last night I felt deflated, depleted, and defeated.

But today is another day. Maybe it will be different.

I started my ICU rounds again before the sun peeked above the horizon. My first stop was a 70-something year old lady that was admitted a few hours ago with gastrointestinal bleeding. I was informed by my resident that the patient is “crashing.” The GI doctor had already scoped her and found a big bleeding ulcer. She had received 6 units of blood already but continued to bleed. We just cannot stabilize her.

Only a few minutes have lapsed after I examined the patient and talked with her family, when she suddenly lost her pulse. “Code blue” (hospital code used to indicate someone requiring emergency resuscitation) was called and we started doing CPR. At least more than 10 hospital personnel came to respond to the code, and packed the room. Nurses, medical residents, respiratory therapists took turn doing the cardiac compression. It was fast and furious.

After about 15 minutes of resuscitation effort, her weeping son who was standing outside the room, and who had witnessed everything that transpired, told me to stop the CPR. Patient subsequently expired.

This is not a good way to start my day.

After offering my condolences to the family, I continued to the next ICU room. Patient was a lady in her 60’s with colon cancer. The cancer had spread almost everywhere in her body despite the most aggressive therapy. In fact she even went to Mexico last month to try “alternative” medicine for cure. But the cancer still progressed.

She currently was admitted with increasing shortness of breath, and was in our ICU for two days now. After work-up, her CT scan of the chest showed hundreds of cannon ball-like lesions in the lungs consistent with diffuse metastasis of her cancer. I told the husband upfront that there was really nothing else we can offer except for comfort. The husband, after making a call to his sons, made the decision to make the patient “comfort care” (a medical care focused on relieving symptoms and allowing the patient to die peacefully) only.

This definitely is not a good day.

The next patient I saw was someone I have been taking care of for several months for an auto-immune disease that had affected her lungs. Her lung condition had limited her severely that she can hardly tolerate any activity. I placed her on high dose steroids and she improved. She was doing well, enough to go to at least 2 out-of-state vacations recently. Unfortunately, being on steroids, which suppresses the immune system, made her prone to infection.

She got admitted in our ICU three days ago with a severe infection and was in septic shock. After a flurry of tests, we suspected that she has systemic fungal infection. Despite all our efforts (antibiotics and all)  she continued to “circle down the drain.” Multiple organs including her heart, lungs, kidneys, and bone marrow were failing. She was hooked to machines and medicines to keep her alive.

Her family, whom I came to know well, approached me after I examined the patient. They told me that she had expressed in the past that she would not want to “live” this way. In truth, they are just waiting for another family member to arrive and after that they would like to discontinue all life support. I told them that I will respect their wishes, and just to let me know when their family is ready.

This day is really becoming a bad day.

I moved on to my next one. Again, almost similar scenario. The patient had been in our ICU for more than two weeks now with respiratory failure that we have not determined the cause. We even performed a lung biopsy, but still no definitive diagnosis. After more than a week on the ventilator, he rallied and improved, and we were able to get him off the machine.

The patient remained in our ICU though as his condition remained tenuous. However, early this morning, he turned for the worse again, and we have to place him back on the ventilator.

The patient’s wife and son were eagerly waiting for me. After discussing with them the grave situation, they have decided as well, that the time had come to withdraw the support and transition to comfort care. We then took him off the ventilator. (He eventually died later that day.)

Not long after I left that room, I was called by the nurse that the other patient’s (the one with auto-immune disease) family were all here and they were ready. We discontinued all life support from the patient, and in few minutes, she was gone. The grieving family approached me once again, and thanked me for all my care. It is always humbling for me, when people are grateful despite the unfavorable outcome. The compassion we provide, sometimes is more important than the outcome.

I went on to see my next patient. He was a young man in his 30’s, whom we admitted last night after suffering a cardiac arrest. CPR was performed by his wife until the ambulance arrived. We placed him on “hypothermia protocol,” that is cooling the body temperature to 32 degrees C for 24 hours, to prevent further brain injury from low perfusion. He was chemically sedated and paralyzed, and was on mechanical ventilator.

After our initial work-up we found that his heart was dilated like a balloon, and was pumping very poorly. For such a young person, this was a horrible condition and carries a grim prognosis. His family was distraught, and was reasonably so. We got to give our best effort to help this man survive.

I looked at my list. Forty more patients to see. It will be a long arduous day.

I happened to glance at the window. It was already bright and sunny outside. The sun rays were being reflected on the glass windows of the nearby building. It is a beautiful spring day outside.

Life on this earth is a like a dew. It is so transient. But despite of all the deaths and the dying surrounding me, I still have hope. Hope that death is also transient. It is after all Easter morning.

Making Things Right

“I just want to make things right.”

That was what my patient told me not too long ago. Wanting to make things right. Don’t we all? Here is his story.

He was in his 50’s, and he presented to the hospital with leg swelling and worsening shortness of breath. After initial work-up in the Emergency Room, he was diagnosed with blood clots in the legs and lungs (veno-thromboembolism). Serious condition.

His chest CT scan also showed a lung mass. After further work-up, which includes a biopsy, it was found to be cancer. Cancer in itself is a risk for developing blood clots. Bad prognosis.

After further more work-up, it was determined that the lung cancer was far advanced. It has spread to the bones, liver, and lymph nodes. Grim outlook.

During his hospital stay, his condition deteriorated and was transferred to the ICU.

I approached him as he laid in his ICU bed. Knowing the severity of his condition, I asked him about his “code status.” That is, what he wants us to do if in case he cannot breathe on his own, does he wants us to place a tube down his throat and have a machine breathe for him? Or if his heart stops, does he want us to shock his heart or pound on his chest and try to resuscitate him? Or, does he just want us to let him go peacefully?

There was a long pause before he replied, as he breathed heavily under the oxygen mask. “I want everything done,” he finally answered. “I want everything done, until I have done one thing. I want to get married.”

Get married? Did I hear him right? Is he of a sound mind or is he confused and hallucinating?

As he continued talking, I ascertained that he was very alert and not confused at all. I did not ask why he wanted to get married, but he explained to me the reason why. Perhaps he saw the quizzical look on my face.

“I just want to make things right,” was his reason. Apparently, he was living-in with his girlfriend for twelve long years. He wanted to make their union legal. This would make her girlfriend the legal decision-maker for him if he becomes incompetent. And she would also inherit his estate without questions, when he dies. But more so, he just wanted to show her how he loved her over the years, but did not quite made it to the altar. Now, he was “making things right.”

Two days later, there was a wedding ceremony in our ICU room. A bride, a groom, a chaplain, and a couple of witnesses. That was all you need for a wedding. Of course there was a gown too. No, not a wedding gown. A patient’s hospital gown. And it was the groom who wore it.

There was many well-wishers too, courtesy of the ICU staff.

The patient’s son was also present. I believe he was his son from a previous relationship, and he came from out-of-state to visit his very ill father. He was probably expecting to attend a funeral, but was surprised that he was attending a wedding instead.

A few days after the wedding, our patient’s condition improved that he was able to be transferred out of the ICU to the Oncology floor. Perhaps, getting married gave him hope and a different outlook in life, and willed himself to get better.

He was started on combined regimen of radiation therapy and chemotherapy. Hope springs eternal.

Two weeks later, his condition started to decline once more. He grew weaker and weaker. It became more and more difficult for him to breathe. This time, he told us, he does not want to be resuscitated if his heart stops or if he cannot breathe on his own. I guess, he already accomplished his one wish, and now he was ready.

Then one day, he quietly faded in the break of dawn. And he left a newly wed bride, a widow.

Cancer stumps hope. A so familiar scenario, sadly to say.

Yet love conquers all.