Halloween Full Moon

Even though I am off this Monday I came to the clinic to do some light work. No, I’m not workaholic. It’s just that I procrastinated to read last week’s sleep studies and now they have piled up on my to-do list. It is my day off as I worked this past weekend.

As I entered and sat on my desk, one partner of mine who was sitting at the other end of the room greeted me and said, “Bad weekend call, huh?”

Yes it was a horribly busy weekend. I rounded on more than 50 patients in the hospital, almost half of them are COVID cases. I am not superstitious but I cannot help but think that it was due to the Halloween combined with a full moon. In fact, October 31st was a Blue Moon too. A Blue Moon is when it is the second full moon in one calendar month. According to information from NASA Earth and the Old Farmer’s Almanac, the last time a full moon fell on Halloween was in 1944.

Photo by Pixabay on Pexels.com

It did not help too that it was Daylight Savings time change, so we fell back one hour. That meant an additional one hour of work for me. And boy, that night was really long, both figuratively and literally. The non-stop activities in the ER and in the ICU put me on skates. Needless to say, I barely slept that night.

After staying 34+1 (Daylight Savings Fall back) hours in the hospital, I came home last evening really exhausted. Right after eating dinner, I went to bed and slept for more than 10 hours. Home-cooked meals and comfortable home bed are life’s luxury. When I woke up this morning I felt refreshed and recuperated. I even felt good enough that I went out for a 3-mile morning run.

So back to the comment of my partner about my bad weekend call. How did she know? I did not tell her about my weekend. Was I still haggard-looking? Did I look ghoulish from the Halloween?

Then she told me that she have noticed that our secretary printed some forms and placed it on top of my desk for me to sign. Based on those, she figured out that I had a rough weekend. What were the forms waiting on my desk?

Eight death certificates. All of them from this weekend.

A New Normal

I have been going to work now with a mask and a shield. No, I did not become Captain America, nor did I become an Avenger. What I meant is I’m going to work with a medical face mask and a face shield. This has become the new normal for me.

If I am going to do a procedure that is at risk of aerosolizing the virus, like putting an endotracheal tube or doing a bronchoscopy on a known or suspected COVID-19 patient, then I even use my “powered suit.” Not a powered suit like that of Iron Man, but it is a battery powered air-purifying respirator or also known as PAPR.

I rarely take my temperature before. Now, it is taken at least once a day and sometimes more. This daily temperature probe is not to determine if I’m ovulating or not, for the last time I checked I am a male. For your information, the “temperature method” is a family planning method that takes the woman’s daily basal temperature to determine if she is in her fertile or infertile periods of the menstrual cycle.

I am having my temperature taken whenever I enter the hospital, with additional screening questions of “Do you have fever, cough or shortness of breath?” If from the hospital I would go to the outpatient clinic building, I would get my temperature checked again and have the same screening questions, with an additional inquiry of “Were you exposed to a person with known COVID-19?” The last question is tricky to answer, for if I say yes, then they might not let me enter the building. But how else could I answer that question if I have just seen patients with confirmed corona virus in the hospital? Lie, if we must.

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I don’t know if we have flattened the curve in our community. I am not talking about the bulge around the waist, for that has definitely ballooned more in many people with the stay-at-home order and the uncontrolled eating, plus with the gyms being closed. I guess a mask can help with this, as it is impossible to eat when you’re wearing a mask. But I digress.

We still have lots of COVID-19 patients in the hospital, though it maybe less compared to two weeks ago. Yet I still saw 15 COVID patients in the ICU this weekend, and many of them were on ventilators. I say it’s less, for at one point we had more than 20 COVID patients in the ICU and had a steady admission of 1 to 3 more a day. Good thing was many recovered fast, although some also died. There was also a time that we registered close to 50 admitted COVID patients in our hospital, both in the ICU and wards. So are we really flattening the curve?

Even though it is terrifying, we as physicians, have gained lots of knowledge and experience taking care of the critically ill COVID-19 patients. One thing we learned is that not all COVID patients with severe hypoxia needed to be on ventilators. Placing them on humidified high flow (pressurized) oxygen via nasal cannula can prevent intubation, and in fact they have faster recovery and less complications with this. Of course there are still patients that would require ventilator as a last resort, but we probably avoided more than half of our COVID patients from getting on a machine. Our experience in our hospital was extremely good that it was even featured in the local news. We might be publishing a paper on a medical journal about this experience in the near future.

Our hospital has also gained so much experience in placing patients on prone position if their oxygenation is failing. Never have I seen so many ICU patients on their belly. If the patient is awake and not on mechanical ventilator, we instruct them to lay not on their back if able. If they are sedated and on ventilator, we avail a team to flip them on their belly. And based on our experience, this really improves their respiratory status – belly down prevents them from going “belly-up.”

Photo by Miguel Á. Padriñán on Pexels.com

There are also interventions that have rapidly fallen out of favor, at least from our experience. Like giving hydroxychloroquine, the anti-malaria medicine, which we initially give to all our infected patients at the onset of the pandemic, but stop doing so. I don’t want to be political, but there is currently no robust data supporting it. We are also part of the on-going study of giving convalescent plasma to our patients, that is transfusing blood from a person that has recovered from COVID-19 and thus has presumed antibodies. We are also giving other drugs like Remdesivir and Tocilizumab, agents that are still under investigation. We are even conducting our own small trials using other novel drugs. At this time, no one really knows which medicine works. It might turn out that all of these medications are worthless.

As we open our communities more and more, I am anxious that we would see a second wave of infection. Yet I have to accept the fact that we cannot keep the world close indefinitely, for that is not considered living either. We just need to embrace the new reality.

For simple recommendations, first, we need to keep a distance from each other. At least 6 feet they said. But is that distance scientifically sound when we know that a sneeze or a cough particle can travel much farther than that? That is why wearing mask is helpful, for it protects us from each other if we cannot keep a safe distance.

So another new normal is that we need to wear a mask when going out. I know it is a barrier for communication as we cannot see the facial expressions when we talk to people. It is really bad for the deaf or for those who read lips. Probably good for people with bad breath, for they can be accepted back to the society. And perhaps sad for many, as we cannot see anymore each other’s beautiful smile.

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Lastly, no more handshakes. This act of shaking hands evolved from an era when nobody was trusting anyone, that people have to approach each other with an open hand to show that they were not holding a dagger as they meet. This developed into the custom of a handshake. Maybe now we need to greet each other with a bow, like some Asian cultures do. Or maybe a curtsy. That would be cute. Or perhaps some kind of a salute. Just not the “Italian salute.”

Stay safe everyone.

A Beautiful Night

I did two overnight in-hospital ICU call in a span of three days lately. This has obviously derailed my circadian rhythm. Normally in our group of intensivists, a doctor only do 24-hour duty once a week or less. But this is not normal times.

So on the day I was off after my back to back calls, I woke up in the middle of the night and cannot sleep anymore. My body was fatigued yet my mind was awake. Instead of tossing and turning in bed, I got up and went to another room so not to disturb my wife who was fast asleep.

I pulled up a chair and sat by the side of the window and stared outside. The night was still and the moon was halfway through the horizon in the sky. The warm glow of the moonlight bathes the whole surrounding and it was quite enchanting. It was after all the super pink moon – the biggest and brightest full moon of this year 2020.

Ah, year 2020. Who could have predicted that this year would be this challenging? At my work we have more than 30 ICU beds, but with the predicted patients surge from COVID-19, our hospital has a contingency plan that we could convert other parts of the hospital into temporary ICUs and that we could potentially take care of 90 critically-ill patients on ventilators. The good thing is we have not seen that kind of surge like what is happening in New York City and New Orleans. At least not yet. I hope we never will.

We do have several confirmed COVID-19 patients on ventilators though, and they are pretty sick. But they are getting better, and the truth is many of them are getting off ventilators after a few days. Even our first ever confirmed COVID-19 patient that ended up on mechanical ventilator improved and got off of it after almost three weeks.

There were deaths though from this virus, even in our ICU and we cannot deny that. In fact the other night that I was on call, there was one patient that was a COVID-19 suspect and I placed him on a ventilator that night. Of course I had my full protective gear when I intubated him. Yet despite of our best efforts he died. But testing came back later that it was not the novel corona virus, but he had positive blood culture for a bacteria and he died from an overwhelming sepsis. People die from other causes as well, not just COVID-19.

As I gazed outside the window, I uttered a prayer for strength and protection not just for me, but for all the healthcare workers that continue to fight this battle. I also prayed for my family and all the families of frontliners who are at continued risk of contracting this disease from us when we come home. More importantly I prayed for the patients and their families that are going through such a woeful and difficult time.

The saddest part of this pandemic is that patients in hospitals are going through their ordeal alone, as family and friends are not allowed to visit them. And for those people who succumbed from this COVID-19, they die alone with nobody to hold their hands even in their last dying breath. It is really heartbreaking.

I looked at the radiant full moon and it was glorious. I observed that the light of the moon cast long shadows on the lawn from the trees. I was unaware on how the trees around us had gone so big and tall now. The evergreens that stayed lush and strong through the cold months and had survived many bitter winters. The deciduous trees that were currently barren but the leaf buds were beginning to appear for it is spring time after all, reminding us that life begins again. I also noticed that there were faint stars in the sky, though their light were subdued by the bright moon, yet they were twinkling whether we see them or not.

All in all, it was a beautiful night.

Photo by David Besh on Pexels.com

Then a thought came to me as if God was answering me. Even if we are going through the night, if we don’t dwell on the shadows and focus on the light, there is still beauty around us. Many times darkness heightens our senses to appreciate the light and other lovely things that we may have taken for granted. Yet the most reassuring thought is that even how dark the night is, morning is surely coming and a new day will emerge.

Yes, we may have lost many in the night and we should remember them, but for most of us, we are going to be alright. Have a blessed and meaningful Easter everyone.

Fearless

I am fearless. But that’s not true. It’s not that I’m scared of spiders or cockroaches. It’s more than that.

I think we all know that we are in a middle of a war. The casualties from this COVID-19 pandemic continues to rise and it is devastating. More devastating are the news that healthcare frontliners are becoming casualties themselves. The news of doctors – from China, Italy, France, Indonesia, Philippines and more – dying from getting infected with the novel corona virus from patients they are trying to save, sends shivers to my spine.

I know there are risks from my chosen profession. From being overworked and being sleep deprived to being cursed by patients and being sued, that goes with the territory of our duties. I can live with that. But to risk your own life from contracting a possible deadly disease and even worse, to endanger your own family from passing on the illness at home makes me afraid. Very afraid.

For those people who are not taking this pandemic seriously and continues to party or not follow the recommended social distancing and community quarantine, or for those who think they are strong and invincible, please think again. If it’s not you who would be severely affected, it may be someone that you love that could suffer, because of your foolish actions.

Today, I came face to face with only my mask in between, with this deadly disease in our ICU. As I place an endotracheal tube to the patient’s passageways to hook her to a ventilator, I can only pray that my personal protective gear will be enough shield from this invisible enemy. Though I pray even more that heaven’s hand will be my shield.

I know this is only the beginning of my daily battle and confrontation with this foe. And it is expected that the worse is yet to come.

Fearless or not, I swore an oath to do this job. So help me God.

(*photo taken at Jardin du Palais Royal)

Hospital, Cafeteria, and Sanctuary

I was in charge of the ICU that day and it was quite busy. Though it was not that up-to-my-eyeballs hectic for I still had time to go down to the hospital’s cafeteria for lunch. Many times I would grab meal to-go and head back to the ICU work station and inhale my food while doing some computer charting. That day I had the luxury of eating my lunch more leisurely in the cafeteria itself.

Our hospital’s cafeteria is by no means a fancy place to dine in. It is after all a cafeteria serving hospital food. Nothing against hospital food, but if I have time to spare, I will eat somewhere else. Our cafeteria though has a section that has glass wall and ceiling that gives you an atmosphere of being outside. Yes it is still winter and there’s snow on the ground, but the sun was shining that day, so I went there so I could soak up the sun for a change.

However if the hospital cafeteria is as inviting as the photo below, once I settled there they have to pry me like a barnacle from my seat for me to go back to work.

(photo taken in the Philippines at Manila Bay, a few years ago)

Besides the obvious of getting food to eat, there is another reason I stay a while in the cafeteria. That is, it gives me a chance to be away, even for a short time, from ICU work and from the constant hounding from the patients, residents, nurses, and other doctors. Though almost always, when I’m on a lunch break that is when I am called to the Emergency Department for a new admission.

But that day was different. I was enjoying my lunch alone and my phone was unusually silent. I guess the cafeteria gods were smiling at me. I consider these lunch escape my sanctuary – away from the chaos and the harsh reality of the ICU.

The hospital has a chapel too. But that is not the kind of sanctuary I am talking about here. I just needed a place to take a breather.

Then while I was savoring my food, but more so my silent interlude, a man approached me at my table. How dare him interrupt my break time? Who was he to disturb my lunch? Of course I did not react that way and instead I looked up and gave him a smile. It may be forced, but a smile nonetheless.

The man introduced himself and said that he recognized me from a previous ICU encounter. I learned that I took care of his mother in the ICU several months ago. After he gave me some details, I remembered her mother – she had cancer and became septic after receiving chemotherapy. She got very ill very fast and stayed in our ICU for several days. But she recovered.

The man then pointed to his mother, my previous ICU patient, who was sitting in a table a few paces away. They have an appointment with their oncologist at the Cancer Center and that’s why they were in the hospital.

How many patients have we taken cared of in the ICU who was as sick as she was, and have a chance to meet them later after their discharge and were doing relatively well? Sadly to say, that is a rarity. For many of them even if they get out of the ICU, they were never the same. And some don’t even get out at all, I mean not to the world of the living.

This man just stopped by to thank me. It was an interruption that I would appreciate after all.

Then when I was about to leave, a man that I met in the ICU earlier that day sat in a table near me. He was absorbed in his thoughts while eating by his lonesome. Like me he was also taking a break. Perhaps the cafeteria was his sanctuary too, an escape to the sobering truth in the ICU.

Though this man’s predicament was much different than mine. His daughter was our patient in the ICU, and she was not doing well. She had a tumor in her brain that was surgically removed, but even after more than a week post surgery, she remained on life support. Her life was hanging in the balance with uncertain future. Worse part is, she was only 20 years old.

It is very understandable for her family to be heartbroken. No wonder her father rarely leaves her bedside, except for a brief cafeteria break. As a father who has a daughter with similar age, I can only imagine the agony he’s going through.

I needed to go back to the ICU. We needed to help this young lady and her distraught father.

Auld Lang Syne: A Look Back

I am reposting an experience I had several years back. Original piece published December 2013.

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I was on-call that New Year’s Eve. As I remember it, even though it was the holiday season and no patient wants to be in the hospital, it was still very busy for us.

It was a time of a bad flu season and our ICU was full. In fact there was even a pandemic that year of a bad strain of influenza A, the H1N1, or otherwise known as “swine flu,” and we had confirmed cases in our hospital. The hog farmers here in Iowa detest the name “swine flu,” as it was detrimental to their trade.

Despite of my toxic duty, I was able to finish my rounds and saw all our hospital patients for the day (took me 12 hours or so), and made it just in time to a gathering of some Filipino friends for the New Year’s party.

I was only warming up with our friends when I was called for a “stat” consult that I have to see right away. Before I left, my friends told me that if I finish the consult and it was still before midnight, then I should come back to the party. It was around 10 o’clock when I drove back to the hospital.

The patient that I came back for was a woman in her 40’s. She had breast cancer and sad to say, despite all the surgery, radiation, and chemotherapy that she underwent, the cancer had spread to the lungs and pleura (covering of the lungs).

The patient was obviously struggling to breathe when I examined her. The chest x-ray that was done that night, which was requested by the oncologist showed hydropneumothorax. That means there was collection of fluid and air in the space surrounding the lungs. And that was the reason I was consulted, to surgically place an additional chest tube (as she already had one in place) to drain the fluid and air.

After reviewing the chest film and comparing it to the previous chest x-rays, I determined that the finding of hydropneumothorax was old. In fact the chest x-ray was unchanged compared to films from few weeks ago.

That meant that the worsening of the patient’s respiratory status was not from the collection of air and fluid primarily. Placing another chest tube would not matter as the lung was trapped and would not expand further. I surmised that her further deterioration was from the advancing cancer itself.

Maybe the patient and her family was hoping against hope that there was still something that can be done. Maybe they were grasping for straws for a possibility that she could see another New Year.

I explained my findings and I then solemnly, but respectfully told them that in my viewpoint, placing another chest tube would not matter, and that would not relieve her breathing difficulty.

Right after hearing my opinion, that was when the patient and her husband made the somber decision that it was time. Time to end it all. Time to let go. Time to transition to comfort measures only. It was time for her to rest.

The patient’s husband went out briefly, maybe to talk with other family members who were outside the room. When he came back, I bid them goodbye and left.

As I went out of the room I saw two girls, both were probably not older than 12 years of age. They were crying, while an older woman was comforting them. I assumed those young girls were the patient’s daughters. I think it would be safe to say that they were not having a “happy” new year’s eve.

I looked at my watch. It was less than an hour to midnight.

By that time the rest of the world was partying while waiting for some fancy ball to drop. At that time most people were celebrating while waiting to welcome the New Year, while another family was also waiting – waiting for suffering to end. Waiting not to welcome, but to say their final goodbyes.

I did not go back to the party. I went straight home to reflect, while the song Auld Lang Syne (translated as Times Gone By) echoed in my head.

Should old acquaintance be forgot,
And never thought upon;
The flames of love extinguished,
And fully past and gone:
Is thy sweet heart now grown so cold,
That loving breast of thine;
That thou canst never once reflect
On auld lang syne.

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Post Note:

For us who will be welcoming another new year, may we face it with hope and optimism, and embrace with reverence this precious life we are given.

(*Auld Lang Syne is traditionally sang to celebrate New Year at the stroke of midnight, but it is also sang in graduations and funerals; photo taken at Musée d’ Orsay.)

He Checked Out

It is a lonely world out there.

Yes, we have this modern technology of all the world being connected and wired through broadband networks, internet, Wi-Fi, and all platforms of social media, and yet the proportion of the population suffering from loneliness and depression is on the rise at a rate that we have never seen before.

A couple of weeks ago, a man suffering from Parkinson’s disease presented to the hospital for progressive weakness and failure to thrive. He needed to be placed on a non-invasive ventilator (BiPAP) for respiratory failure. He was admitted to the ICU by my partner the night before.

I went to see the patient the next morning. Before going in to the patient’s room the nurse at the station made a comment to me, “I think he just has no more will to live.”

I examined the patient and I spoke to him. Despite him on the BiPAP mask, he was still able to communicate. After learning more about him, he expressed to me that he wanted to be DNR (Do Not Resuscitate), meaning, to let him go peacefully if his heart stops.

I learned from the patient too that his wife passed away recently. He also had a son that lives in the area but he did not want him contacted. His next of kin that he put on record was his church pastor.

I tried to get him off the non-invasive ventilator but his oxygen saturation dropped so we had to place him back on it. But I told him that we could take him off the BiPAP mask briefly to let him eat, however he said that he had no appetite.

After our initial work-up, his condition was still a conundrum. He was not in congestive heart failure. He had no apparent pneumonia. He had no viral or bacterial infection. He was just unwell.

I think the nurse’s assessment was spot on. The patient simply gave up on living.

That night, a little past midnight, my phone rang. It was one of the ICU nurse telling me that our patient went bradycardic (low heart rate) and then went into PEA (pulseless electrical activity). The nurse commented, “He checked out.” He gave up the ghost and died.

The saddest part as I learned later, was that there were no friends nor family that visited him. There was nobody around, except for our hospital staff, when he died.

I don’t really know what was the story behind this patient. What I know is that he was lonely and that he did not care to live anymore. What if somebody was there for him? Could it have made a difference?

Please take time to show people, specially our loved ones that we care.

(*photo taken from here)

An ICU Love Story: A Reload

I have posted more than 850 articles and stories over the years since this blog’s inception, which in a few months, will be 10 years. It’s quite a popular practice in the media to have reruns or replays. Even social media have their “throwbacks.”

I would like to repost a throwback story/article once in a while, not that I am running out of ideas or stories, for as a matter of fact, I have more than 30 unfinished articles in my draft bin. But sometimes, I just want to relive a bygone moment, or perhaps give a new breath to a favorite story from the past.

Here’s a reload of a love story that I witnessed a few years ago:

Making Things Right

“I just want to make things right.”

That was what my patient told me. 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). A 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. A bad prognosis.

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

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

I approached him as he lay 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 wants us to shock his heart or pound on his chest to try to resuscitate him? Or does he wants us to just 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? Was he of a sound mind or was 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. But it was the groom who wore it, for I’m not pertaining to a wedding gown, but rather a patient’s hospital gown.

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. His respirations became more and more labored. 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 away at the break of dawn. And he left a newly wed bride, a widow.

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

Yet love conquers all.

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(*This story was originally published in July of 2011; featured photo was taken a few weeks ago.)

Unburdened

It has been rough going for us in the past few weeks. Our work group is limping with regards to our coverage of clinic duties and hospital calls.

One partner is on maternal leave. There were sickness in our ranks as well for two of my partners went down with flu at the same time and they were incapacitated for a day or so, and we scrambled to cover for them. Then another partner underwent surgery and have limitations on doing procedures that we have to switch around our rotations. And with recent spring break season, there’s always one of us that is out of town for a vacation that has long been scheduled.

But life goes on and we managed.

I am in-charge of the ICU for almost two weeks now. It is awfully busy and I am in a lot of stress to say the least. My wife have noted that I’m in a foul mood in the past few days. Perhaps I’m becoming a grumpy old man. Or perhaps it’s male menopause, if that’s even a thing. I still blog though, partly to de-stress.

Then a couple of days ago I received an e-mail from our group’s Risk Manager forwarding a letter from the hospital’s Guest Relations Office.

When the hospital’s Guest Relations Office is involved, it is mostly to pacify disgruntled patients and families and to hear their grievances. And when Risk Management contacts a doctor, that’s not a good sign, as most of the time it means a patient is complaining or worse yet, filing a lawsuit.

This is at the heels of a recent local news of a patient that sued a doctor and the jury awarded the complainant several million of dollars for damages. The compensation was so steep that most medical doctors could not earn that amount of money even in their whole lifetime. As a physician it bring shivers down my spine. I am not saying that the doctor in that case is not at fault, but this is just the reality of the world we lived in.

The e-mail I received said that the call came from the family of a patient that I took care in the ICU. It was an elderly woman who became severely ill and died under my care. She was one among the recent strings of our hospital fatalities.

I am already under a lot of pressure from the ICU’s workload and I don’t need any more bad news or added stress.

But as I continue to read the letter, my yoke was suddenly lightened. In fact my burden was lifted and turned into joy.

The letter said that the patient’s daughter reached out to the hospital’s Guest Relations Office and recommended that her experience be forwarded to the appropriate leadership body. And it named me specifically.

What the patient’s daughter wanted was that me and two of my residents “be recognized for our hospitality, warmth, and kindness.” She shared, “they were wonderful in explaining my mother’s circumstances. I cannot even find the right words to express what they did for me. It was so heart-warming.”

God knew I badly needed some encouragement. And I am so grateful He provided me one.

(*photo from the web)

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.

********

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.