Tag Archives: ICU

He Checked Out

10 November 2019

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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

8 July 2019

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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.

**********

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

Unburdened

15 April 2019

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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

10 March 2019

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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.

Cold and Dead

2 December 2018

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Part of the duty of a medical resident in a teaching hospital is to formally pronounce a patient dead. When a patient dies, the nurse would call the resident-on-call to assess and examine the patient and confirm that he or she is indeed dead. Normally this is done in a timely fashion, within several minutes after the patient breathes his/her last breath, and the resident would chart the time the patient was pronounced dead. This would be the official time of death.

I understand that in a non-teaching hospital the attending doctor would be the one to call. If the doctor is not available, a nursing supervisor or a charge nurse can declare the patient dead. 

You may argue that it does not really take a lot of training to determine if a person is dead. Any reasonable person can discern this. Though there are some people you probably know who look like dead, but I’m not talking about that. So why do we need a doctor or an experienced nurse to pronounce a person dead? I think it is more for a medico-legal purpose.

Of course sometimes your judgement that a person is dead can be challenged  by somebody. The following is an actual exchange of questions and answers as recorded in a court documents:

A lawyer was cross-examining a witness, who was a pathologist.

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive, practicing law somewhere.

Several nights ago, we had a very busy night in the ICU. I believe we had 7 admissions to the ICU in a short span of time. This is in addition to the 20 or more critically-ill patients that we already had in our unit. So “busy” may even be an understatement.

One patient that we had that night had been in the hospital for almost 2 months and had been in and out of the ICU a few times. This time around the family had decided that they would transition to comfort cares and the patient would be taken off life support. So death was imminent and expected.

For some reason, whether the medical resident was not called, or he was so busy at that time, or he was called but forgot to do it promptly, but the patient who was taken off life support was not officially pronounced dead right away. Of course everybody knew that the patient expired – the ICU nurses knew, the family members who were gathered in the room knew, and even the morgue and funeral personnel knew.

Perhaps it was assumed the he was already pronounced dead, so the body was taken down to the morgue within an hour or so after the patient died.

It was not after a few hours later that our medical resident learned that the body of our deceased patient was taken to the morgue without him officially examining the patient and pronouncing him dead.

So what would a diligent medical resident do? 

Our conscientious resident went down to the morgue in the wee hours of the morning to search for the body. He pulled out the body from the freezer. He opened the body bag. He identified the deceased patient. Then he examined the body and pronounced it dead. I know, it sounds like a plot of a horror movie. At least he had an interesting story to tell his co-residents the next morning.

A couple of days ago, I received a notice from a funeral parlor to complete and sign a death certificate. Part of the certificate is to write down the official cause of death. Since I had 3 death certificates to complete that day I checked each of the patient’s hospital electronic medical record to be accurate on what I would write. That was when I read our resident’s note on the chart and I could not help but smile: 

Patient examined in morgue. On exam patient did not respond to verbal or physical stimuli. No heart or lung sounds were heard and patient has no response to painful stimuli. Pupils were fixed and dilated. Patient pronounced dead at 0336.

Since the patient was only officially pronounced dead after a few hours in the morgue’s freezer, should I write “froze to death” as the cause of death?

Of course I did not.

photo taken with an iPhone

(I meant no disrespect to the dead, nor do I make fun of a rather serious situation. I am just relating a light moment in the otherwise morbid world of ICU I lived in.)

Black Friday

23 November 2018

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Thanksgiving week is the busiest time for travel in the United States. Students who are in distant colleges and universities, family members who have moved away from their parents, and most people who have wandered far, all journeyed back to the place they call home to be with their family.

For a day the family gathered around the table with a spread of bountiful food and gave thanks. For a day the family was one again. Unless you have no family, or you don’t like your family, or you hate food, it is hard not to like this holiday.

Of course for some people this time is for vacation and some time off work. For some it is about parties. For some it is about parades. For some it is all about watching football. And yet for some they make this holiday time all about shopping – the Black Friday event. But primarily, this time is for families and about giving thanks.

I am in charge of the hospital’s ICU this week. I know there’s no good time to be sick and be admitted in the ICU, but being sick during the holidays is terrible. It is particularly difficult for the families involved.

We have one patient who was admitted in our ICU about 10 days ago. He is in his mid 50’s and he got really ill. He has multi-organ failure. Despite all the efforts, he did not get better. He is on mechanical ventilator, on continuous dialysis, and on several medications to keep his heart pumping and blood pressure up, yet he is sliding away. More concerning still is that he is not waking up.

His family would like us to continue our intensive management until many of his family, especially his children, who are in other states could come and see him and then they would say their goodbyes. For one more Thanksgiving, they gathered, though not in front of a bountiful dinner table, but in an ICU room, as one family again. Then today, Black Friday, they decided to transition to full comfort cares and let their father passed on after a final farewell. It’s kind of hard to give thanks in such circumstances.

Sadly to say, that story is not unique to that family.

In another ICU room, a mother who is only 40 years old, has metastatic breast cancer to the brain. She failed all surgery, chemotherapy and radiation therapy, and is now having frequent seizures. Family would like to keep her in the hospital until Thanksgiving day. Last night they took her home with Hospice to die.

In yet another ICU room, a man who is in his 70’s suffered a large intracranial hemorrhage a week ago. Even after surgery to the brain to evacuate the blood, the patient remains comatose and is in continued vegetative state. The family also would like to have family members from far away places to come on Thanksgiving to see him. Today, they took him off life support.

The saddest of all is in another ICU room. The patient is in his 60’s who had cardiac arrest and prolonged CPR four days ago. We cooled his body down (hypothermia protocol) to try to preserve any brain function. However after we rewarmed his body temperature and discontinue all sedation, he’s not waking up. There is no family members around and we cannot find any one except for a friend that said they don’t know any family of his, and perhaps he is estranged from his family. Both the cardiologist and I felt that continuing life support is medically futile given his significant anoxic brain injury. We let him passed on peacefully, with nobody around him except our ICU staff.

To many, today, Black Friday means bargain sales and wild shopping spree. But in this frantic place, inside these ICU walls, it has a different meaning. It is the solemn color of mourning.

For those of you celebrating this holiday time, may you cherish each moment you have with your family, and commemorate this season in it’s true essence.

(*photo taken with an iPhone)

Where Teddy Bear Dare Not Trod

8 November 2018

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A child’s Teddy Bear should not witness sad and painful experiences. Yet they do. Here’s a story for you.

I was working that weekend in the hospital for more than 24 hours already, mainly in the ICU, but still had a whole day to contend with. Then came Sunday morning, I was called to the Emergency Department (ED) for a CPR-in-progress. It was a woman in her 40’s who had a cardiac arrest. I was told she was still talking when she was brought by the ambulance. However she became unresponsive and her heart stopped few minutes upon arrival.

When I arrived at the resuscitation room of the ED, a team was furiously doing CPR on the patient, with the ED doctor directing the care. A Lucas device (a robotic contraption) was strapped on the patient’s chest doing the mechanical cardiac compression, while other personnel were hovering around the patient assisting in any way they can.

After about 30 minutes of CPR, which is already an eternity of CPR time, we still could not establish a stable cardiac rhythm. We probed the chest with an ultrasound while the Lucas device was temporarily paused, and it showed that there was no heart motion at all. In simple terms, the patient was dead.

But before we completely pronounce the patient dead, one of the team members suggested that we get the patient’s husband to the room so he can be present. So the CPR continued until the husband can be at the bedside. It is now acceptable to have family members in the room when CPR is in progress.

One study from France that was published in New England Journal of Medicine (a leading medical circulation) in 2013 showed that family members who watched CPR on their loved one have far less post traumatic stress disorder three months later. Similar later studies support this as well, stating that family presence can help ameliorate the pain of the death through the feeling of having helped support the patient during the passage from life to death and of having participated in this important moment.

When the husband came in to the resuscitation room, he was tugging along their son, who was clutching a Teddy Bear. The boy, I believe, was about 8-10 years old. The moment I saw the boy walked into the room, my heart sank. I felt that the boy should have been left outside and should have not witness this traumatic event. But it was too late.

Perhaps whoever spoke to them outside the room did not suggest that it was better for the boy to stay outside. Perhaps there was nobody who can stay with the boy outside the room. Perhaps it was the father’s decision to bring along the son to the room. Perhaps they have no idea of what they would witness. Or perhaps the father was not thinking clearly as he had more serious issues to grapple.

The boy was squirming while his father was holding him, and was shielding his eyes with his Teddy Bear. Finally he was able to escape from his dad’s grasp and he dashed out of the room with his bear. Was the scene too much for the boy or too much for the bear?

The father stayed in the room though until we finally stopped the CPR and pronounced the patient dead.

To lose a mother was already a tragedy. But to lose a mother at such a young age and witnessed it as she die was really heartbreaking.

Many of us feel that we should try to shield children from the painful facts of life. We believe that children should be all fun and play, sugar and spice, and everything nice. Yet for some kids, sooner or later, they have to deal with the ugly realities of this world.

I know Emergency Rooms are not for Teddy Bears. But I do not care about the bear. I care about the boy behind the bear. Besides the comfort from his cuddly companion, I pray that he finds lots of love and reassurance from the remaining family he has.

5354f750a2816333f42efbeeacb4e244

(*photo from Pinterest)

Friday the 13th

13 July 2018

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Today is Friday the 13th. For superstitious folks out there, please beware!

Many people consider this as the unluckiest day in the calendar. According to an article from National Geographic, the fear surrounding Friday the 13th may be rooted in religious beliefs. It has to do with the 13th guest at the Last Supper, who is Judas, the apostle who betrayed Jesus, who in turn was crucified on a Friday.

The fear for Friday the 13th is so widespread that psychologists even have a term for people who suffers from it: paraskavedekatriaphobia. That’s a mouthful. The irrational fear for the number 13 is called triskaidekaphobia.

Irrational or not, many buildings don’t have a 13th floor. So elevators will go from 12th floor and then skip to 14th floor. In 2002, based on an internal review of records, a report from Otis Elevator Company estimated that 85% of the buildings with Otis brand elevators did not have a floor named the 13th floor.

Most hotels have no room 13. Many hospitals have no room 13. Even our own ICU has no room 13. So you think medical institutions are not superstitious? Though I get it, I think patients or their family will freak out if they learn that they are being admitted to ICU room 13.

Speaking of ICU, I have been the ICU attending for the past couple of weeks now. It has been busy, plus you know that July is when the new residents or physicians-in-training start, so it is an added stressor to me. To destress, I blog.

It is known in the medical world that the rate of medical errors and surgical complications spikes in the month of July. The hospitals even have a name for it: the July effect. This is not due to a mystical phenomenon, but due to a very logical reason stemming from the inexperience of the newbie doctors.

Thus I am supervising and watching my residents like a hawk this time of year. And today, Friday July 13th, I will even be more vigilant.

To end, in connection to mystical events, I would like to share a story that was posted by a batchmate in the group chat:

Murder Mystery at the Makati Medical Center

There was this case in the hospital’s Intensive Care Unit where patients always die in the same bed on Sunday mornings at 11 A.M., regardless of their medical condition. This puzzled the doctors and some even thought that it had something to do with the supernatural or even murder. No one could solve the mystery as to why deaths happen on Sunday at 11 A.M.

Mr. Licauco, Fr. Bulatao and the Ateneo paranormal folks were called. They arrived armed with special photographic equipment, infra-red devices and motion sensitive radar to detect any presence.

So on the next Sunday morning, a few minutes before 11 AM, all the doctors and nurses nervously  waited outside the ward to see for themselves what the mysterious phenomenon was all about. Some were holding wooden crosses, strings of garlic, amulets, prayer books and other holy objects to ward off evil spirits.

Just then, the clock struck 11. And then……..

Mang Joe, the part-time Sunday janitor, entered the ward, unplugged the life support system and plugged in the vacuum cleaner.

Have a happy Friday the 13th folks!

happy-friday-the-13th-1

(*photo from the web)

Bad Night

19 March 2018

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We’re sleeping in the hospital now. It started this year. Our calls are now in-house as the hospital wanted us to physically man the ICU 24/7. This is besides the resident-on-call who is already in the ICU. Sleeping in a call room of the hospital about once a week, makes me feel like I’m a resident or a doctor-in-training all over again. But I understand, the times are changing, the practice of medicine is changing, and the liability of this profession is changing. We have to adapt.

Few weeks ago, I walked in at 5 in the afternoon to take over the call for the night. The moment I walked in, I was called by my partner who was in charge of the ICU all day, to meet her in the cardiac catheterization lab (cath lab) so she can sign out to me the patients.

When I came down there, I found out that there were two patients currently in the cath lab that were both going to the ICU.

One was a man in his 40’s with severe pancreatitis and was having multi-organ failure, including severe respiratory failure that was not improving even if he’s on mechanical ventilator. So large-bore catheters were being inserted in his neck and groin, so we can place him on Extracorporeal Membrane Oxygenation or ECMO (see previous post about ECMO).

The other patient in the cath lab was a man in his 70’s that had a cardiac arrest. He required prolonged resuscitation. The cardiologist was putting an Impella device in his heart, a device placed inside the left ventricle of the heart to help pump out blood. When that’s done, the patient would be transferred to the ICU. He was already on ventilator as well.

impella

Impella device (photo from Medscape.com)

Then my partner told me that there were two more patients already in the ICU that she was called to evaluate, but did not have the chance to see yet, as she was stuck in the cath lab for the last hour or so, assisting in this patient that require ECMO.

One patient in the ICU was a transfer from another hospital, he had fever with very low blood pressure. He also has advanced esophageal cancer and on chemotherapy. He has no immune system to fight the infection. After the initial work-up, he turned up to have Influenza A.

The other patient in the ICU to see was a trauma patient, who was in a vehicular accident. He had several broken ribs and a collapsed lung. The Trauma Team has admitted the patient, but they were having difficulty oxygenating him despite being on a ventilator, thus they were consulting us for assistance.

She also told me that we have 21 other patients in the ICU that were relatively stable at the moment, but can turn volatile anytime, besides the four new ones that needed my immediate attention.

Lastly, she said that she declared the patient in room 15 as clinically brain-dead, hence, legally dead. Patient was a young lady in her 20’s who overdosed on drugs, and unfortunately was not found immediately. When she was brought to the hospital, she was too far gone. The patient’s family agreed to have her organs donated, so she’s still on life support until they can harvest her organs. The Transplant Team wants us to do a bronchoscopy to assess if the lungs and airways were normal and appropriate for harvest.

Hearing the long laundry list, I thought to myself, this would be a long night. That’s not even considering more new patients that may come.

Shortly thereafter, I got a call from the Transplant Team asking me when could I do the bronchoscopy in room 15. I told them that I would take care of some more pressing issues, and when I get free, I’ll do it, but I already contacted the endoscopy nurse to come and set up for the scope. I thought, let me take care of the living first, before I deal with the dead. But I didn’t tell them that.

When I came up to the ICU, the patient from the cath lab who had a cardiac arrest and got the Impella device, also arrived in the ICU. I evaluated the patient, and it was obvious he was doing poorly. He was requiring 3 IV drips (1 drip is a poor sign already, let alone 3!) to keep his blood pressure up. This was despite the device in his heart to pump blood. He already looked dusky and gray.

I sat down with the patient’s family, and told them that the odds were not in our favor. I don’t believe he would survive the night. I also told the cardiologist that I felt bad for him as well, as all his efforts may be all for nought.

The patient died less than 2 hours after he came up from the cath lab.

While I was working on this patient, I got a call from the Emergency Department about a new patient that needed to come to the ICU. The patient was in her 80’s, with advanced dementia, and was from a nursing home. She was septic, perhaps from a urinary tract infection. I may think that she was not the best candidate to spend my limited time and resources at that time, but who am I to say who lives and who should not. A life is still a life. So I sent my resident to evaluate and admit the patient.

When the ECMO patient came up to the ICU from the cath lab, that was where I spent most of my time and effort. We even consulted Nephrology to start the patient on dialysis too. However, despite all intervention, with ECMO, dialysis, mechanical ventilator, and several IV medication drips, the patient continued to deteriorate. I felt like we’re just spinning our wheels without gaining any traction. I noticed that the patient’s heart rate and blood pressure were drifting down. Definitely an ominous sign.

I gathered the patient’s family and brought them at bedside to the patient. I honestly told them, there’s nothing else we could do.

The patient died 5 hours after he was hooked up on ECMO. I felt defeated and deflated with these events.

In between the deaths of my 2 patients, I was able to squeeze time to do the bronchoscopy on room 15. It looked healthy, so I relayed to the Transplant Team, they can perform their harvest.

After midnight my night quiet down a bit. I caught up and was able to see all the patients I needed to see. When I had some down time, I reflected on what I accomplished and those I failed to accomplish.

At least I was able to stabilize the elderly patient from the nursing home, right? She will get better from the infection, then she’ll go back to the nursing home in a few days, and spend the rest of  her existence in bed with very poor quality of life due to her advanced dementia. How about the patient with metastatic esophageal cancer? He’ll get better from the influenza. But he still have to deal with his cancer and more chemotherapy with bleak hope of a cure. And the sad list just goes on and on.

Nights like this, make me question if it’s really worth doing this. I got several more pages through the night, but I survived to see the morning.

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A couple of weeks after that disheartening night-call, I received a letter. It was from the Organ Donor Network. They were thanking me for my effort in assisting to obtain donor organs for transplant. Because of this, they informed me that a young man was given a new lease in life as he received new lungs. There were other patients too that received “gifts of life” with their transplanted heart, kidneys, cornea and so on.

I then realized that even in patients who died under our care, we can make a difference. It still worth it after all.

(*photo of dawn, taken with an iPhone)

Concert in the ICU

24 February 2018

8 Comments

Inside ICU room 34* of our hospital, there is an ongoing musical performance. One young man is playing an instrument and another young woman is singing.

Music therapy is a burgeoning field of science. We have known since the history of man, that music has a healing property. During Biblical times, young David was summoned to play his harp whenever King Saul of Israel was stressed and troubled. Pythagoras, Plato and Aristotle all wrote about how music affects health and behavior.

Now, modern science and current medical studies back this up. In Harvard’s Health Blog, one article mentioned that music therapy can aid pain relief, reduces side effects of cancer therapy, restores lost speech in people who suffered stroke, and improves quality of life for dementia patients among other benefits.

One study from Austria conducted in General Hospital of Salzburg, has found that patients who are recovering from back surgery had increased rates of healing and reported to have less pain when music was incorporated into their rehabilitation process. I consider Austria a leading authority in music science, after all that’s the country where great classical composers like Mozart, Strauss, Schubert, Czerny and Haydn all came from.

Several years ago, when I was doing my Critical Care Medicine training in New York City, we had a music therapy team that plays to our patients in the ICU. The team, composed of a flutist, a violinist and a cellist, would go from room to room in the ICU and would play for about 5 to 10 minutes in each room. Even if the patient was medically sedated or comatose, they would do it anyway. It was soothing for us medical staff as well, when they come, as we got to listen to their music.

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ICU music therapy (image from wakingtimes.com)

Since music therapy is the in-thing right now, I even told my daughter to look into a career in this field, that is if she would be interested, since she is pursuing a music degree. Perhaps I can have my own therapy someday.

Back to our ICU 34, the mini-concert though is not done by our hospital’s music therapy team, for we don’t have an official team like that as of yet. The music is being performed by the patient’s son and daughter who are both college-age and are both enrolled in music degree.

The son is playing his French horn, and the daughter is singing. The daughter even composed a special song for her mother, our patient, and would sing it for this special occasion.

However, their mother, who is only 44 years of age, is not going to wake up again. Not even with the beautiful music rendition from her children or any music therapy session on earth for that matter. She suffered a devastating head bleed which caused her to be in perpetual comatose with no hope of meaningful recovery. She is just being kept alive by life-sustaining machines.

The whole family agreed, that their mother would not choose to live a life in a vegetative condition like this. So they decided that they will take her off all life support. But only after they perform their mini-concert in her presence. They would like to dedicate their music as a send off, as she passed on beyond this world.

Sometimes music can be a therapy too for the broken-hearted and for those who are left behind.

(*ICU Room number was purposely changed)