Spinning Plates

When I was much younger, I had a fascination for juggling. I learned how to juggle on my own. I could juggle 3 tennis balls, or toy blocks, or even plastic bowling pins. Though I did not and would not try juggling chainsaws.

Juggling is an art. The more dangerous and challenging the feat, the more captivating it is.

Have you seen an act of spinning plates, where the juggler spins several plates on sticks? He goes from plate to plate to keep them spinning or else the plates drop to the floor and break.

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Three weeks ago I had one crazy weekend duty. I think it would fall as one of my busiest calls in the ICU in my recent memory. It was so busy that my Friday to Sunday, kind of blended to one very long day with only a few hours of sleep in between.

In one particular stretch of that call, hell broke loose.

I worked on a very sick young man in his 30’s, who was admitted to ICU room 3. I intubated him, placed him on ventilator, placed a large neck catheter for IV access, and started several medication drips on him, all in one rapid succession. I was in the midst of trying to stabilize him when another patient, a lady in room 18, went into cardiac arrest. “Code Blue”* was called.

I have to drop what I was doing on the first patient and ran to room 18. When I got there, the ICU resident was already running the code. After 10 or 15 minutes of CPR and fast paced intervention, we were able to resucitate her back. With her heart rhythm semi-stable, I ran back to room 5, and continued what I was doing.

Not too long after, the patient in room 18 went into cardiac arrest again. I ran back to that room once more. This time I beat my resident to the room and took charge of the Code Blue. My resident who eventually arrived told me that she got hung up in ICU room 16 who was also crashing. I saw another resident who responded to the the Code Blue, but I sent him to room 5, to continue on what I was working there.

After more than 10 minutes of CPR we got our patient in bed 18 going again. It was heartbreaking to see that while the CPR efforts were in progress, the family was just outside the room crying and wailing as we work furiously on their loved one.

After we got the patient’s heart beating again, I gathered her family to a nearby consultation room and discussed with them the dire situation. I told them that there was no guarantee that her heart would not stop again. But given of how sick she was, especially after successive cardiac arrest already, I knew her chances of walking out of the hospital was close to nil, and continuing to do the CPR would be an exercise of futility.

I was talking to the family, when I was called emergently to see room 16 who they were about to call Code Blue. This was the one my resident told me about earlier. We got the patient intubated and hooked to ventilator, started several IV medications and got him stabilized, at least for the time being.

After getting out of room 16, the family of room 18 approached me and told me that they have decided that if her heart stop again, to let her go peacefully.

Less than 30 minutes later, she died.

The patient in room 16 that we attended to also continued to circle down the drain. And despite our efforts, he also succumbed several hours later.

I finally was able to concentrate on room 5 when there was a lull in the chaos we were in. I decided to place him on extracorporeal life support, also known as ECLS** (see previous post about ECLS here), as he would not survive without it. The ECLS team was mobilized, and around 2 o’clock in the morning, the patient was off and running on ECLS.

I have not even mentioned the other 17 ICU patients under my care, but were not actively crashing during that time, nor the other 3 new ICU admissions that came during that span of 4 hours of absolute craziness. I even accepted another patient from an outlying hospital during that period, for whom I ordered our flight crew to fetch. Though the patient did not make it to our hospital, as he was so unstable and our helicopter crew was reluctant to fly him unless they stabilize him more for the flight. I heard he died shortly then.

Spinning plates? Seems like it, right? Sometimes I wonder if I could  keep up with this pace or would I like to continue doing this. Don’t get me wrong I do like my job. But I don’t like the awful stress and the awful reality that comes with it. For it is not just plates that are falling and breaking.

About the patient in room 5? He improved after we placed him on ECLS. He eventually was weaned off ECLS and ventilator after almost 2 weeks in the ICU. He went home from the hospital the other day, walking unassisted and off oxygen.

Success stories like him, though few and far between, keeps us going. After all, I believe it is still worth doing this.

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*Code Blue: an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate resuscitative efforts.

**ECLS: extracorporeal life support (ECLS) is an extracorporeal technique of providing both cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange to sustain life. It is done by siphoning blood out of the body and artificially removing the carbon dioxide and giving oxygen to the blood by running it through a special machine.

Broken

I take care of “broken” people. Both broken, physically and emotionally.

Due to the nature of my specialty, I deal regularly with people who overdosed and those who attempted to commit suicide.

This past week, we have a lot of them. Every single night we have at least 2 admissions to our ICU of attempted suicide by drug overdose. There’s one that even slashed her wrist besides taking medications. It was full moon after all.

I am not superstitious, but I believe there is a real science behind the connection of the cyclical phases of the moon and human’s crazy behavior. Just like the gravitational pull of the moon affects the ocean tide, maybe it can influence our mind too. The human’s brain is 75% water anyway.

Most of the times our drug overdose admissions are “trivial” overdoses. They took a handful of pain or sleep medications as a cry for help, with the so familiar line of “I just want to escape from my problems” or “I just want to take a long sleep.” Though many will also claim, “I just want to end it all.”

Most of these overdoses just needed to be closely monitored for several hours in the ICU as they sleep off the effects of the drugs they took. When they sober up, we call the psychiatrist to evaluate them whether they are clear for discharge or transfer to the Psych unit.

However there are some who are “serious” with their attempts, that they overdosed with an awful amount of drugs or took highly toxic substances that they present to our ICU half dead. They have multi-organ failures, and would require infusion of medical antidotes if there’s any, be placed on life support, including mechanical ventilator, cardiac and circulatory support, and even dialysis, if the medication or poison they took can be dialysed out. Few of these gravely ill patients would slip through our fingers and die despite of our best efforts.

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Taking care of overdoses and attempted suicide patients is my least favorite in the line of my job. Why?

First of all, as I mentioned above, most of them don’t really need ICU care, as they just require time to sleep it off. But I guess they needed to be in a highly monitored bed in case something goes wrong. So many times it just add to the burden of the ICU staff who are already overloaded in caring other critically ill patients.

Secondly, for those who are “serious” in their suicide attempt and comes to us almost dead, after we work our tails off saving them, they are not even grateful to us when they recover. They are even bitter. Why? For the obvious reason that we prevented them from getting to their ultimate goal, which is to die. It is a thankless job.

Over the years that I have been an ICU physician, I have observed that our admission of drug overdoses and suicide attempts seems to be increasing. Has our society gone so cold and uncaring that many among us feel so lost and so unloved, that they are willing to do foolish things just to get the care and attention they hunger for? Maybe it is the world that is broken. Maybe it is all of us.

As a health care professional, it is my duty and my obligation to care for these people when they come to our ICU, irregardless of how “stupid” their acts seems to be. I’ll listen to their stories. I’ll reassure them. And if care and attention is what they want, deserving or not, I’ll give it to them.

Even though these “broken” people think that the world is so indifferent and no one seems to care, but when they leave our ICU, I can honestly say to them, I cared for you.

 

(*image from emaze.com)

 

Steak and Rye

It was late afternoon of New Year’s Eve, and I was rounding on our patients in the ICU. I came to one room and the patient was sitting upright in his bed. On his bedside table was a tray with a large piece of steak on a plate, a drinking glass, and a bottle of rye whisky. What? Is this a restaurant or hotel? Is this the new hospital food?

Most of our patients in the ICU are not awake enough to eat food, let alone have a solid meal like that. We provide nutrition through a tube in their nose that goes to their stomach and they feast on liquid feedings. Or if their gut is not working, we give them “gourmet” nutrition through their veins. In fact once patients can eat solid food, most of the time they graduate out of the ICU.

But what about this patient? A slab of steak? And is alcohol sanctioned by the hospital now? Here’s the story.

He presented to the hospital with worsening shortness of breath. After some imaging work-up, he was found to have a large tumor in his chest. I saw him several days ago when he was admitted in a regular room, not in the ICU. We were consulted for the lung mass and I scheduled him to have a bronchoscopy (a procedure putting a flexible scope to the lungs) and biopsy.

However before the scheduled procedure could be done, he suffered a cardiorespiratory arrest, got intubated, was hooked to a ventilator and was moved into the ICU.

Good thing was despite the circumstances, he improved enough that we got him off the ventilator. Yet we don’t have a tissue diagnosis to confirm that what he has is cancer, even though the signs indicated that it was malignant. But we needed to be sure.

So I proceeded with a bronchoscopy and got a biopsy, and finally established a diagnosis. It was lung cancer alright.

Unfortunately his condition got worse again. He again required ventilator support, though a non-invasive type, which is like a CPAP machine. I told him that the final pathology proved that it was cancer. And based on its extent, plus with his grave condition, he was an unlikely candidate for any surgery, or chemotherapy, or radiation to treat his cancer.

That’s when he decided that he wanted to go on his own terms. His own way. Like Frank Sinatra’s song, “I did it my way.”

He requested that we discontinue the non-invasive ventilator, even though he was struggling without it. He asked to have a New York steak and a bottle of rye whiskey for his last meal. So in between labored breath and heavy heaving, he chomped on his steak and sipped on his rye.

When I came to his room that afternoon, despite his terrible situation, he was even smiling while having his last supper.

After he had his meal, we transitioned him to full comfort care per his request. No more ventilators, nor machines, nor any more interventions. Only comfort medications. And while he was watching TV in his ICU bed, waiting for the ball to drop in New York’s Time Square, he quietly slipped into a blissful sleep.

Just before the old year ended, our patient went out peacefully into the eternal night. He exactly did it his way.

For us who made it through another year, may we find new aspirations, new hope, and renewed zeal for life, as we face this new year.

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When You Wish Upon A Star Wars

I entered the room and stood silently at the foot of his bed, watching him breathe. He was hooked to a small ventilator that is connected to a mask covering his face with straps around his head, that he looked like a jet fighter pilot. Beside the bed was his father and his mother who were obviously distraught, yet trying to hold off tears.

Luke* (not his real name) was one of our ICU patients. Even though he was only in his 20’s, he had his fair share of surgeries and hospitalizations than many patients in a geriatric floor combined.

He had a genetic disorder that prevents the development of various organ system. This affects the skeletal system giving them a peculiar look and stature, that some people coin the term FLK syndrome: Funny-Looking Kid. Though for me, there’s nothing funny at all. This disorder also causes heart defects, and can involve other organs like the lungs, liver, gastrointestinal tract, lymphatic and blood system. Even so some people with this genetic disorder could live to adulthood, some would succumb to this disease early in life.

Luke had a number of surgeries to fix his heart problem, and other procedures too many to recall. He had been treated in well-known hospitals like Mayo Clinic, for his disease. But despite of all the technology and medical interventions, his body continued to betray him.

For the last several months he had been in and out of the hospital, usually staying for several weeks at a time, including ICU stay. I have taken care of him a number of times in the past.

In spite of his illness, Luke tried to live his life as “normal” as possible. His family gave him the opportunities and the best care they could. His mother, who was a patient of mine too, had the genetic disorder as well, albeit with a milder manifestation, thus I knew the family well.

One thing I learned, was that Luke likes Star Wars, even though the first Star Wars movie came out more than a decade before he was born. Yeah, he was a fan of this movie genre, just like the rest of us, I guess.

In this last hospital admission, Luke came in with a lung infection causing respiratory failure, requiring intubation and mechanical ventilation. He came on Thanksgiving Day.

After several days in our ICU, we were able to extubate (take out the endotracheal tube) him, only to place him on a non-invasive positive pressure ventilator (NIPPV) with a face mask, as he cannot breathe on his own. This is like a CPAP machine. At least he can stay awake and not be sedated on the non-invasive ventilator, and he can speak as well. He can only tolerate a limited time off the NIPPV, and had to be hooked right back on it. He would not survive without it.

As I watched him with his “jet-fighter mask” with his bed as his vessel, what came to mind was that in a cruel twist of fate, this kid who likes Star Wars, now breathes like Darth Vader: whoooh….poooh, whoooh…..poooh, whoooh…..poooh. Every breath, there’s a gush of pressurized air coming out of the ventilator and through his mask.

After one holiday, another one is approaching. Christmas is just around the corner. And Luke remains in the hospital, ventilator-dependent, with no clear sight that he’ll get better. He knows it, and his family knows it. Luke’s days here on earth is numbered.

With wishful thinking, maybe he can linger a little longer to see the new Star Wars movie which he was looking forward to seeing for the longest time. But how? Him in the hospital? On a ventilator?

But wait, isn’t it Christmas season after all?

Wish granted!

After making elaborate arrangements and collaboration, Luke and his family will be going to a movie theater, to be accompanied by some medical staff, for a special private showing of the “Star Wars: The Force Awakens,” when it opens this weekend.

After that trip to the theater, Luke will be going home for Christmas with his family, on hospice care. No more hospitals. No more ventilators. No more pain.

Perhaps he could stay home until Christmas. But if not, Luke could soar into the heavens and once and for all, walk on stars. His final home.

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(*name intentionally changed for privacy)

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Update 12/22/15: after posting this story here, I learned that our patient was featured in the local news. See link here.

 

 

A Christmas Spectacle

One of the hallmarks of Christmas is the wonderful shows, parades, or spectacles that happen during this season. The second story I want to re-post is about a different kind of Christmas spectacle.

I originally published this story, “The Christmas Homecoming,” on December 17, 2011.

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The Christmas Homecoming

He arrived with much fanfare. Clad in a brightly orange suit, with two escorts on each side. He made a jingling sound with every small step he made. People turned around and looked as he walked and passed through the hospital corridors, for it was an unusual sight to see. But he did not mind their glaring stares. He came for a special purpose, and that’s what matters. He came to see his father.

His father laid in our ICU. He suffered an acute and severe bleed to his head. The bleeding was so extensive that he required a neurosurgical procedure to evacuate the large collection of blood inside his skull, and placed a shunt in his brain to relieve the high pressure, in an effort to save his life.

However despite of all the intervention, his condition did not improve. In fact, it even got worse. After the surgery, he had more bleeding and swelling to his brain. And no further surgery could fix or decompress the pressure that was squashing his brain. There were no “miracle” medicines that can be infused on him that would make him better. No further medical intervention left that could be done to save him. His condition was unsurvivable. Sooner or later, all the life-sustaining machines hooked on him would be deemed worthless as he would be pronounced brain-dead.

Due to the grim development of events, the patient’s family were all in agreement to discontinue all life support. Though they had one request before that happens. They pleaded for the patient’s son to come before he dies. A son who had not seen his father for a long time.

In the past 10 years that I have been an ICU physician, I have signed for diverse medical and non-medical requests – a disability form for a patient who was critically ill, a leave of absence for a relative who’s loved one was in our ICU, a letter to the military requesting for a deployed soldier overseas to be permitted to come home to be with his mother in her last days, or a letter to the US consulate for a patient’s mother in a foreign country requesting for a visa to see her son, who was in near-death.

This time I signed a request for a prisoner to be released briefly from jail, to visit his dying father.

And so he came.

The brightly colored clothes was not because it was the holiday season, but it was the standard issued jumpsuit from the prison. The jingling sounds as he walked, was not from trinkets or bells to announce some holiday cheer, but rather from the chink of the chains that binds his ankles. He brought no gifts as he came empty-handed, except for the handcuffs. There were guards that flanked him as he made his way through, and people watched and stared, but it was not a parade.

He was led into the ICU room where his father laid. Her mother who was at the bedside, cryingly welcomed him with open arms. It was an embrace of acceptance to their “wayward” son. Like a homecoming of a prodigal son, if you will. Yes, it was a sort of homecoming alright. A very sad homecoming indeed.

As the son stood silently beside the bed of his comatose and dying father, the tears began to flow from him. Prison, I supposed, did not harden him enough to be devoid of all emotions. If only his father can see his tears, but it was too late. Whatever demons he had in the past, and I don’t care to know, he was still human after all. Just like you and me.

Was the tears for his father, who he knew he failed, and who he would never see again? Or was the tears for himself, as he had caused his family such heartache and disgrace? Was it tears of painful loss and farewell? Or was it tears of remorse and repentance? Or maybe it was a combination of all of those reasons. Whatever it was, he alone knows.

After some time, he was escorted out of the room and back, I assume, to the penitentiary.

There will be no singing of Christmas carols, I’m sure, in his dark and lonely cell tonight.

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Post Note: I have not witnessed a similar spectacle since, nor do I have any word of what happened to the son afterwards.

(*photo was taken by my wife)

A Christmas Miracle

We have entered the month of December and Christmas is only 3 weeks away. For this month I would like to re-post stories that happened around Christmas, which I have witnessed first hand, and that I have written several years back.

I first published the following story, “Gift of Life,” on December 15, 2010.

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Gift of Life

Everybody said that her pregnancy was ill-conceived and ill-advised. But who are we to judge her?

Mary (not her real name) lies in our ICU. Her 21-year-old body looks frail and debilitated, her skin is pale and sallow, and her breathing is irregular and shallow. Attached to her sick body are a number of tubes, catheters and monitors. The regular bleep and tracings in the monitor screen above her bed tells me that she is still alive, although she looks otherwise.

Mary was born with cystic fibrosis. This is an inherited disease caused by a defective gene that causes thick mucus plugging of small tubes and ducts, mostly affecting the lungs and the digestive system. Patients suffer with frequent lung infections, digestive problems, and usually succumb with respiratory failure or liver failure. The disease is fatal that many patients will die in their childhood and adolescence. However, in the past few decades, with the improvement of care, patients who made it through adulthood has an average lifespan of 35 years.

Mary’s childhood was anything but normal. She was in the hospital or doctor’s office so often more than she was in school. She was on medications constantly. She had known more doctors than childhood friends. She experienced more than her share of suffering and disease. But she had beaten the odds. Now, that she made it through 21 summers tells me that she is a fierce survivor.

But now, this pregnancy. Her family doesn’t want her to have this. Her doctors told her that her body may not be able to tolerate the additional stress of pregnancy and that it will be very high risk to continue. But she made up her mind that she will keep this child whatever the cost.

Due to developing problems and complications, she was admitted to the hospital’s maternity ward on her 32nd weeks of conception, where she was expected to stay for the rest of the pregnancy. However, after a few days in the hospital her condition worsened. Her liver function deteriorated and she went into fulminant hepatic failure. Mary slipped into coma. She was then transferred to our ICU.

Because her baby may get compromised further, we had no choice but to deliver the baby, even if it was barely 33 weeks old (full term is 38-42 weeks). Mary underwent an emergency caesarean section.

Now, 3 days after her baby’s delivery, Mary still remains in our ICU. She continues to be comatose.

As I stand beside her bed to examine her, I see the pictures of her newborn baby posted on the wall of her room. Being a parent, I cannot help but feel a twinge of sadness. Will she ever know that she brought forth a beautiful baby, premature, but otherwise healthy boy? Will she ever hear the yearning cry of her dear child? Will she ever see the sweet smile of her son? Will she ever hold her baby in her arms, the life that she fought for so dearly to bring to this world, even if it meant going against medical advice?

I just hope that someday this precious boy would be grateful and proud to the mother, he may never know. And may he appreciate and realize the challenges, the difficulty, the sacrifices her mother went into, to give him the gift of life. Yes, even in exchange of her own life.

But wait. This is Christmas season. Time of miracles. Maybe there will be one here tonight.

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Post Note:

After I published this story, Mary did improved and recovered. She got out of the ICU and eventually went home to take care of her beautiful baby. I took care of Mary a few more times and I always asked her about her baby boy. Her son became her pride and joy.

Sadly, Mary eventually succumbed to her illness last year, leaving a very young son, who at least experienced a mother’s love, even for so short a time.

Frankenstein Medicine

For this week, I have been spending 8-9 hours a day inside the classroom and in the simulation laboratory trying to learn something new. Never too late to learn a new trick, even for an old dog. Though I admit I was almost half asleep in some of the lectures.

The hospital where I have affiliation with, will have a “new” intervention available as soon as next month. This treatment is called Extracorporeal Life Support (ECLS) or also known as Extracorporeal Membrane Oxygenation (ECMO). So they are training us doctors (critical care specialists, cardiologists and thoracic surgeons), as well as nurses, respiratory therapists and perfusionists, so we can have this life support system off and running.

In a simplistic way, ECLS entails placing large tubes to suck out the blood from the patient. Then having the blood run into a machine where it will be bathed with oxygen and then pumped back into the body. ‘Extra’ means outside, and ‘corporeal’ means relating to body, thus out-of-body life support.

Does this mean the patient will have out-of-body experience?

For patients, whether kids or adults, whose organs have failed for one reason or another, especially the heart or the lungs, can be placed on this life support system to sustain them and keep them alive and buy some time. The use of this intervention is not by all means the first line of treatment but rather of a last-ditch salvo. But it definitely has saved lives, and more and more advanced centers are offering it. Our hospital will be one of the first to provide it in our state.

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baby on ECLS (photo from the net)

ECLS is not really a new procedure. This has been done for several decades now. Except before, the intervention is only limited to short period of time, like several hours only. The main use of this before was in the operating room during cardiac surgery. They run the blood out of the patient’s body and through this machine, while the surgeon stop the beating heart and tinker on it. I can imagine the heart surgeon singing Sting’s “Be still my beating heart” while he operates. Then the machine is shut off once the heart is beating again.

Now ECLS is also being used outside the operating room, and people are placed on this life support while in the Intensive Care Unit. They can be on this for a few days, a few weeks, or sometimes even months – while their own body and organs recover, or while they wait for a new heart or a new lung, or both, or until “kingdom come.”

Of course the complexity of this intervention is beyond what I can explain here, not to mention the immense cost to the already burdened health care system and the sensitive ethical questions involve, like who to place or who not to place, or when to continue and when to stop. Are we playing God?

While we are doing the training, one of the trainee commented with a sinister smile, “we are Dr. Frankenstein.”

Is this as close as we get to Frankenstein medicine? I don’t think so. We have not created a monster. Yet.

 

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)

Heart Tones

I just arrived home one early evening when I received a call from the hospital’s Emergency Department. On the other line was the Emergency Room physician who said that he needs my help on a patient that he was admitting to the ICU. After hearing the severity of the situation, I knew I had to come back to the hospital. At least it was still early and not in the unholy hour of the night.

Our patient was a woman in her late 20’s, who was brought in by the ambulance after having a prolonged seizure. Her family noted that after the seizure, she was not breathing at all. Her family started CPR and called 911. When the emergency responders arrived, they continued the resuscitation efforts and worked on her for more than 15 minutes before a stable cardiac rhythm was established.

When I arrived at the hospital, the patient was already in the ICU. She was unresponsive, intubated and hooked to a mechanical ventilator. After examining the patient and placing orders, I assisted my medical resident placed a large triple lumen catheter for IV access in the patient’s jugular vein for better management.

Not too long after, two more doctors came to the room to evaluate the patient. They brought along a heart monitor, not for the patient herself, but for the “other” patient involved.

Other patient? Yes, our primary patient was 36 weeks pregnant.

I have noted that once in a while our patient was going into a “stiffened posture.” This posturing is a tell-tale sign of a probable brain injury. To be certain, we consulted a Neurologist who came in several minutes later to assess the patient as well.

With two lives hanging in a balance, the Neurologist, the two OB-GYN physicians, and me, arrived on a decision that an emergent Caesarian delivery was necessary.

All along during our discussions inside the room, on the background, we can hear the baby’s heart tones from the fetal doppler: blup-blup-blup-blup-blup-blup-blup-blup……

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I entered the ICU room and the patient was lying motionless in her bed. Taped in the railing of the bed was a paper with a footprint of her newborn baby.

It had been seven days since my patient had the seizure and the subsequent cardiac arrest. Seven days since she had the caesarean section and delivered her baby. Seven days, and she had not waken up.

As I performed a thorough neurologic testing with prodding and certain maneuvers, she did not respond at all. Does she know that I was examining her? Does she know that her family was all worried and praying for her? Does she even know that she had delivered a beautiful baby boy?

Sadly to say, she has no idea at all. For she was gone. And the only things that were keeping her “artificially” alive were medications and machines.

Life is precious, yet so fragile. One moment you are a picture of health with all the promise of joy and life, then the next moment you are dangling by a thread with nothing but loss and despair. May we value and appreciate every fleeting moment of our lives.

We met with the patient’s family in the consultation room outside the ICU. They were obviously distraught and heartbroken. After explaining the facts to them, including the EEG (brain wave tracings) and brain MRI results, we gave them the grim news. The chances of a meaningful recovery was nil.

Amid the crying and whimpering, the family related to me that they just wanted to have the patient’s baby brought to her ICU room to have some time to be with her. Then, they will take her off life support.

Before coming out of the consultation room, we gave the patient’s family a token in a small box. A keepsake for her baby.

*******

In a lonely nursery, a baby was being lulled to sleep by a rhythmic sound coming from a small box hanging in his crib. It was a recorded heart tones of her mother. A mother he will never get to know.

Lub-dub lub-dub lub-dub lub-dub lub-dub………

3

 (*image from the net)

The Dead Speaks

Part of the benefits of a physician practicing in a teaching hospital is that there are regularly scheduled academic conferences and meetings where you can attend and learn something.

This morning I attended the Medicine Grand Rounds which was a clinical and pathological presentation of an interesting case.

A senior medical resident talked about a woman admitted in our Intensive Care Unit several weeks ago, who came in very ill. Her condition deteriorated quite rapidly that she died in less than 24 hours after admission despite of all the efforts to save her. An autopsy was requested from the family, to know what caused the patient’s demise, and in addition it was felt that the information from it would help us care for future patients.

After the history and the hospital course was presented, the Pathologist revealed his findings. He showed pictures of the gross and microscopic features of the autopsy. He then gave the verdict on the cause of death. And it was something unexpected. At least for me.

For all the medical specialists, it is the pathologist that always have the correct and final diagnosis. When I was still in medical school, which was more than 20 years ago, I have heard this saying:

“Internists know everything but they don’t do anything.” (Meaning internist like me have all the knowledge but don’t open up and explore the patient to intervene.)

“Surgeons don’t know anything, but do everything.” (Meaning, even though they don’t know yet, they open up and explore the patient to find out.)

“Pathologists know everything, and they do everything, but it is too late.”

Though in fairness to the surgeons, nowadays, with the advent of all the high-tech imaging modalities, like CT scan and MRI, they almost always have all the information they need before they cut open the patient.

I would say that part of a doctor’s learning is from the morgue. In fact, when we have a patient that died and we were granted permission for an autopsy, I make it a point to have my medical residents rotating with me, to come down to the morgue during autopsy and learn what the findings of the pathologist were. I think this is essential for a good training.

I am not trying to gross you out, but that’s the reality of our line of work. Though with all the TV shows, like CSI and NCIS, anybody can witness an autopsy, whether it is real or imagined.

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scene from an episode of NCIS

My first exposure to a real autopsy was when I was a 4th year medical student in University of Santo Tomas, in the Philippines. I was rotating in Forensic Medicine at Fort Bonifacio. There was a victim with multiple gunshots, and two pathologists were performing the autopsy. It takes a lot to gore me out, so it was no big deal to me. Plus we have been exposed and even dissected cadavers in our Anatomy class. By the time we got used to it, we can even eat our lunch in the Anatomy Hall.

While the autopsy was underway, an army sergeant walked in into the morgue with several new army recruits in tow. The sergeant told the recruits to stand in the corner and watch the autopsy so they know what would happen to them if they were killed.

As the pathologists extricate the internal organs one by one to examine them, I have noticed that the new army recruits who were standing in attention started to sway. Their stoic faces started to grimace. Well, who wouldn’t? I guess it was a sort of cruel initiation for them.

Since then I have witnessed several more autopsies over the years, not including what I watched in NCIS. It is not that I enjoy them, but I have to admit, I learn from them.

However I have maintained my utmost respect for the deceased. These bodies that were cut open for us to study were once living individuals. They were persons. They have a name. A purpose. A life. But now gone. Yet in these hallowed halls, they still speak.

Inscribed over many entrances of morgue, medical examiner’s office and anatomy hall is the Latin maxim, “mortui vivos docent,” meaning “the dead teaches the living.” Yes, indeed.