Some days you can’t save them all

“Dok, please Dok. Gawan n’yo po ng paraan, Dok! Parang awa n’yo na, Diyos ko.”

She wiped the flood of tears with the ruffles of her daster, clasped her hands, and bowed her head, as if in prayer. I was her only hope and she begged.

Across the room her daughter lay, dying. Eyes frozen, hands and feet full of puncture marks, a tube in her mouth to force air into her lungs. They were unable to afford the cost of renting a mechanical ventilator. If the father were to stop manually deflating the Ambu bag, she would stop breathing altogether.

“Kung ooperahan pa po natin siya ngayon, ’Nay, baka lalo lang pong mapadali ang buhay niya.”

Her blood pressure would plummet from the anesthetic and her heartbeat would become erratic, I thought of saying, but she would not comprehend, and the science would not matter at this time. I put my hand on her back.

“Tabihan mo na lang ang anak mo. Yakapin mo. Kausapin mo habang kasama mo pa siya.”

After a crescendo of inhalations, she paused, and let out a wail that echoed a mother’s sadness and anger and regret.

They were a family of scavengers. Earlier that day, her only daughter Ofelia, who had been playing hide and seek in a cemetery, slipped and fell from the topmost tomb, breaking her skull in several areas. A massive blood clot accumulated inside her head and she rapidly lost most of her brain function. Ofelia would die, regardless of what we did.

“Pasensya na po, ’Nay. Hanggang dito na lang po tayo.”

Would these words alleviate her pain, even by a tiny bit? Or was the token apology only a means to exculpate myself? To shake off guilt for knowing what could have been done and yet being unable to do anything. What good was understanding the pathophysiology of brain injury, or being able to enumerate the steps in evacuating an intracranial hemorrhage, if in the end the patient would die anyway just because her family could not get to the hospital on time?

The sleepless nights that stretched all the way back to medical school, endured in the hope of being able to save every valuable life, suddenly became worthless.

“Ganyan talaga ang buhay,” the callous would say with a shrug.

I thought about my mother. Put in the same situation, she would have cried harder. She would have gone hysterical. She would have thrown blood specimen vials and kicked the ER’s waiting chairs, refusing to be restrained or pacified. In all likelihood, she would pass out.

I should call her in the morning. She had to be reminded to bring my scrub suits and white coats for the week, and if possible, to come late at night so I could have dinner with her and have time to ask about how my brother and sisters were doing.

 - - -

I was training  to become a neurosurgeon at the Philippine General Hospital. Neurosurgery residency was a five-year program until 2012, when it was extended to six. I entered the program in 2010 and was thus mercifully spared from the extra year.

First year consisted of quarterly rotations under the trauma and general surgery divisions, where I learned the basics of suturing and wound care, assisted in opening up people’s abdomens or taking out their cancerous breasts and inflamed gallbladders, and even performed appendectomies and chest tube insertions on my own. That was the highlight reel.

The rest was mostly scut work, carrying out orders from the consultants, the team captain (i.e., general surgery resident on the final year of training), and mid-level residents called vice chiefs. Some of the things I did every day:

1. Push stretcher beds from the ER to radiology and back
2. Sprint between the blood bank and the operating room complex with packs of red blood cells and fresh frozen plasma
3. Ensure patients scheduled for elective surgery had the medical clearance and supplies they required
4. Persuade the hospital’s social service unit to waive fees for diagnostic exams
5. Pilfer antibiotics and sutures for patients who could not afford to buy them
6. Dress infected wounds and change bottle drains before ward round every morning
7. Repeat #1 and #2 while waiting for the outcome of #4

The inefficiency of processes in the hospital called for unquestioning diligence among the junior residents, otherwise it would take a long time for patients to move along the care pathway.

For example, it would take no less than five steps to get a chest x-ray in the middle of the night for a patient with difficulty in breathing. Imagine how much more effort it entailed to bring a patient to the operating room for emergency surgery. To get the unanimous approval of the chief surgeon, chief anesthesiologist, and chief nurse, you needed to move mountains. You could choose to do it with reason, charm, force, or any combination of the three, for as long as the job was accomplished and you were willing to deal with the consequences of your actions. Unfortunately, a few would resort to deceit. When uncovered, you would get the residency equivalent of being sent to the principal’s office.

After one year of general surgery, I was surrendered to my home department—the section of neurosurgery—where I would spend every day of the remaining four years learning to operate on the human brain and spinal cord.

The day always began at five thirty in the morning on weekdays and seven o’clock on weekends. Vacation leaves and holidays did not exist. With a pile of CT and MRI films tucked underneath my right arm and held close like they were my most valuable possessions, I would walk past the charity wards and dining hall of PGH, and make my way to morning rounds at the Neurosurgical Special Care Unit (NSSCU), an eight-bed ICU on the second floor dedicated to the most critical neurosurgical patients. That is, if I had not chosen to stay there overnight.

As a first year neurosurgery resident, I was a denizen of the NSSCU. Whenever I was the resident on duty (ROD), that was where I took phone calls, filled out patient forms, and ate my meals at unpredictable times. In the refrigerator, I (somewhat illegally) stored my 1.5-liter Coke bottle that kept me running on sugar.

During the wee hours, in between answering referrals from other departments and accomplishing assigned tasks for my forty-eight-hour duty shift, I would choose an empty patient bed where I could lie down and take a nap, grateful for finally getting a chance to rest my back. Never mind if a patient had just died on the same bed an hour earlier. Nothing that couldn’t be remedied by a generous wipe of 70 percent alcohol on the mattress. If the NSSCU happened to be fully occupied, I requested for hospital linen from the nursing aide on duty. I would spread the linen on the floor behind the head nurse’s desk, a two-square-meter cubicle walled off from the patient beds and nurses station by an accordion divider. I used my bag as pillow, set multiple alarms ten minutes apart, and lathered on mosquito-repellent lotion before retiring to my makeshift nest.

That way, if any of our patients from NSSCU or the surgical ward deteriorated overnight, the nurses no longer needed to look for me all over the hospital. One of them simply woke me up. I resuscitated the patient, facilitated an emergency CT scan, updated my team captain on the events, and went back to sleep after the patient had been stabilized. Every minute of rest was precious. The cacophony of cardiac monitor bleeps, mechanical ventilator alarms, and slurping sounds of the suctioning machine lulled me to sleep. The unit had air-conditioning, and after being in the hospital for days on end, that was all an ROD needed.

Sometimes, I slept all the way through five thirty. The nurses doing their endorsement rounds would interrupt my dreaming with gentle taps on my shoulder, pity and embarrassment in their eyes. “Sir, pinapagising na po kayo ni Powix (the chief resident).”

I would sit up startled.

Kamote! Ano pa ba ang mga hindi ko nagagawa?

Kamote was hardly a good way to start a day.

 - - -

There is never  enough time when you belong to one of the busiest neurosurgical services in the country. The neurosurgery residents are in charge of all eight NSSCU beds and twenty-two beds in the adjacent Ward 6. At any given time, there are thirty to fifty referred patients from neurology, pediatrics, and trauma. In addition to the charity patients, there are thirty or more patients admitted under the consultants, in the private floors of the hospital’s central block. Their consciousness levels range from the vegetative and insentient, barely meeting the minimum definition of alive, to the fully awake and rambunctious, hurling expletives as if it were as essential as breathing. If any one of these patients needs attention, or if a new patient turns up at the ER, it is the neurosurgery ROD who gets called.

“Dr. Ronnie Baticulon po ako sa neurosurgery. Kami po ang mga nag-oopera sa ulo. Kung sakaling kailangan kang operahan, kami po ang mag-oopera sa iyo.”

I would see anywhere from five to fifteen new patients on an average duty day, on top of the patients I would examine in the outpatient clinic during Wednesdays and Fridays.

I had interviewed them all: the wife who would tentatively promise to procure operating room needs for her husband with a clot in his brain from uncontrolled hypertension, the loud mother demanding that her toddler who fell down the stairs be seen right away, the drunken bastard who crashed his motorcycle into another vehicle, and the clueless bantay who could not even tell me where his patient’s blue card was.

After the first hundred patient encounters, I learned that the least useful question in our institution was, “Bakit ngayon lang kayo kumonsulta, e [time frame] na pala niyang nararamdaman iyan?”

The answer was painfully predictable—“E kasi Dok, wala ho talaga kaming pera”—like a broken record on an infinite loop, albeit in a different voice each time. The question had neither diagnostic nor therapeutic value. It served no purpose other than to bare a physician’s indifference to his or her patient’s socioeconomic circumstances, so as a trainee I abandoned asking the question early on.

When I asked them, “Bakit sa PGH n’yo pa po dinala ang pasyente?” (counting the number of public and private hospitals they passed along the way), they answered the same thing.

Occasionally, they said, “Dito kasi sa PGH Dok, alam namin nandito ang mga magagaling.”

Reflexively, I would clear my throat and chuckle.

“Naku, nagbobolahan na tayo dito,” I would say.


Editor's Note: This is an excerpt from Ronnie E. Baticulon’s essay “Some Days You Can’t Save Them All,” which won 2nd prize at the 2018 Carlos Palanca Memorial Awards for Literature and is the title piece of his first book. Some Days You Can’t Save Them All was published by the University of the Philippines Press and is available at Shopee and Lazada.

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