Huwag Kang Puputok

Siguro lahat tayo ay may kakilalang tao na malakas magpaputok. Hindi rebentador o kaya baril ang ibig kong sabihin. Ang tinutukoy kong putok ay iyong nakakainis na amoy mula sa katawan. Sa ibang salita, body odor o B.O.

Kung ikaw ang may putok, sana makatulong sa iyo ang artikulong ito.

Isang senaryo sa Pilipinas: nasa loob ka ng jeepney.  Dahil sa sobrang init at trapik ay tumatagaktak ang pawis ng lahat. Tapos, may mamang sumakay at sumiksik sa tabi mo. Pag-arangkada ng jeep, itinaas ng mama yung kanyang braso para humawak. Sakto naman yung kanyang kili-kili sa mukha mo. Pag-hinga mo, boom! Parang gusto mo nang tumalon sa jeep, o kaya’y ilawit ang iyong ulo sa labas at pipiliin mo pang suminghot ng maiitim na usok ng jeep at bus, kesa mamatay sa putok ng katabi mo. Naka-relate ka ba?

Ano ba ang sanhi ng putok?

Ang medical term sa putok o anghit, ay bromhidrosis. Ito at ang masangsang na amoy dahil sa pawis. Ang pawis ay mula sa sweat glands. Maaring tanungin mo, bakit ba ginawa ng Diyos ang sweat glands kung ang magiging sanhi lang nito ay anghit?

Ang sweat glands ay importante sa kalusugan at mismong buhay ng tao. Ito ay para sa thermoregulation ng ating katawan. Kung hindi tayo papawisan tayo ay mag-o-overheat at maaring mamatay, parang makina ng kotse na kailangan ng tubig sa radiator para hindi pumalya. Kaya’t sa ayaw mo man o gusto, hindi lang si Andres Bonifacio, kundi tayong lahat ay anak-pawis.

Isang klase ng sweat glands ay ang apocrine glands. Maraming apocrine glands sa axillary area (kili-kili) at pubic area. Maliban sa pagse-secrete ng pawis, ito ay nagse-secrete din ng hormone, na ang tawag ay pheromones. Ito ay may kakaibang amoy. Ang pheromones ang siyang naamoy ng mga hayop, para ma-attrack sa kanilang ka-partner. Ito ang dahilan kung kaya kahit sa malayo ay nakakaakit ang paru-paro, baboy-damo, o aso ng kanilang kalaguyo.

Pagnagbinata at nagdalaga na ang tao, dumadami ang apocrine glands at secretion nito. Pero sa ating tao, hindi gaya sa hayop, hindi masyadong kailangan ang pheromones upang humanap ng ka-partner. Kasi may on-line dating site na (aha-ha). Isa pa, mas mabisa siguro ang bulaklak at chocolates kesa pheromones para sa tao.

Balik natin ang usapan sa pawis. Sa katanuyan ang pawis ay walang amoy. Ngunit kapag may mga bacteria sa ating katawan, na nagre-react sa ating pawis o hormone na galing sa ating sweat glands, lalo na sa apocrine glands, sa halip na walang amoy, nagkakaroon ng mababantot na mga chemical. Mga chemical tulad ng ammoniaE-3-methyl-2-hexanoic acid at 3-hydroxy-3-methyl-heaxnoic acid, (konting chemistry lesson lang po). Ito ang isang sanhi ng putok.

Minsan ang ating diet, gamot, mga toxins, metabolic disorders, at ibang sakit, tulad ng liver at kidney failure, ay nagdudulot rin o nagpapalala ng mabahong amoy ng ating katawan.

Ang bromhidrosis ay maaring makaapekto sa kalusugan. At sa kalusugan din ng ibang kawawang taong makakaamoy. Pero maliban sa pisikal na kalusugan, ang taong may bromhidrosis ay maari ring magdusa ng social isolation at low self-esteem. Sino nga bang gustong mag-hang-out sa taong may putok?

Anong dapat gawin, o ano ang mga lunas sa isang taong may bromhidrosis?

1. Maligo ng regular.

Malaki ang nagagawa ng personal hygiene sa putok. Dahil may kinalaman ang bacteria sa masangsang na amoy, mababawasan ang bacteria sa katawan kung maliligo ka nang regular. Hindi ko sinasabing maligo ka nang apat na beses isang araw, pero sikapin kahit minsan sa isang araw. Maari ring makatulong ang pag-gamit ng anti-bacterial soap.

2. Gumamit ng anti-perspirant at deodorant.

Ang anti-perspirant ay nagpapabawas sa pagpapapawis. Ang common ingredient ng mga antiperspirant ay aluminum salt. Ang “tawas” na popular na ginagamit para sa anghit ay hydrated aluminum potassium sulfate, at ito’y mabisang anti-perspirant. Ang deodorant naman ay mga pabangong nagkukubli sa mabahong amoy. Marami sa mga produkto ngayon ay magkasama na ang anti-perspirant at deodorant.

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Kryptonite? No, Tawas Crystal!

3. Hair removal

Dahil ang buhok ay maaring mag-trap sa bacteria, maaring makatulong ang pag-aahit ng buhok sa kili-kili. Kaya pwedeng slogan: May anghit? Mag-ahit!

4. Palitan kaagad ang damit na pinagpawisan.

Panatilihing tuyo ang katawan. Hindi sa dahil ikaw ay mapupulmonya kung matuyo ang pawis. Pero mababawasan ang mabahong amoy-pawis kung huhubarin mo kaagad ang basang damit na pinagpawisan mo. Isa pa, gusto ng bacteria ang mabasa-basang environment.

5. Iwasan ang mga pagkaing may maaamoy na spices.

Siguro naobserbahan mo na rin na may mga pagkaing amoy kili-kili. Hindi ko ikinakaila na masarap ang mga ito. Subalit kung amoy kambing ka na, bawasan mo na siguro ang mga maaamoy na spices tulad ng curry, cumin, sibuyas at bawang. Pero pwedeng rason na OK lang mag-amoy bawang, kasi at least walang aaswang sa iyo.

6. Huwag manigarilyo.

Hindi sa nagpapabawas ng pawis ang hindi paninigarilyo. Pero ang sigarilyo ay isang sanhi ng mabahong amoy. At mabahong hininga. May B.O. ka na nga, may bad breath ka pa, eh kawawa ka nang talaga.

7. Removal of apocrine glands.

Sa malalang bromhidrosis, ay maaring i-offer ng mga duktor ang pagtanggal ng apocrine glands. Maari itong tanggalin sa pamamagitan ng surgical excision, liposuction, o laser therapy. Hindi dahil nabasa mo rito ang laser therapy, huwag mo sanang tangkaing na sunugin ang iyong kili-kili. Please consult your doctor.

Hanggang dito na lang at sana ay may natutunan kayo. At tandaan, hindi lang sa Bagong Taon po bawal magpaputok!

(*photo of tawas from the web)

Barriers

He was always there.

Constantly standing outside the ICU room, that is closed by a sliding glass door. He looked worried. The expression on his face was if he was begging for any news or information to any hospital staff that goes in and out of that room. Except that even when we tried to talk to him, he does not comprehend any word we say.

He does not speak English. Yet I believe he had a sense of what was going on. I think he somehow knew that something very bad was going on. Except nobody can really confirm it to him in a language he can understand.

His wife was inside that ICU glass room. Lying in bed hooked to several monitors and to a life-sustaining machine. Infusing into her veins were several liquid medications in upside down bottles hanging from poles. Coming out of her body were several tubes and catheters – some in natural body orifices, and some in surgically made openings.

The room was a negative air-pressure isolation room. Meaning, that all air droplets were being suck out of that room to a special outlet to prevent from spreading. And all personnel that go into that room needs to don a gown, a mask or a respiratory hood, and gloves.

As he stands outside that glass room looking in, several barriers are separating him from his sick wife, and from the world.

First is the physical barrier of being in an isolation room. This is being done as we suspect she has a highly contagious disease that can spread not just to the other hospital patients, but also to the hospital staff. If only he can be constantly at her bedside. Of course he is free to go inside the room, as long as he wear all those protective gear.

Second is the language barrier. Being a new immigrant to this country and not understanding its language can be very isolating. Not able to communicate even the simplest of questions is already difficult, how much more understanding a very complex situation.

Perhaps he and his wife came to this country to escape hardship or persecution. Perhaps they came here to pursue a dream and to begin a new life. Then, this happened. Which leads me to the biggest barrier of all, the barrier of the unknown tomorrow. What will happen to his wife? To him? To their dreams? And their future?

For the past two days we have been talking to him only through a phone interpreter. Due to the circumstances’ limitation, most of the conversation with him was to explain a procedure or a test that is needed, and to obtain his consent. Consent for blood transfusion. Consent for the CT scan and MRI. For the spinal tap. For chest tube insertion. For percutaneous abdominal drainage catheter. For bronchoscopy. And other more. But sitting down and explaining to him every nitty-gritty details of her wife’s illness and its prognosis, we have not done yet.

Finally, the social worker was able to get an interpreter to come to the hospital. Being an obscure dialect of a certain language, it was hard to get an interpreter in person.

So I sat down with him, and with a live interpreter, explained in as much as I could, the gloomy situation. I explained to him the severity of her wife’s condition: with overwhelming still-to-be-determined infection, plus the ravaging systemic lupus affecting almost every organ including the brain, the odds were plainly against us.

As I converse with him through the interpreter, I learned that he has no relatives and the only family he had here in the US is his wife. I also learned that at night he still goes to work at a meat-packing factory so he can keep his job, and then come and stay in the hospital all day. Somehow he just tries to sneak some naps in the ICU waiting room during the day. No wonder he looked so haggard. Life can be tough at times.

Then he asked me the crucial question, “Would my wife get better?”

I gave him my honest answer, “I don’t know.” I told him that there’s a possibility that his wife may die. Even though she’s only 22 years old.

His face became more saddened. Perhaps that’s an information that he was afraid to learn. Now through the interpreter, he fully grasps the gravity of the state she’s in. Sometimes I think, that not knowing is better. Perhaps not understanding, is bliss.

Two more days passed, and he was there most of the time. Outside the glass door. Looking. Pleading. Hoping. I almost wanted to avoid him, for there’s no comforting words I can say, with or without the interpreter.

But today is different. I cannot wait for the interpreter to arrive so I can talk to him. I needed to tell him the news. I think we have found an answer. I think she is slowly getting better.

I needed to tell him, that I believe she will live.

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(*photo taken with an iPhone)

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 😑.

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 😢.

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 😞.

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.

ecmo

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 “cultural” 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’s 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’s 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