Friday, April 4, 2014

Where It Counts

These past few days to weeks to months, I've felt a little bit more stressed than what I've been used to. And for someone well into the his second year of Adult Cardiology fellowship, that is going to be a little bit understated.

But yes, I have felt a little bit more strain on my resolve lately from worries about friends and family and work has not been doing me any favors. My country's tax arm is slowly taking aim at my profession and at the same time poking one of the world's biggest countries. Talk about a messed-up government.

But that's beside the point...

This blog was initially just meant to be an outlet of sorts -- a chronicle of life experiences and work situations where I felt I turned the corner, not just as a physician but as a person as well, and maybe have the chance to have these little life stories touch whoever reads them.

I have in my care, a female charity patient, 28 years old who came in for difficulty in breathing. She is reed thin and any lay person could see the cachexia was eating away a few minutes of her life each day. She developed pulmonary edema (fancy words for fluid in the lungs) so she couldn't breathe well and we had to intubate (that thing on TV where we put a tube in someone's mouth). She had severe mitral stenosis (the valve that guards the left atrium and ventricle of heart is half-closed, or half-open, depending on how you look at it) with severe pulmonary hypertension (the pressure in her lungs were really high). Her right side heart chambers were extremely dilated, there was severe leakage of her tricuspid valve, and because of the right sided pressure and volume overload, the left ventricle was reduced to less than half its normal dimensions.

She was in severe heart failure. To what, I couldn't really say for certain unless I did some more tests. I couldn't subject her to valve replacement surgery because sending her to the procedure would be sending her to death on the table due to the severely elevated lung pressures. We had to figure out why everything was what it was before doing anything else.

But how? They were in the charity service for a reason. They had no money. How do you tell a mother or an expectant sister that you could not do anything more? We could not do hemodynamic studies, they had no money for medications and we barely scraped by with our three free days in the ICU.

Now she is thankfully out of frank heart failure. I see her everyday with her mother, sisters, brother and aunts, and everyday I tell them of how her heart is failing her and that she could go anytime. Yet they smile, seemingly in denial and acceptance at the same time, and say that "Prayers are all we have, doc" and "It is in God's hands now." I nod every single time, knowing how true it was.

Today, I went up to them and told them that as of this time, this is the best we were going to get -- out of failure, able to walk a few meters, smile and entertain guests, her talking about getting a whole serving of her favorite halo-halo and the possibility of home oxygen therapy -- until such time we were able to come up with funds to do the next steps in her treatment. They nodded and I ended the morning signing my name on their discharge orders and take home medications

Sometimes, I feel helpless amidst all the poverty, all the economic ruin my country is supposedly in, all the stress of training and the emotional strain with every family member getting sick or a friend in trouble. With all this, it would be so easy to dismiss the troubles of patients who can not pay their way to even a decent diagnosis, but I don't. I would never want that for anyone.

I have never thought of going abroad and plying my trade there nor has there ever been the desire to do so. I will work and serve patients here, and continue doing my best for patients with whatever I have just like how every physician gives a part of themselves to each patient that walks through their clinic doors. Despite this messed-up country, I feel that I am where my life counts and giving back to where it counts the most.

Thursday, November 28, 2013

Love Goes On

I received a phone call a few days back from a dear friend telling me her father was coming in for admission. He had been having exertional dyspnea (difficulty breathing on exertion) and a bothersome cough that got worse once he was lying down. I said I'd take care of him while she was still finishing up a few things as she was completing her residency training in my hometown.

I had gotten the chance to meet her father before at her wedding, but never got the chance to know him and on his admission, I shook his hand and introduced myself. He was a cheerful guy with an easy smile, talked about his symptoms and I reviewed his case. His medications, I couldn't understand since he had gotten them from somewhere in South America (for the life of me, I never knew we had blood thinners that we could dissolve in water). From just that conversation, I could see how his daughter got her demeanor -- calm, calculating, and a seemingly exceptional control over his emotions.

I walked out of the room, glanced at his labs and electrocardiogram and nothing stood out. His chest X-ray had some signs of congestion but it was on looking at his echocardiogram that I felt my heart sink a little. His heart showed a significant drop of his ejection fraction (the amount of blood pumped out of the heart with each beat) to 27% (normally >55%). His chamber walls were enlarged and barely moving. Everything about it was definitely not good.

I called my friend and broke the news. I owed it to her to tell the truth both as a friend and as a doctor. She asked me what was next, and being a doctor herself had questions and suggestions of her own. I said a viability study could be next to check the extent of surviving heart tissue, then maybe a coronary angiogram and if there is anything we can do next, cardiac bypass surgery or angioplasty. She took the news in with all the strength I knew her for. I could hear her voice cracking a bit as we spoke over the phone but I said we'll take it one step at a time, get the extra fluid out of his system, decongest his lungs and take it from there. She was coming in two days after some exams and we would talk then.

The next two days would have me visiting my friend's father often, chatting a bit and he was significantly improving. No more coughing on lying down, and he was up and about, walking around his bed, in the hallways and all the way to the hospital chapel. When she arrived, we all chatted in the room, and caught up. Everything was as smooth as can be.

Then came the call.

The resident's call came in at around 3 pm, "Doc, our patient went stiff and is unresponsive!"

"What?" "Who?!" "What happened?!" I could hear my friend in the background, screaming.

It was the fastest I've ever responded to a code in my life. In less than a minute, I ran from the male doctors quarters to the fourth floor and found my friend's father unresponsive. "Bri, he's not responding! He just complained of sudden dizziness and then this!"

Numbly I processed everything, tried to remain calm and tried to establish an airway. I brushed off the nurse offering a pair of gloves and a mask so I could save a few more precious seconds as I inserted his ET tube, while my friend took out her father's dentures. Arrhythmia most definitely, as I ran down the list of differentials in my head. We started CPR and waited for the cardiac monitor to come. Ventricular tachycardia, torsades (really bad abrnormal heart rhythms), you name it, we had it. He was responsive, restless and was still able to respond to us by blinking his eyes. We did everything -- antiarrhythmics, defibrillation, CPR for a good two hours. I did not want to stop until I had him back, talking, smiling.

But I knew it was bleak. His heart was too weak.

It broke my heart to see my friend, her tears freely flowing, never leaving her father's side, saying everything was going to be okay, that they will take care of each other if he chose to go, that it was alright to let go if it hurt too much already. She looked at me and I gave her a hug as she sobbed. I knew she saw the defeated look in my eyes and she managed a nod. She understood how most of these situations turned out.

We stopped everything after nearing two hours of resuscitation.

I keep asking myself, what could I have done differently to make sure we had a different ending? Everything was so sudden, and in just one sweeping moment, I lost a patient. A patient who not only was someone who just happened to walk in through the ER doors, but someone who was dear to a close friend. And that made him, part of me. And now, his memory is part of mine.

How God chooses when to bring people from this life into the next is beyond any man's comprehension. One thing I've learned from this profession is that each death is meant to teach us something, no matter how close it hits to home. I have to brush away notions of what-ifs and what-would-have-beens to able to look my friend in the eye and say "I'm sorry for your loss," and carry on with treating more people.

Life and love truly go on after a loss, and as I see my friend and her family carry on, I am reminded of how fragile our existence is on this earth and how unpredictable our life scripts are being played out, and how, despite everything, we should make this existence count.

Saturday, August 31, 2013

Whispers To Sadie

There is this moment every night when every well-meaning parent looks in on their child sleeping soundly and whisper a short prayer of thanks or a well-meaning thought or hum a favorite lullaby, gently stroke the hair on their heads and kiss them goodnight.

On most nights, I look in on my daughter sleeping in her crib, tossing and turning, letting out a little whimper or a small laugh as if enjoying a nice dream, and I marvel at how truly great God is to have given me such a gift.

These moments are the times where our imaginations as parents roam as we think of all the possibilities that lie ahead for our children. We smile at the prospect of seeing them walk and talk, growing up and going to school, fending for themselves and finding their own friends, falling in love, choosing careers and walking down the aisles and seeing grandchildren walking up with them as they visit for a weekend. Oh how they will grow up so fast.

Then come the fears of how the world we live in will be just a little bit too much for our little ones. The pollution, the growing moral ineptitude , disease and disability, accidents and we shut our eyes and hold back tears as we drive these thoughts out of our minds. We will be fine.

Then come the prayer to Him who granted us this chance to be parents in the first place. That He watch over this little angel sleeping peacefully, so innocent, so full of hope and promise and as vibrant as all the little children whom He let come to Him even when he was burdened and tired.

Just like all the other well-meaning parents in the world, all these emotions wash over me each night looking at my daughter in deep slumber -- all the happiness, the fears, the tears, the joy, the excitement and the hope that we will be okay.

The hope that someday our little girl will tell us the same exact thing.

So I whisper to her just before fixing her pillows and kissing her good night, "I love you little girl, with all my heart. I thank the Lord each day for giving you and your mother to me. May you always have a reason to smile. Always be good. I'll see you when you wake up in the morning."