My first patient was an older guy who was morbidly obese and had some underlying cardiovascular disease with a baseline heart rate in the 50s (not because he was healthy).  He was intubated and was lying on his side for a couple of hours for his back surgery.  He was a difficult intubation so the plan was to take him to recovery still intubated and wait until he was fully awake before extubating him.  When it was time to flip him back on his back at the end of surgery, I disconnected the machine from his breathing tube (so that it won’t accidentally be pulled out during the move).  It took the team, maybe, 4 seconds to flip him on his back.  I immediately hooked him back to the machine.  Within 2 seconds, he turned dusky blue and the oxygen saturation on the monitor read 72 (normal should be >97).  I immediately pulled him off the vent and started pushing air in manually but I could not squeeze air in no matter how hard I tried.  His sats continued to drop.  I had asked the nurse to call my attending immediately and within seconds he was in the room, took him 5 seconds to do a first assessment and immediately called for backup (the patient’s heart rate was now in the 40s and we thought he was going to code).  Before I knew it, I had 3 attendings in my room.  From then on, it was just a whirlwind of controlled chaos as we tried to break the patient’s bronchospasm so that he could breathe again.  We finally managed to break the bronchospasm, his vital signs stabilized, and we took him to recovery still intubated.  We waited until he was fully awake before we extubated him and he did well afterwards.  Actually, he went home today.

My second patient was a young guy who was overweight and has been a heavy smoker for half his life, started in his teens.  Other than that, he seemed pretty healthy.  He was having surgery on his neck so I decided to intubate him using a device that has a camera at the end so I can visualize his airway anatomy and watch the breathing tube go into the trachea.  He had a lot of secretions (smokers!) but I easily got the tube into the trachea.  I manually pushed air through the tube and waited for the return of carbon dioxide to confirm that I am in the trachea (even though I watched it go in).  There was no return of carbon dioxide.  My attending and I decided the tube must have slipped out for some reason and ended up in the esophagus.  So we pulled the tube out and tried again.  Looking through the camera the second time, there was yet more secretion but again, we watched the tube go into the trachea.  This time, we made sure that the tube did not move.  Again, I tried to squeeze air in and waited for the return of carbon dioxide.  Again, nothing.  In fact, it was quite difficult to squeeze the bag.  By now, we watched his oxygen saturation steadily drop…100…99…98…97…92…90…88.  Geez, not again!  Indeed, he developed bronchospasm where his airways just clamped down so neither oxygen can get in nor can carbon dioxide get out.  We had to turn up our pressures and gases on our machine to break through the spasm.  Eventually his airway relaxed, and we were able to ventilate normally.  His surgery went smoothly.  At the end of surgery, I called my attending to let him know the patient is about to wake up and be ready for extubation.  The patient, again, had a lot of secretions in his mouth and I suctioned all of it out as he was waking up.  He started bucking and coughing because the breathing tube was bothering him.  I assessed if he was ready for extubation.  He was already breathing on his own.  When I asked him to open his eyes, he somewhat followed my instructions and fluttered his eyelids.  When I asked him to squeeze my hand, he squeezed it hard (meaning he was not still paralyzed).  He continued to buck on the tube.  Knowing that he just had neck surgery, the increased pressure from him bucking and coughing may cause further trauma to his incision site.  Weighing the possibility of this happening, I decided the right decision was to extubate him.  I was wrong.  Immediately after I took the breathing tube out, he clamped down with his teeth.  If I hadn’t put in a soft bite block at the beginning of the surgery, he would have bit off  his tongue.  He started jerking around on the bed, his teeth still clamped together, and he started turning dusky blue while the alarms on my anesthesia machine started going off because his oxygen saturation was dropping (noticing a trend here?).  I immediately threw a breathing mask on his face, pushed it down to get a good seal and tried to push oxygen into his lungs.  By this time, my attending was already in the room.  As I was doing this, he again called for backup.  This time, it was not because we thought his heart would stop but because we have no access to his airway.  If the patient continues to clamp down, it would be very difficult to pry his teeth open to even intubate.  Within seconds, help was there.  I continued to push the mask down on his face to get air in while my attendings started drawing up drugs and getting everything set up for immediate intubation.  After I pushed a paralytic, my attending pried the patient’s mouth open and stuck the scope in.  Looking on the screen, we couldn’t see anything but secretions.  After suctioning, we finally saw a little tiny hole that was to be the trachea.  We successfully placed a breathing tube into the trachea.  Even after that, the patient’s oxygen saturations continued to be low.  We had to completely deepen him with anesthetic gases and took him to recovery to be placed on a vent.  While in recovery, he continued to have low saturations as he woke up.  We were concerned that he may have developed fluid in his lungs or actually popped a lung.  Clinical evaluation was not consistent with either of those problems, but he continued to have intermittent desaturations.  Ultimately, we decided we could not safely extubate him and admitted him to the ICU sedated.  I checked on him today.  After being intubated overnight, he was finally extubated this morning and is doing well.

So I am not going to go into the reasons why this happened to both my patients.  If you really want the pathophysiology behind it, you can ask me.  It was a terrible day but also the most exciting as I learned a lot yesterday.  Like everybody else in training, I have read a lot about bronchospasm and laryngospasm in all my textbooks, but I didn’t really appreciate the severity of it until yesterday.  There is an absolute difference between reading about the causes and symptoms and treatment of bronchospasm and then witnessing it in patients that have multiple other health problems that needs to be addressed as well.  Everything just happened within seconds.  But like I said earlier, it was controlled chaos.  I didn’t even have time to panic; I just did what I needed to do.  It was as if my brain and body went on auto-pilot and just did things to manage the situation.  Not until the patient was stabilized in the recovery room before my adrenaline slowed down and my hands started shaking as I started thinking about how much worse it could have been (like if I didn’t put in that soft bite block and he chewed off his tongue or if we couldn’t re-intubate him).

And as I talked about it over dinner that night, I realized how much I have grown in the past 6 months.  Reflecting back to the first day in the OR, I was terrified and unsure of myself.  I was hesitant to push large quantities of medications, I was scared that I would prematurely wake my patient up if I turned my gases too low.  And I would have freaked out if my patient started bucking on the vent.  I don’t know when I started feeling more comfortable being in the OR by myself, and I absolutely don’t know when I started developing this sense of control over adverse situations.  But over the last 6 months, it has happened and certain things has now become second-nature to me.  This is what it means to be in residency, to endure all those long workdays and unlimited hours of studying.  It is days like yesterday that proves to me that all that hard work has been worth it as it has made me into a more competent physician.

We went to New York under the pretense that we were celebrating our anniversary but it’s really because Calvin wanted to see the US Open and it’s an excuse for me to see my friends.  We had a great time with our respective friends and we managed to live it up just a bit with only the two of us. Calvin would definitely point this out if I didn’t mention this but I totally forgot that it was our anniversary on the day of.  I was so tired and I’m sure I would have eventually remembered as the day went on.  But he was very sweet and got me an “anniversary” band to go with my engagement ring and wedding band.  Pictures later as it is being resized right now for my freakishly small fingers.

Instead of dinner, we decided to celebrate with lunch at Eleven Madison Park…partially because we could not afford their dinner prices.  It was fantastic.  Not to sound like a Yelp.com review, but we had a great time there and the food and waitstaff was amazing.  When I made the reservations, I told them we’re celebrating our anniversary and they gave us a corner booth and gave us a nice card.  Since most fancy places don’t do much besides say “Happy Anniversary”, we thought it was a nice touch to give us some privacy.  Then at the end of the meal, they brought out a couple boxes of mixed chocolate and fruit desserts for our anniversary.  Then before we headed out, the maitre d’ gave us 2 jars of granola and winked and said “for the morning after”.  I laughed.  It was definitely great service.  Even Calvin enjoyed himself despite the price of the meal.

Here’s some pictures of the amazing food.

Tomato Tea - smells fragrant but tastes just like the name

Eggshell Creme with Sturgeon and Chives

croissant bread with goat and cow butter

The Octopus

The Rabbit

The Lobster

The Fish

The Pork

The Beef

Goat milk for dessert?

Chocolate

sesame wafer with chocolate

granola and chocolates

I was completely stuffed by the end of the meal.  It was so delicious.  We then waited in line in the rain for 1/2 off tickets and we decided to watch Priscilla Queen of the Desert after we talked to a flamboyantly gay guy who recommended it.  We should have known better but it was a fun, fabulous, and gay show.  We had a good time, that’s all it matters.

Just finished hiking up the mountain to Manoa Falls.  The reviews on google says it’s an “easy” hike.  I beg to differ.  Easy means gravel paths that even Granny can go up.  We had to climb up large boulders and walk on a 2-foot ledge where one mistep will take you tumbling down the mountain.  There were some FOBs that decided to wear high heel sandals, clogs, and flipflops.  Good luck to them.  Maybe they have secret Tarzan skills that I don’t have.  But the end was so worth it.  The whole hike was so gorgeous and the waterfall was breathtaking.

Yesterday, we scuba dived for the first time.  It was so beautiful down there (approx 40 feet).  But both calvin and I decided this isn’t something we would do on a regular basis.  Mostly because my ear is still popping and it has been over a day.  Plus I had a lot of trouble standing up with all my gear cuz it was so heavy.  But it was awesome.  We did it with Oahu Diving. They were awesome people, definitely recommend for anyone interested when they are vacationing in Oahu.

Right now, we are eating more shaved ice at Wiaola Shaved Ice.  It is this ghetto chinese dirty hole-in-the-wall place but highly rated on Yelp.  And we have to agree.  I had the azuki bowl with mochi (see pic) and it was delicious.  The ice is so finely shaved that it just falls apart on the spoon.  So so good,  have to agree with the reviews that this place is better than Matsumoto’s.  And they sell spam sushi.  Tastes just like it sounds but so good.

We are trying to pack in as much stuff as we can before we leave tomorrow.  I don’t want to leave.  It is so nice here.  Sigh!

I climbed through a huge patch of sharp rocks to get some amazing pictures.  I wore water shoes which has proven to be super advantageous on the aforementioned rocks.  Alas, I endured a battle wound.  It bled for quite some time, probably because of the salt water.

Last night I received an unexpected present from my travel agent.  It was a fluffy robe, so considerate.  Calvin didn’t get anything.

We are now on our way to the Dole plantation and eat pineapples until our tongues bleed.  Then we will be heading out to the ocean and go scuba diving.  I am prepared; I have my scopolamine patch behind my ear so bring it on, motion sickness, bring it on!

After a long tedious transport time, we finally arrived in Hawaii yesterday.  It was so warm when we walked out of the airport, no more 10 degree freezing snow!
It is so nice here and everyone is so friendly.  When we went to rent our car, I thought they were going to give us some crappy car.  To my surprise, the people at Alamo led me to the parking lot and just told me to pick out whatever car I wanted.  So we got the Toyota Prius Hybrid.  It took us a good 15 minutes to figure out how to turn the car on.  It also took us a good 2 minutes to figure out how to put the car in park when we got to the hotel.

Our hotel.  FABULOUS! I have never been treated so well.  It is like I am a celebrity except I am wearing crappy clothes.  We told them we were on our honeymoon and they immediately upgraded our room to the 9th floor where our view is a gorgeous mountain.  And they gave us champagne.  Apparently every US president since LBJ has stayed here and a ton of celebrities.  They have their own waterfall and DOLPHINS.  They have their own private beach and little islands.  It is paradise.

We just finished our buffet breakfast and now on our way to Shark’s Cove on the northern end of Oahu.  It is a cloudy morning so I wasn’t able to get sunrise pictures but tomorrow is a brand new opportunity…

Today, one of my patient’s passed away.  Now, I’ve had patients pass away before but I never really had any emotional connection with them.  When I was a med student, I had patients on my team who passed away but I felt no ownership of them.  Last week, a patient died as I was doing my initial exam on him.  I have never talked to him before and I knew going in that he was already at the end of his life.  So when he passed away, I felt sympathy for the family but I went through the rest of the day not really giving much thought to it.

Today, however, was different.  I would say that she was my first “true” patient that passed away under my care.  Yes, she was admitted to the hospital because she has severe lung and heart disease, and yes, she has already discussed hospice care with her primary care physician.  But still, she was 2 days away from her 95th birthday and I was so hoping that she’ll make it out of the hospital and enjoy her birthday with all her children and grandchildren and probably great-grandchildren.

I made a real connection with this patient.  Just a few hours ago, she was sitting there yelling at me because I didn’t put in an order for her to eat or drink (not my fault, btw).  At the end of the interview, she held my hand and asked me if she’ll be out of the hospital by Saturday for her birthday party.  I told her I’ll try my best.  Who knew that her condition would deteriorate so fast within a couple hours.  When I got called from the nurse, she was already struggling to breathe.  Knowing that she didn’t want CPR or intubation, there wasn’t much else I could do.  And that’s the worst feeling of it all — feeling like you ran out of options but still not enough to save the patient.  I felt like I let her down.

When the family (some of whom I met earlier) came in, we explained the situation.  Her daughter asked me if this is reversible, and I said no.  Part of me wanted to scream “let’s intubate her!”.  But I know that’s not what the patient wanted and it would just prolong her suffering even more.  In the end, the patient passed away 5 minutes before 5pm.  I pronounced her.

I think when people talk about how insensitive doctors are, I think it’s because sometimes we have to put up that wall.  Otherwise, we get so bogged down with emotion that we cannot take care of ourselves, let alone other patients.  At times, I wanted to cry with the family but I knew I still have other patients to take care of.  After I pronounced her and said my condolences to the family, I went about my day just as if it was any other day.  It is only now when I am relieved of my patient care duties that I can reflect on what happened.

To end this on a brighter note, the patient was surrounded by all her loved ones when she passed and she was comfortable.

We took part in the Hakone Roundcourse, meaning we basically traveled 1 big circle around town.  IT was neat, we rode in a pirate ship and went up into the mountains on a cable car.  We got some amazing pictures of Mt. Fugi and we went to a volcanic site and tried their sulfurous eggs.  We got 5 eggs so we gave 3 to some crackers since we assumed they spoke english…yes, very racist.

We went to a Japanese restaurant for dinner.  Calvin did not take off his shoes; they were too polite to yell at him but i wasn’t.  We then ordered the most american meal on the menu: deep fried prawns covered with mayo.  I thought it was disgusting but then again, I hate mayo.  Calvin seemed to like it.

I’m still in awe with the Japanese bathrooms… they heat the seat, it’s very nice touch on my butt.  And the flush level can be pushed depending on if you peed or pooped.  And then there is the bidet…every time I sit down, the water starts running and I’m petrified that it would accidently misfire and start shooting water up my butt.  It’s a real concern of mine…just saying…

So today was kinda crazy, spent all day traveling from Hong Kong to Tokyo.  Highlights of my pounding heart:

• When we got to the HK airport, it took me a while to go pass security/customs.  I was so scared that they were not going to even let me enter China even though I’m just passing through.  After a while of typing on the computer, the guy finally stamped my passport.
• The first leg was delayed…meaning we only had 1/2 hour to get from one plane to another in Beijing.  Not only that, but the two gates were seriously like a mile from each other.  And then we had to wait in a huge long customs line that barely moved.  We were lucky we saw that another line was opening up and we cut in front of a guy in a wheelchair.  Yes we’re the assholes that would take the handicap spot in parking lots…
• We made it on the plane with less than 15 seconds to spare.  Not even exaggerating.  I hate China

Tokyo is refreshingly awesome.  Security was just awesome, they fingerprint you and then you have to stare at some camera.  I dunno, just awesome.  And then Calvin didn’t know how to open the door to the tourist office.  The door said “push” so he pushed but you’re just suppose to touch the button that says “push” and the door slides open.  The people inside laughed at our stupidity.  It took us awhile to finally find the hotel, we had to hail a cab.  The cab driver was so ridiculously polite, I wish I knew how to speak Japanese.

To end an exhausting day, our hotel is awesome.  It’s really small but it’s really neat.  I guess Calvin just tried the bidet, said it was terrifying.  I’m sure he could give more details.  They have free tea and most importantly, internet.  Life is good.