Feb 22, 2016

The Story behind the Nasal Prong

I remember taking the history from the patient's uncle sometime last week. He was unrousable at that time, lying in bed and seemingly unconcerned with anything that was happening around him. Nobody really knew what happened; the workers at the factory simply told the relatives that he fell down and was unconscious for an hour while on security duty. The details are sketchy. It happened around 8.00 a.m. and they then brought him to the clinic. Before he was sent home, he was advised by the panel doctor to go to the hospital. At home, he vomited twice.

A lot of things happened afterwards of which none of them I can elicit from the relative or the patient himself. That includes having three episodes of seizures, the last occurring after being discharged home from a 6-hour observation. The second admission to the acute ward gave the doctors a working management plan of treating him for infection of the brain and its lining (meningoencephalitis).

I recall walking into the ward that day and looking for the census of the list of patients admitted to the ward. I wanted to clerk a neurological case and from a glimpse at the record I thought he was a good case. Middle-aged, nearing 40 but morbidly obese - I wanted to practice taking history and performing relevant examinations. But he was not available that day so I went searching for another patient. That is what we medical students usually do.

Image from Google search

This morning I walked into the ward with the same routine. I had studied a bit about more neurological conditions and I was hoping to clerk a patient with a stroke. After finding a suitable patient from the census I went to the patient's bed to find it empty but the bed next to his was the patient that I saw last week. With him was a male houseman (HO) as his attending doctor. I thought that while waiting for my patient to come out from the restroom I could as well join the HO and see what was going on.

At first I did not recognize that it was the same patient that I last saw last week. He can move around now, fully conscious and aware of his surrounding. In fact, he could move so much that he decided to walk out of the ward when he is supposed to be on 3L oxygen via nasal prong. As I approached them, I saw that he was getting out of breath. 

"Tu la orang dah suruh duduk je and pakai nasal prong ni awak degil. Sekarang kan dah sesak nafas." I heard the HO said to him. It was said in a stern and low voice, but I could almost detect the loathsomeness and weariness in his voice. 

"Kita bagi rawatan ni untuk awak juga. Bila dah datang hospital kenalah dengar cakap doktor."

"Dokt.. sesak.. nafas. Dokt..!" 

He was getting more breathless by the seconds. I was internally agitated. This is simply not the time for a scolding. He can't be treated from it. The HO put on the nasal prong on him while I watched them just at the end of the bed. Watching him as he was gasping to breathe terrified me suddenly. I remember getting almost drowned when I went white water rafting last year I was so panicked I thought I was going to die. Similarly I recalled a patient I met in ED who had panic attack after having a heart attack. He was hyperventilating as he also thought he was going to die. All three of us, in a way connected neither from fate nor reasons, experienced a sense of impending doom, albeit mine seemingly inferior when compared to them.

"La.. Ila.. 
Ha.. Ila..!"

"La! Ila!"

He was getting worse and I started to feel terrified of the slow response from the HO. He repeatedly trying to say his syahadah but he could not finish it. Ya Allah! How wretched he must feel, fearing he is going to die but can't finish the syahadah. How cruel is it, when your breath count is nearing its last one, as surely as your soul is inches from getting taken by Izrail? By then his loud gasping could be heard throughout the whole back section of the ward. What could I have done?

What could I have done, indeed. 

There is a stained feeling of guilt in my heart even though I am not a part of the working team. Could I have done something - anything, please! - instead of backing away with a pretext of finding the said HO whom was suddenly not there? 

Where on Earth is the HO? What is this?!

Then the HO came with a simple Hudson mask as it can deliver more oxygen more effectively. The nurse came and drew the curtain circling the bed. He then had a seizure. IV valium was urgently requested while the HO asked me to inform the MO in the ward. By the time I came back with the MO, the fitting has stopped but he was unconscious.

And his heart has stopped. He had no pulse.

Ya Allah. Not another one.

Resuscitation was done with two attempts of intubation. After 40 minutes of resuscitation he was pronounced dead at 9.44 a.m. There was no relative of his at that time. His wife was supposed to come this morning to discuss about the treatment plan but she could not as she had no transport.

Two hours later the wife finally came and was brought to the bed where her husband is. The MO was explaining to her when she finally registered what had happened. She collapsed to the floor, sobbing hard. I was nearby and my own wretched heart could only prompt me to quickly bring over the chair for her to sit down.

*     *     *     *     *

And as I am typing this down hundreds of thoughts swim me by. If I am the HO, would I do it differently? Would I be quicker, more urgent, and be more understanding? Would I try to communicate with my patients in a way that they understand the nature of their treatment? Or would I be cross all the time, grumbling about difficult patients with their quirks and antics? 

Would I see the patients as just another pile of work that needs to be done? When deaths are unavoidable and a part of Allah's will to make it common when I work, will I stop taking care of any mortality case seriously?

Would I care for them as how I would like myself and my family to be treated, at the best quality of care?

Would I be able to sleep at night after dealing with a mortality when I know I could have done better? Would I like to be treated like how I treat my patients when my life is shaken and stripped bare, exposing my shortened stained soul to be taken any time soon? Or would I come up with plans and improvements, with constant reflection like this to patch up my own tainted soul?


  1. I like how you expressed your feelings and the situation in this post. i really do understand your situation. Well, my mom passed away September 2015 because of lung cancer. She had brain metastasis so not much that we can do anymore at that time as the cancer was in stage 4 already. However, I feel like the staff nurse and the MO can do better at that time. My mom suddenly got seizure after coming back from radiotherapy treatment that night. She was having difficulties in breathing so i was so panic. I called the staff nurse but they were so slow. I guess they were not expecting my mom would got seizure since she was okay before that,no vomiting at all after the RT treatment. Then,they tried to put the oxygen mask to my mom but because of panic,they couldnt put the oxygen mask properly. The other staff nurse had to call the MO to assist them putting the oxygen mask. It took 15-20 minutes to actually put the oxygen mask. I was so disappointed because i think they can do better and quicker and less panic?The MO also came very late so by the time they managed to put the oxygen mask,my mom was not breathing anymore but the pulse was still there but it was very slow. The blood pressure kept dropping and after few minutes, she passed away. The MO was so rasa bersalah because she was quite panic and maybe she felt she could have done better?Exactly like how you rasa dalam situation tu kan? So,my advice is, once you become a doctor, just do your best!I know its not easy to handle yourself after a mortality but thats how you deal with a doctor's life. :) Although I'm not a doctor but my sister is a doctor.She always told my mom "I should have done better kan mak?I feel useless bila x dpt tlg my patient and cause another death no matter how hard i usaha. " but yknow what my mom replied? "you have done your best!always remember that.you sacrificed your time to treat your patients kot.Allah knows whats in your heart" :) All the best in your future undertakings.