Question and Answer: Sakit sa Balakang (2)

I have been asked diverse questions on this blog, from how much is a kilo of chicken liver, or where to get anting-anting, to how to counter a kulam. But there are some medical questions as well.

A certain Adrian, asked me a question regarding his condition, and I would like to answer him through this post. I hope the information here would help him and others who may have a similar problem.

Hi Doc,

May ilang buwan na din po nasakit yung right side ng balakang ko pati po yung kanang binti ko. Ngayon nararamdaman ko parang lumalala na kase diko na mapaliwanag yung sakit, masakit na nangangalay. Nung una po nangangalay lang yung right leg ko kaya binalewala ko lang, sinisipa-sipa ko lang hanggang sa tumagal nararamdaman ko na lumalala na. Hindi na ko makatayo ng matagal kase nangangalay yung binti ko at sumasakit din hanggang sa pag upo yung balakang at binti ko sabay sumasakit na parang na-ngilo ūüėĎ.

Pati sa pag higa nangangalay pa din kaya palagi ako nakatagilid, hanggang sa pag gising at pag bangon ko doc masakit. Hindi ko na kaya iunat yung dalawang binti ko kase sumasakit ng sobra yung likod ko dun sa gitnang part ng balakang. Pati pag yuko masakit parang konektado sa buto pababa ng binti yung sakit kapag nayuko ako ūüėĘ.

Doc may simtomas ako ng scoliosis. Dahil po ba dun yon kaya sumasakit yung balakang at binti ko?

Nagpa check-up na po kame sa doctor. Nag pakuha na po ko ng ihi at dugo at wala naman nakita. Niresitahan lang ako ng gamot tapos nag pa x-ray ako. Hindi naman ganun kalala yung scoliosis ko pero napansin ko na hindi na pantay yung balakang ko, doc mejo mataas yung right side. Patulong naman doc ūüėě.

Salamat po.

Salamat Adrian sa iyong tanong. Dahil medyo extensive and pagkaka-describe mo ng mga sintomas mo, kaya may idea ako kung anong nangyayari sa iyo. Siyempre iba pa rin yung tunay na harap-harapang pag-tingin at pag-examen sa iyo ng duktor.

Una sa lahat ang tungkol sa scoliosis. Scoliosis is defined as lateral curvature of the spine. Maraming maaaring sanhi ng scoliosis, tulad ng neuromuscular disease (tulad ng polio), vertebral disease (tulad ng osteoporosis, tuberculosis of the spine, Rickets), disorder of connective tissue (gaya ng mga genetic disorder na Marfan’s syndrome at Ehler Danlos syndrome), at iba pa.

Kadalasan ang pinakaapektado ng scoliosis ay ang thoraco-lumbar area. Kung malala talaga ang curvature ng scoliosis, maaring maapektuhan ang mga chest organs tulad ng baga at puso, dahil unti-unti silang naiipit o nasasakal. Maari ring maapektuhan ang mga muscles ng braso at hita at ito’y humihina.

Ang evaluation ng scoliosis ay sinusukat kung gaano kalala yung angle ng curvature. Kung hindi naman masyadong malala, ay pwedeng conservative management lang, tulad ng mga strengthening exercises and therapy sa spine o kaya ay paglalagay ng brace.

Kung talagang malala naman ang curvature, ay maaring lagyan ng bakal (rods) ang spine para ito dumiretso. Payo ko lang, huwag lang sa magbabakal o sa talyer kayo magpalagay ng bakal sa likod, kung hindi sa kwalipikadong orthopedic surgeon.

Adrian, hindi ko matiyak kung ang nararamdaman mo ay sanhi ng iyong scoliosis. Pero sa pagkaka-describe mo, ang aking hinala ay lumbosacral radiculopathy ang iniinda mo. Ibig sabihin, parang naiipit na yung ugat (nerve root) sa may vertebrae mo sa lumbosacral area, kaya’t parang nangangalay, sumasakit, at nanghihina ang iyong likod, balakang at mga binti.

Ang mga pinakamadalas na sanhi ng lumbosacral radiculopathy ay vertebral disc herniation (disc bulging out causing nerve root compression) at spondylosis (narrowing of the intraspinal canal due to degenerative arthritis). Mga iba pang sanhi ng lumbosacral radiculopathy ay infection, inflammation, neoplasm (tumors), at vascular disease.

Ang pinaka-magandang evaluation kung hinihinalang may lumbosacral radiculopathy ay CT scan o kaya MRI of the spine. Ang simpleng x-ray lang ay maaring hindi sapat na evaluation.

Hindi naman lahat ng sanhi ng lumbosacral radiculopathy ay kinakailangan ng surgery. Minsan pwedeng gamot lang gaya ng anti-inflammatory agents, o exercises, o physcial therapy ay uubra na. Baka makatulong kahit si Mang Kepweng.

Pero rinirikumenda ko pa rin na mag-follow-up ka sa iyong lokal na duktor, at kung kinakailangan kang i-refer sa espesyalistang nararapat, ay ito ang pinakamabuting gawin mo.

Adrian, sana ay nakatulong ito sa iyo. At paki-padala na lang yung dalawang hopiang munggo na bayad ko. Salamat po.

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.

 

Daddy is Home

It was a long day.

In reality, it had been a series of long days, and long weeks, of a long month. You see, I have been the ICU attending physician for the past 4 weeks, and the stress of work and taking care of very sick patients was like a dragon breathing down my neck. It was wearing me down.

I came home feeling depleted and defeated.

Even though it was late, my wife and kids were just happy to see me home. My wife has even waited for me to eat dinner, though I knew she was tired and hungry too. It felt good to be home after such an arduous day.

Before we went to bed, we had a family prayer, just like every night.¬†My son led the prayer, and I heard him say, “Thank you God, for bringing Daddy home.”

Suddenly, all the day’s cares melted away. I felt so blessed.

As I rest my head on the pillow, I thought of the other fathers in the world that were not able to come home. The overseas contract workers. The soldiers deployed somewhere away from their home. And the others for some reason or another that cannot come home tonight. Including our patients that were languishing in the ICU. I felt sad for them and their kids who cannot say the prayer of thanks that my son did.

I especially thought of the father I took care earlier today. He will not come home. Ever.

May he rest in peace. And I pray that his family find peace.

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waiting for daddy

(*photo from here)

When Doctors Cry

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

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

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

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

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

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

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

The situation had turned from serious to grim.

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

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

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

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

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

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

That son, was now in our ICU.

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

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

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

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

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

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(*names have been changed)

Bloody Sunday

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

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

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

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

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

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

This is not a good way to start my day.

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

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

This definitely is not a good day.

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

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

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

This day is really becoming a bad day.

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

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

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

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

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

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

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

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

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

One-Handed Ninja

Black Ninja is hurt.

Friday morning last week, I started feeling some soreness in my right wrist. I did not pay much attention to it and performed my work as normal. However by the end of the day, the right hand became painful enough that I had difficulty using it. That night, my hand was swollen and red. The pain kept me awake, and not until I took an anti-inflammatory pill, did I experienced some relief.

I was miserable over the weekend due to the severe wrist pain. I was unable to type on the computer keyboard, nor play the piano, nor do much of anything (not even play the Fruit Ninja) with my right hand. And I am right-handed too. By the way, when I broke my arm when I was in kindergarten and had my arm in a cast for 6 weeks, I learned to use much of my left hand, including writing and drawing.

Back to my recent injury, the daily grooming ritual became painstakingly slow as well as painful – brushing my teeth, taking a bath, washing, combing my hair….. Oh I forgot, I have no hair to comb! And for traditional Filipinos who are not content with just using toilet paper but instead uses tabo (water dipper) and soap to wash after using the restroom, performing this ‚Äúcultural‚ÄĚ hygiene was almost impossible with one hand!

Doing things with one good hand, made me understand how we take for granted things that people with only one hand, or no hands, or with arthritic hands struggle every single day. I detested clothes with buttons! Good thing my wife assisted me to some extent, getting dressed.

My wife even urged to take me to the Emergency Room or Urgent Care (it was a weekend, so doctor‚Äôs offices were close), so a “real” doctor beside myself can evaluate my swollen hand. But being a stubborn patient, I reasoned: what can they do for me that I cannot diagnose and take care myself? I got a wrist splint from the pharmacy and continued my intake of ibuprofen.

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my splinted hand

Monday came and I went to work as usual. My rotation was the ICU, and also had a few bronchoscopy scheduled that day. When colleagues asked me what happened to my splinted hand, I told them that I sprained it sparring with Pacquiao. That will keep their distance. When patients asked me how did I injured my hand, I told them, I dealt with a patient who was not following my orders. That will keep them in line.

Then as the day went on, I surrendered to the fact that I was really having difficulty performing the bronchoscopy and other procedures I needed to do. I was humbled that I could hardly intubate (placing an endotracheal tube for breathing) a patient in an emergency situation. I need two healthy hands to do my work!

That’s when reality set in that I have to seek help. I showed my swollen wrist to one of our trauma surgeons in the ICU for a curbside consultation. He told me that it was not a simple carpal tunnel syndrome which I first thought it was, as that does not cause redness nor significant swelling. He thought it may be bursitis or tendonitis, but recommended that I see a hand surgeon, just to be sure.

I am now fully cognizant that I should not let this be a career-ending condition.

I called my office and requested to clear my schedule so I myself can see a doctor . When I called the hand surgeon‚Äôs office they initially told me that they can see me in 3 weeks. Three weeks?!! I “kindly” protested and told them that I am also a doctor, so they gave me a special consideration. I was given an appointment in 3 days.

In the meantime, as I waited to see the specialist, my hand started to get better. The redness improved, and the swelling went down. The pain had decreased as well, that I could use it more with less inconvenience.

By the time I saw the surgeon, my hand was almost back to normal, except for a minimal tenderness in one area. I even thought of canceling the appointment, but what the heck, I already cleared my schedule to have an afternoon off just for this.

After taking my history of what possibly could have precipitated my injury, and after examining my hand and taking hand x-rays, the surgeon diagnosed me with tendonitis. Worse scenario, he told me, that I might need a steroid injection in the wrist. But since it was already healing, he just advised to continue the wrist splint and anti-inflammatory meds, things that I have been doing all along. I sighed with relief, no surgery required!

The possible culprit of my injury? The push-ups. The hand surgeon told me that doing the open-palm push-ups can strain the wrists. Does this mean no more push-ups for me? No way! I can still do knuckle push-ups. Or better yet, use handle bars for this exercise.

As for wearing the hand splint, maybe I should get this kind…..

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Ninja hand claws

My Restive Dance

“Mom, my legs feel funny. I have to move them to make it go away.” That was what my son told my wife a few days ago. Sadly to say, I think he inherited my condition. Poor kid, he has to deal with this. And he is not even 10 years old.

I have Restless Leg Syndrome (RLS). At least that’s my excuse for being fidgety.

I am not the¬†first one in my family with this condition.¬†I remember when we were very young, my father will have this “fits” at night that he had to move his legs like he was swimming in bed. My mother said that he¬†was “balisa” (Tagalog for restless), and¬†chalked it¬†all up to¬†stress. My dad would ask me and my little sister to massage his legs with our little hands, and that seemed to soothe him. We had no idea of what RLS was at that time.

When I was in college, I started noticing the same symptoms. But not only at night, but also during the day. I had to move my legs a lot, to be comfortable. I always do the “kuyakoy” (legs shaking) whenever I was sitting. I thought that was just normal.

Once, when I was in medical school, we were taking an exam, and I was constantly jiggling my legs to help me relax. Another classmate who was sitting at the other end of the table was doing the same. The whole table was shaking like an earthquake, that the one who was in the middle, complained and called our attention. I did not suspect that I have RLS then yet.

Now that I am older, I still have antsy legs, if not even worse. There were episodes at night when I was lying in bed that I would have this urge to move my legs (sometimes arms as well) and I would kick and flail vigorously like a fish out of the water. The difference now is at least I understand what RLS is.

RLS is a disorder in which there is an irresistible urge or need to move the legs to relieve the unpleasant sensation. It can develop at any age and generally worsens as one gets older. It can disrupt sleep and can cause daytime sleepiness and fatigue. It is one of the more common condition of sleep disorders we see. It is ironic that as a sleep specialist, I myself suffer from this condition.

In many cases, no known cause for RLS can be identified. Though studies have shown that it may be related to imbalance in the neurotransmitter dopamine in the brain. Dopamine is a chemical released by the nervous system to send messages to control muscle movement.

RLS for most part is not a serious condition, but more of just an annoyance. Though sometimes it can be related to other medical conditions, like peripheral neuropathy, iron deficiency, Parkinson’s disease, and renal failure. Pregnancy for some reason can worsen this syndrome.

I know I don’t have any other medical conditions related to RLS. I don’t have iron deficiency as I eat steel nails for breakfast. Not! I am also definitely sure that I’m not pregnant, for the last time I checked, I am a male. Just blame it on my genes.

RLS can be hereditary and runs in the family in at least half of the cases. Scientists have identified the site in our chromosomes where the genes for RLS may be located. So the problem is not just in the legs or in the brain, it is deep in our genes.

There are several medications that can be effective for RLS. Moreover there are plain lifestyle changes and home remedies that can help people with this disorder, like warm baths and massages, heating pads, relaxation techniques, exercise, and avoiding caffeine, alcohol and tobacco.

You may say, “Physician, heal thyself,” but I am not prescribing myself any medications. At least not yet. Besides I am not fond of taking pills. I prefer using lifestyle and simple remedies. I find that listening to relaxing music is very effective for me. A caressful rubbing from my wife also helps. If nothing else works, I just do my ‘horizontal’ Celtic dance in bed. And I am not even Irish.

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The real Irish dance (photo from Riverdance)

My wife also suffers from some form of restless legs. She just have to walk it off. In the mall. Shopping. Is that genetic too?

Angel’s Wings

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

* see related post about bronchoscopy here

** see related post about hyperbaric oxygen therapy here

Of Monkeys and Men

Last week, I saw a patient in the hospital that our group was following for consult. Though it was my first time to see the patient, she had been in the hospital for almost a month already. A little longer more and they could have named the room to her.

Our patient was morbidly obese and had constant difficulty breathing. She was on 10 liters of oxygen continuously, and supposed to wear a CPAP at night for her sleep apnea, though she hates it and not compliant with it. She also had decompensated congestive heart failure, poorly controlled diabetes, and unrelenting seizures. We were unable to discharge her home due to her persistent poor condition.

When I entered the patient’s room, she was having breakfast: heaps of bacon strips (I believe it was more than 10 strips), a large serving of scrambled egg, four heavily buttered toast, a good size donut, and 2 small cartons of milk. My jaw dropped in disbelief! How could we allow this in a patient who was already having serious problems, and in the hospital at that?

I was tempted to yank the tray away from her. And I did, but just to examine her. She was obviously annoyed that I interrupted her breakfast, or should I say suicidal meal.

There was a recent research in the UK that found that about 75% of hospital food has more saturated fat than Big Mac, and 60% of hospital dinners have dangerously high salt levels. It is a fact that our hospital food is so unhealthy, that patients might be safer to be at home than to be in the hospital.

I worked in a hospital before in New York city that has a fast food chain in their cafeteria. It was ironic that you can find both McDonald’s and the cardiac cath lab in the same floor of the hospital. So you can eat your fat greasy burger and if you happen to suffer a heart attack, they can just wheel you straight down the hall into the cath lab for your angioplasty.

There was a study conducted more than three decades ago that was funded by the National Institute of Health, about feeding a fatty diet, like the regular hospital food, to a group of rhesus monkeys. The monkeys probably had a blast with all the banana milkshake and crispy bacon instead of their normal diet of bananas and occasional insects. After 16 months of eating the fatty foods, one of the monkeys had a first heart attack.

As the study continued, eleven more monkeys had suffered similar heart attacks. This study clearly demonstrated the relation of diet and heart disease. So the take home message from this study for you is if you get hospitalized, don’t stay more than 16 months in the hospital, or it will kill you. Huh?

Back to my patient, after seeing her breakfast tray, I quickly reminded her that she was not doing herself a favor by continuing to eat all these high fat foods. Just looking at it gave me a chest pain. However after I walked out of her room and changed her diet to a heart healthy one, I was called by the nurse later on, that the patient simply refused to follow my diet order. She just wanted to eat what she wants to eat.

I felt displeased initially, but more saddened afterwards for my patient. She is not an isolated case. Her attitude is the same as the pervading attitude of our society today. We are inundated with advertisement of foods that are rich in fats and sugar, people indulging on the “good life,” and yet our commercials show models with thin and beautiful figures. Somehow there is a great disconnect here.

For the health professionals, we practice salvage medicine, where we kind of put a band-aid in a hole on a dam that is about to explode. Somehow advising people to eat the right food and live healthy to prevent diseases becomes secondary. Besides we can always prescribe Lipitor for their high cholesterol and give them insulin injection for their diabetes. It is good for the business and for the pharmaceutical companies, right?

In our society we are conditioned and deemed it acceptable to crack the chest open to do the coronary bypass surgery for a heart disease, or whack out or staple a part of the stomach for gastric bypass procedure to help patient lose weight as mainstream medical practice. Yet telling patients to adhere to a lifestyle change like converting to a vegetarian or vegan diet to reverse their disease, is considered too extreme and radical.

About the monkey studies again, part of the study was switching back their diet to low-fat diet, perhaps back to their normal food of bananas and other fruits. I am not sure if the monkeys protested, as they got used to the hamburger, fries and milkshakes. But what it showed is that with the healthy low-fat diet, there was a regression of the cholesterol build-up (atherosclerosis) in their arteries Рproving that fatty diet can cause the disease and switching to a healthy diet will reverse the disease.

We know we can do something for atherosclerosis or hardened arteries. But can we do something for hardened attitudes?

Now, if I could also curb my cravings for a Whopper…….

(*photo from here)

Reason to Continue

Last week I saw a patient in our clinic for follow-up after he was discharged from the hospital more than a month ago. Let’s just say I was not expecting to see him this way.

This was a man found lying unconscious in his driveway amidst the pouring rain. He was brought in the emergency room comatose, got intubated and was hooked on a ventilator. He was subsequently admitted to our ICU where he spent 4 long and difficult weeks.

He was on life support for most of his ICU stay and at some point he was requiring the highest oxygen and mechanical ventilator support we can give him. He was on multiple medication drips to keep his vital signs from flat-lining. For a couple of weeks his mentation fluctuated between unresponsiveness, extreme agitation, and light sedation. It was touch and go for him for a time. And many thought, including me, that he will not make it.

But he did!

Of course he spent a few more weeks in the hospital and rehab after he went out of the ICU, but he eventually went home.

When I saw him last week, he looked like a different man compared to when I saw him in the hospital. He was walking without assistance and even able to do fast-walk. He was talking clearly as his tracheostomy site had completely healed. His mental faculties were sharp and he really looked good.

He was very grateful for all our efforts and that he was given a second lease on his life. I told him that I wish I can take credit for this, but I can’t. His recovery was beyond me. It is amazing how a human body can heal and recover.

In the past 10 years that I have been in practice, the patients that had been this critically ill and required prolonged ICU stay, and was able to come to see me for follow-up in our clinic are fewer than my fingers. And for this patient to come back almost without noticeable disability, is simply sweet.

I know my ICU career is most of the times trying, and at times downright depressing . However, because of the few cases, like this one, gives me the drive to continue on what I am trained and entrusted to do.