I was crying dry….

in Blog Rounds/Medicine/Orthopedics by

(Disclaimer: All names and characters in this story were deliberately changed to protect the privacy of the patient concerned. If you felt the story was referring to you or someone you know, you are wrong.)

“Hepe, you might want to go the ward now.” The nurse on duty ‘s voice on the phone, sound a little bit gloomy. I just came down from assisting a junior for an OR that extended to almost 12 midnight and I barely touched “the bean bag” to rest. My team wasn’t on duty that night.

“Bakit hepe?” (Hepe, is our pet calls for male residents and male nurses in the wards, sort of brotherly respect). “Nag code si Nanay Delia..Ikaw yung hinanap nya…” For a moment, I don’t know what to think of or how to react to this news. I immediately ran to the wards and joined the code team doing ACLS on Nanay Delia.

Just 5 hours ago Nanay Delia and I are happily exchanging goodbyes and hugs in what supposedly a very heartwarming patient-doctor relationship punctuated by a successful OR procedure. To thank me, she insisted I’ll take a gift wrapped Pierri Cardin hankies and neckties fresh from underneath her pillows. To Nanay Delia, I was her savior-son. To me, she was a motherly patient I can never forget. I am her surgeon.

“She what???!!!”

I first met Nanay Delia in the outpatient clinic two weeks before this incident. She was this jolly faced 56 years old lola with a very happy disposition and a charming talker. Without make up but only the ever infectious smiles you see in your grandma’s face, her wrinkles in the forehead looked like lines of happiness. Needles to say, resisting her motherly charms is totally futile. Unable to walk because of nagging pain in her right hip, she was totally unfazed by her predicament and was in fact very much hopeful she can walk again.

“Sa tulong at galing nyo doctor!” Nanay Delia was proudly chatting with some patients at the end of the clinic room. She was already infecting the whole OPD team with her crazy punchlines and contagious laughter. We can’t help but be swooned by her charm.

After examining Nanay Delia and her xrays, a decision was made to have her right hip replaced (a procedure known as Total Hip Arthroplasty) to ease out pain and make her ambulate again. I asked her and her son who was assisting her to come back next week for admission and OR.”Talaga duktor? Makaka pamalengke pa ulit ako??!” Everyone in the clinic saw the face of Nanay Delia lit up. She is over flowing with joy giving hugs to all the members of my service. A gesture that touched everyone in my service. Nothing extra ordinary, but a gesture in the right timing and execution, will melt the hearts of stone cold surgeons that we are. “Nany Delia just smooched us all!” Said one of my juniors.

Our arthroplasty service see quite a number of outpatients everyday . Believe me, Nanay Delia seem to be an epitome of hope among these poverty stricken and ill patients. In this institution, residents spend hours and days haggling for funds and implants among sponsors, philanthropist and politicians(with their CDF),so that these patients can have their OR, free.We were able to get funds for her implants, and since the surgeon, anesthesiologist and procedure itself is free, Nanay Delia will be operated with minimum of expenses.”Hay, salamat talaga duktor!”

Nanay Delia passed the cardio-pulmunary clearance and labs easily. The internist classified her “low risk” for this surgery. So the next week, I saw Nanay Delia happily sitting in one of our ward beds. A number of bantays and ambulatory patients were already crowding near her bed. I can even here the laughter and giggles these people made because of Nanay Delias funny stories and punchlines. She was the center of attention in our wards because of her friendliness, jolly type personality and talkativeness. She even talk loudly with patients on the other end of the ward, at least 10 meters far from her bed! “Kung tayo nga na infect ni nanay, mas maganda tong mga patient natin masaya din!” I jokingly told my service.

When Nanay Delia saw me and my team coming for the ward rounds, she shouted: “Shhhhhhh! Tahimik na tayo, nandyan na ang mga gwapong doctor natin!” She was gesturing her companions to keep quite but I still could here giggles from the other beds. “Nanay, napasaya mo ata ang buong ward ah!!!

I talked with the cardio fellow and seek out another CP clearance, this time asking for repeat ECG and echo cardiogram. This premonition somewhat baffled me also. She was already cleared for OR twice and I was still asking another one. Obviously the fellow hated me for that, but I got what I wanted. Nanay Delia was cleared for OR. Nothing in the repeat labs picked up anything suspicious. Getting the final pointers and go signal from my consultants, I scheduled the OR in two days.

Talking to Nanay Delia about the procedure, the risks, the benefits and preparations, we were all set for the OR. If there was one happiest person involve in this procedure, she was Nanay Delia herself. She was so happy and proud that at some point, we heared her overtly exaggerating our scalpel wielding prowess that I can only sigh in disbelief and smile.

It was not my first THA as a resident and I have planned for this procedure several times In all of my previous surgeries, I have been chided for being too detailed on preparation and precautions to the point of obsession. Nanay Delia‘s case was no special procedure and she too did not escape my obsession to preparation. Ironically she was a symbol of hope for most of our patients admitted to the wards. Her happy disposition is so infectious that my service actually felt the outcome of her surgery will be the barometer of how good our delivery of service was. “If this procedure will have a glitch, we will be devastated. So lets make this again, our best!” I pleaded my team.

It was an uneventful OR indeed and the most satisfying one, finishing faster than we expected. Nanay Delia tolerated the OR well and we were so admiring of the outcome of the procedure. The planning paid off and more. Everyone in the OR team had a pat on the back and even Nanay Delia, who was mumbling my name under anesthesia.

The next day when I made my rounds, Nanay Delia was already sitting at her bed, her eyes glowing in joy. “Dok!, salamat po sa inyo. Maraming salamat talaga!” Coupled with a hundred more praises and exaggerations, I can’t help but gave her our “akbay barkada“, a gesture we made to our nicest friends. She was already inviting me to her upcoming birthday and the christening of her grand son, to which I would be a godfather.

“Nanay, you still have to start your hip range of motion exercise so that by tom, I can teach you how to walk with quad crutches.“I deliberately changed our topic of conversation.”Yes doc” was her smiling reply. I just shrugged my head. But deep inside, I was extremely please at the sight of one very happy and satisfied patient.

The next rounds she was motioning my team again to her bed. “Kain tau dok!” “Mamaya na po Nanay after ma dress natin yang sugat nyo and maturuan namin kayo ng quad crutch ambulation.” Teaching Nanay Delia ROM exercise was no sweat at all. She was even proudly showing off to us that her hip pain is gone. I was just smiling at her antics. “Hinay-hinay lang nanay!” I told her, she will be discharged tomorrow, once I inspected her wound and assessed her fit for home ambulatory rehab program.

That discharged never happened.

Another epi please!” I was shouting while doing chest compression(CC). I am perspiring heavily since nearly doing CC for almost 10 minutes already. I’m still dazed as to what has happened but I’m racking my brains at reviving Nanay Delia. “Why was I not informed immediately about this?!” I was shouting already. “Hepe, ginigising lang si nanay nung bantay nya for meds nung napansin di na pala humihinga. Before natulog yan nakipag kwentuhan pa sa mga katabi at tawa ng tawa. She was asking for you and looking for you at may sasabihin daw.”

It was a massive MI according to the IM in the code team. “How can that be?” I said, Nanay Delia was cleared two times before this OR! Even the 2D echo did not pick up anything! It is frustrating to look for impossible answers. The obvious reason was, I, my service became attached so much to Nanay Delia. Nobody was expecting this event to happen because everything went well and she was one hundred percent happy just before sleeping. She never woke up to walk again.

When the IM declared Nanay Delia dead, I was still shocked and dazed. I was literally angry and frustrated at the same time. “Why did this happen? Was there anything we could have done that might have save her life???” I can see Nanay Delia‘s smiling face in my mind.

I mustered enough courage to talk to the family gathered around her bed. I offered my best consoling words. I almost cried when each of the family member hugged me. “She was asking to see you before she slept, doc. She was very fond of you.” I was in the OR

I excused myself and hurriedly left for the call room. I sat in one corner staring at the blank wall. I am looking at nothing. I still couldn’t believe what has happened. Nanay Delia and that this whole procedure meant nothing. I wanted to cry, but I couldn’t. I don’t know where to get my tears..I just sat there and wanted to cry but couldn’t…I was crying dry…

In my most isolated and stoned cold medical life, . I am hardened by pain and several deaths to our patients. I have trained myself to get detached and not be affected by emotions. I was trained to empathize, not sympathize.Yet, every time something like this happened, I felt it is easier to just cry and make ease the burden of guilt. It feels lot lighter and starting again, becomes easier.

But tears never came.

Perhaps, it was because Nanay Delia‘s jovial face smiled on us every time. That for a short time, we were able to make another patient happy and satisfied with what we can do with our god given knowledge. That we learned from this mistake and that she gave hope for our other patients. More importantly, Nanay Delia taught us all that happiness is a constant state of mind. And you need no superfluous things or event to enjoy it. No excuse.

I cried dry…

Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is Chief of Clinics at General Santos Medical Center and Medical Specialist II Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (www.remomd.com).