Constipated Teaching

Since I am practicing in a teaching hospital, besides treating patients, part of my duty is educating and training residents (doctors-in-training) and medical students. In fact the state university even gave me an academic title. My official title is: Adjunct Clinical Associate Professor. Adjunct, means extra or accessory. In other words, not that major. Maybe “A Junk” Professor is more appropriate. In my native language, saling-pusa.

Anyway, most of the time when I am seeing patients in the hospital, I am accompanied by medical residents or medical students. In the ICU though, my entourage could be quite large, composing of 2 to 3 residents, a medical student, a pharmacist, 1 to 2 pharmacy students, a respiratory therapist, and respiratory therapy students. Then when we round on a specific ICU patient, the nurse taking care of that patient will join our discussion too.

Having a group shadow me on my rounds has its perks, as many of the scut work the team could already accomplish in my behalf. Plus the bigger the entourage, the bigger the likelihood that people think you are important (not mere “a junk”), just don’t let that get into your head. But it has its disadvantages too. For one, I have to ask permission to break rounds, every time I needed to go to the restroom.

In our rounds, besides talking about the patients’ cases and our plan of treatment for each one of them, we also discuss about snippets of medical teachings, current trends of practice, new drugs and even latest research that support our plan of management. Thus I really needed to be updated on the most recent guidelines and studies.

Few weeks ago, as I was conducting my ICU rounds, we have been dealing with some very difficult cases as well as some unfortunate patients in our ICU whose chances of surviving were slim. As we went through consecutive depressing cases, I could sense the sadness and stress rubbing in into my team. I could feel the morale of the team was low, for taking care of these sad cases of patients.

As the captain of the team, besides making sure that the right management is given to each of our patient and assuring proper education and adequate training for my residents and students, I feel that it is my duty as well to keep a high spirit in my team.

One particular patient that we have was having a bad case of constipation that was made worse by his requirement for pain medications, on top of all his other life threatening conditions. We then discussed causes of constipation and its management in general. One complication of using opioid pain medication is constipation, as it can slow down the intestinal movement. So we decided to give our patient the relatively new injectable medicine for constipation that blocks the opioid receptors in the gastrointestinal tract without decreasing the pain relieving ability of the opioids.

Then I asked the team, “Have you heard of the long-awaited big study on constipation?”

They all looked at me shaking their heads as they have not heard of it, and anticipating more words of wisdom from me.

To this I said: “It has not come out yet.”

Realizing that I made a joke, and not to be outdone, our knowledgeable pharmacist chimed in, “But I heard of the recent study that said that diarrhea is hereditary.”

The team was smiling now, and seems to be in a better mood , waiting for the punchline.

The witty pharmacist concluded, “Because it runs in jeans (genes).” Eeeww!

With that we moved on into our next ICU patient.

*******

Pahabol na hugot: Constipation ka ba? Kasi I cannot get moving since you dumped me.

 

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)

A Perfect Day

I was on-call last weekend. It was not particularly busy that I was drowning in work, but enough to keep me occupied in the hospital most of the days during the weekend. I had more toxic calls before, so I really cannot complain.

I was making my rounds in the hospital and making headway on my long list of patients to see. I have seen all the ICU patients and working on the rest of the patients in the hospital. On my way to the other side of the hospital, I passed the crossway that overlooks the center garden of the hospital.

I stopped for a while and gazed longingly at the garden.

our hospital's central garden

our hospital’s central garden

It was already early in the afternoon. It was sunny, but the temperature outside was not hot, nor was it cold. It was just right. It was early September after all, when summer and autumn are in their crossroads.

It was a perfect day to be outside.

I could have been outside. I could have been sitting outside in that garden with the beautiful flowers in bloom. I could have been outside shooting hoops with my son. Or could have been outside having barbecue with my friends. Or could have been outside riding my bike on some engaging bike trail. Or could have been outside just lying on a hammock under a tree. I could have been outside……

Instead, I was inside the hospital walls. Working.

The next stop on my rounds was the Oncology floor. I entered the room of our patient who has history of rectal cancer and was treated several years ago. But now found to have his cancer come back with vengeance, spreading to his lungs. I was suddenly reminded of my mother who has the same circumstances.

My patient was having difficulty breathing. It was quite obvious that even with high flow oxygen he was struggling. Every movement was an effort. He has been hospitalized for some time now, with no clear indication of when he can go home. Or will he ever?

As I entered his room, he was looking at the window. He was looking at the same central garden that I was looking at, a little while ago. Perhaps he had the same thoughts that I had: I could have been outside enjoying this beautiful day.

But he can’t. And perhaps he never will.

That’s when a thought dawned on me. There’s a reason why I am not outside. I was placed here inside these hospital walls, for a sacred duty to care and give comfort for people who cannot enjoy a beautiful day outside, just like today.

It was a perfect day indeed.

********

(*photo taken with an iPhone)

 

When Doctors Cry

It’s alright Melissa. You can dry your tears now. This is just part of the job we do. I know, textbooks and medical school did not prepare you for situation like this.

Melissa* is our young medical resident (doctor-in-training) who was on-call that night in the ICU. I received a call from her a little past midnight for an admission, who was doing poorly. So I had to go back to the hospital.

Our new patient was a 19 year-old kid. Yeah, I consider that age a kid. He was brought to the Emergency Room (ER) after he complained of unable to breathe, then collapsed, and became unresponsive.

When the ambulance arrived, he was not breathing and had no pulse. They did CPR (cardiopulmonary resuscitation) and worked on him for almost 30 minutes before a heart rhythm was re-established. Thirty minutes are an eternity to have no heart beat.

In the ER, he was treated for cardiorespiratory failure, thought to be from severe asthma attack. He was hooked to a ventilator and started on medications for asthma. He was subsequently admitted to our ICU.

After the patient was transferred to my care in the ICU, I thought that the story does not make sense, though asthma can be very severe at times. Plus, the heart shadow on the chest x-ray appeared to be huge in my opinion. So I asked my resident to get a CT scan to rule out a blood clot in the lungs or other pathology.

The result of the CT scan caught us by surprise. It showed a big tumor in the middle of the chest, compressing the heart and the main airways. No wonder, our patient cannot breathe. Furthermore, he had extensive “free air” in the abdomen, signifying that he had a ruptured bowel. What caused it? I could only speculate.

The situation had turned from serious to grim.

When I examined the patient, I noted that aside from being comatose, his pupils were fixed and dilated. He did not respond to any stimuli at all, but was having “seizure-like” movement. That was an ominous sign. It was indicative of irreversible severe brain injury, perhaps from the prolonged anoxia (lack of oxygen) to the brain. What else could go wrong?

I then went to the ICU waiting hall to meet my patient’s family. The room was dark, as the lights have been dimmed. In every corner of that hall, were relatives of other ICU patients, who were sleeping on the floor or make-shift beds. They have camped out in this room, some for a few days, others for weeks. I know each of them have a sad story to tell.

I found a quiet space in the waiting hall to meet with the family of my 19 year-old patient. There were two sisters, and the grandparents. We spoke softly, so not to disturb those who were sleeping. I informed them of the severity of the situation. I was frank and direct, telling them that I have no good news. It was all bad. The family was distraught. And understandably so.

When I asked them who would be making decisions in behalf of the patient, I heard more depressing news.

The family told me that it would be her mother who would make the final decisions. But she herself was sick.

The mother had been a patient in our hospital less than a year ago. She suffered a devastating stroke and was in our ICU for more than a month. She slowly improved, and after a couple of months in the hospital she eventually was discharged to a rehabilitation facility, where she stayed for several more months. Finally she was able to come home two months ago, only because his son took responsiblity of fully caring for her.

That son, was now in our ICU.

How about the patient’s father, I inquired. The grandfather glumly told me, that he died not too long ago from an accidental electrocution at work. Was this the saddest string of unfortunate stories or what?

After my talk with the family, one sister planned to get their ill mother at home, so she could see and say her goodbye to her son. And then they will decide whether to wait it out a little longer, or take him off life support.

I went back to the ICU’s workroom to write my note, and that’s when I saw my medical resident crying.

Perhaps she was emotional due to changing hormones, as she was pregnant. Or perhaps she was just exhausted, and it was already 3 o’clock in the morning. Or perhaps these medical sad stories was too much for her to handle.

I know, it was too much for me too. And twenty years of experience did not make it easier at all.

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(*names have been changed)

The Wedding

The young couple looks gorgeous that day. He looks impressive in his impeccable Marine Corps Dress Blue uniform. While she looks beaming in her gorgeous flowing white dress with a beautiful bouquet of flowers in her hands.

The minister was ready. The most important guests were in attendance and ready. The place was basking in radiant lights and ready. It was time for a wedding.

Many would dream to have their wedding in a big historic cathedral. Others would prefer in a more Edenic scene, like an enchanting garden. While some would choose a more relaxed yet romantic place, like an exotic beach.

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photo I took in a beach at Ilocos Norte

But the wedding that I witnessed did not happen in any of the above special places. Instead it happened in one of our mundane Intensive Care Unit (ICU) room.

Yes, you read it right, a hospital ICU room.

At least the room has a big window with a view of an old nearby church. At least the room was warm and bright, as it was gloomy and cold outside in that wintry afternoon. Not to mention that it was a very expensive room to be in. A day’s stay in the ICU is far more costly than a night in Ritz-Carlton Hotel in New York City.

The groom’s mother had been sick for a while. She had been in and out of the hospital for several months for a variety of medical problems. And now she got seriously ill and had been lingering and languishing in our ICU for about a month. She had been on mechanical ventilator and we were unable to get her weaned off of it.

The groom’s father had been sick as well. In fact, he was admitted also in the hospital and just got out a few days ago.

But the young couple wanted to commit to their vow to each other, whatever the circumstances may be. Perhaps they have been planning for their wedding for some time. The groom even came home from overseas where he was stationed. And I’m sure that the original plan was not to get married in a hospital. But you roll along with what life offers you. It must go on.

So in the presence of their parents and choice guests, in that cramped hospital room; there was no bright glare of church’s grand chandelier, but instead a glow of ICU floodlights; no wedding bells were ringing, instead intravenous pumps were alarming; no melodious birds were singing, instead the constant chirping of the ICU monitors; no sounds of ocean waves lapping on the sand, just the low hum of the ventilator: where the two lovers exchanged their sacred “I do’s.”

There is no such thing as a perfect place for a wedding. No such thing as a perfect day to get married. There is no perfect circumstances. Not even perfect couple. Just perfect love.

In the midst of sickness and suffering, when life hangs precariously in a dance between life and death, in a world of uncertainty and unclear tomorrow, love still conquers all. It always will.

May you all have a meaningful Valentine’s.

*****

(*This is the second ICU wedding I witnessed; read the other one here.)

Angel’s Wings

It was a dreary snowy day in January. I drove to the hospital with snow coming down and with strong blowing winds, that it was almost a blizzard-like condition. Unlike schools and other offices that can close down for a snow day, hospitals runs business as usual, with or without blizzard. Besides, I am in-charge of the Intensive Care Unit (ICU) that month. I got to be there.

I knew I had a very busy day ahead of me. I had 17 ICU patients to take care of, 5 scheduled bronchoscopy* I need to perform, and 1 new consult for hyperbaric oxygen therapy** I need to dive. It would be a long, long day.

Our ICU was bursting in its seams. It was the height of a “bad” flu season. We were always pressed for beds, and we had to juggle patients, sending them out of the ICU as soon as we stabilized them, only to replace them with more sicker patients.

Then during the course of that day, as if my plate was not yet full, I had 4 more additional admissions to the ICU: 1 coming from the operating room, a patient who had a cardiac arrest while in surgery; 1 coming from the medical floor, a patient who had received a lung transplant years ago and was now in respiratory failure needing mechanical ventilation; 1 patient coming from another hospital who had an advanced liver disease and was on liver transplant list, and now with fulminant hepatic failure; and 1 patient who was brought to the Emergency Room (ER) with fever and chills.

Since there was no more available ICU bed, the patient in the ER had to stay there, until we open up some beds.

That was when I went down to see the patient in the ER. I brought along the senior medical resident with me.

Our patient was in her 70’s. She was diagnosed with malignant melanoma several months back. Unfortunately the melanoma had metastasized to her bones and lungs. She had received several treatments including investigational therapy. In fact, she was involved recently in a clinical trial in Mayo Clinic, and according to them the drug seems to be working, but the study was discontinued and she stopped receiving the said therapy. Needless to say her cancer continued to advance.

Now she presented to our ER with a high-grade fever, shortness of breath, low blood pressure and worsening confusion for 2 days. I reviewed her labs and radiographic tests, and it was consistent with severe pneumonia. Due to her immunocompromised state (from cancer and chemotherapy) she cannot adequately fight the infection. She had an overwhelming sepsis and was in septic shock, a very serious condition.

I swiftly examined the patient, who was barely awake, confused, and was incognizant of her condition. After that, I approached her husband and introduced myself (even though my name and specialty was already clearly embroidered on my white hospital lab coat) and told him the severity of the situation. I gently laid the facts to him that she was indeed critical yet we will give her our utmost care, but mortality can be 50% or higher.

The patient’s husband silently broke down in tears. He told me that she was his best friend, his life’s partner, and wife for 48 joyful years. “Please take care of her and treat her as your own,” he stated submissively.

I politely told him that we will take care of his wife to the best of our ability. That’s when he patted my shoulders and said: “I know you will, I can see your angel’s wings.”

I paused for a moment. Never have I heard those words spoken of me before. I was really touched with his remark. I looked at him straight in the eyes as I respectfully and whole-heartedly thanked him.

I then quickly excused myself. Perhaps he noticed I have tears in my eyes too.

I am not sure I deserve the compliments (frankly, I received a chilly reception on my next patient), for I am merely human as anybody else. But it surely made me fly through a long and difficult day.

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(Photo of the hospital’s center courtyard that I have taken with my iPhone later that day. Please take note of my reflection on the glass window: I have no wings.)

* see related post about bronchoscopy here

** see related post about hyperbaric oxygen therapy here

Don’t Get Sick in July!

Experts say that if you’re going to get sick, don’t pick the month of July. This is the worst month to be in the hospital. And it is not due to certain planetary or star alignment phenomenon in July. Nor it is due to the fickle wrath of Asclepius, the Greek god of medicine. It has a much simplier explanation.

July is when the more than 21,000 newly graduate doctors enter their residency training in hospitals here in the US. The influx of the inexperienced doctors may cause the increase in medical errors in teaching hospitals as has been suggested in many studies. Though there are also some studies that are more forgiving to these new resident doctors.

Having passed that road before, I can emphatize with the new doctors; because the only way we can learn and gain experience, is to start somewhere. Learning from your mistakes though is not by all means acceptable in the field of medicine, especially if it cost a life. So I hope we always remember the principle of Primum Non Nocere (First, do no harm).

Now that I am working in a teaching institution, it is part of my responsibility that these young physicians learn and gain experience without “doing any harm”. Though I’m still a bit anxious being in charge of the ICU this month with newly minted doctors. May God help us.

So, is there a greater chance of dying in the hospital in July? I pray not in my watch.