Raindrops

One dreary morning,

I was slowly traveling,

The world I cannot see,

For everything was blurry.

                             I turned the wipers on,

                             Yet the haziness remain,

                             For it was not the rain,

                             It was my tears and my pain.

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(*This poem is brought to you by ibuprofen. My body aches again. Damn that volleyball!)

(**photo taken with an iPhone)

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)

The Language of Grief

I was sitting in a consultation room of our ICU. I was having a discussion with the family members of one of our patients in the ICU who was not doing well. Not doing well is an understatement. On the brink of death may be more like it. With me were the cardiologist, our senior ICU resident, and the patient’s nurse.

There were several family members in attendance there in that room. Most of them don’t speak English, or understand very little of it, if at all. We were talking through the patient’s grandniece who speaks English, albeit with a distinct accent.

Our patient was a Cambodian man who collapsed at his home. When the emergency responders arrived he had no pulse and was not breathing. After gallant efforts to resuscitate him, which took them almost 30 minutes, they were able establish a heart rhythm. He was then brought to the hospital and eventually was admitted to our ICU.

We placed him on hypothermia protocol to try to preserve whatever brain function he have. This intervention is used in out-of-hospital cardiac arrest survivors as studies showed that this improves mortality and neurologic outcomes. The intervention entails lowering the patient body core temperature to 33-34 Celsius through cooling blanket and infusion of cold IV fluids.It also involves deeply sedating them and medically paralyzing them, while placing them on life support. This process is an effort to slow the metabolism of the body and thus prevent further ischemic injury especially to the brain. After 24 hours of cooling them, they are rewarmed, and sedation and paralytics are weaned off.

The moment of truth comes after the patient’s body is rewarmed. If the patient will show signs of recovery, they will wake up. If not, they will remain unresponsive or show signs of brain injury from hypoxia(low oxygen supply) stemming from the cardiac arrest. And that will be a very poor prognosis.

Sadly to say, our patient did not wake up. After rewarming, he remained comatose and he was even having seizure-like activity, a tell-tale sign of severe hypoxic brain injury. And that was what brought us to this consultation room. To tell the family the heart-breaking news and help them decide further direction of care.

After we presented the bleak situation to them, the grandniece interpreted for the whole family what we have said. What followed was back and forth discussions among the family members in their native tongue. Some spoke animatedly. Some in whispering tones. No doubt I was lost in their discussion as I have no idea what they were saying.

After anxious moments, one by one the family members started crying, some softly, some more loudly. I don’t have to guess what they were saying anymore. I don’t comprehend their words, but tears is a universal language. I understand it loud and clear.

After more minutes, the grandniece spoke to us, and stated that the family was in agreement, that they just want to have a Buddhist monk come and say a prayer for the patient, and then they will take him off all life support.

Not too long after we left the consultation room, a Buddhist monk garb in a traditional orange robe came. There were about 20 people who came and crammed in that small patient’s room. Usually our ICU regulation only allows 2 to 3 visitors at a time, but this was loosely followed to accommodate family’s needs. I heard incantations and prayers through the closed-door. Then this was followed by sobs and weeping.

Grief. It transcends cultures, religions, and language.

Postscript: The above article was published in Manila Standard Today on July 1, 2012.

A Reason to Write

I know I mused in the past that I had not made any single cent yet in writing and blogging. Well, I am not expecting I will anyway. At least not for now. I don’t think I will be changing career anytime soon.

This morning in church, a relative of the lady that just passed away, who was dear to us, approached me. He read my blog about her late grandmother, and was very appreciative of it and thanked me in behalf of his family. He said it brought tears in his eyes while he was reading it.

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I also wanted them to know that it also brought tears in my eyes while I was writing that piece. And now it brought tears in my eyes, but joy in my heart to hear that my words mattered. I think this is more than anything I can be paid for.

This is the reason I write.