Pages from the Philips Seeking God's leading in medical missions

Worst Losses…

We've clearly not been doing the greatest job on frequent updates, however we do have new pictures, some exciting developments and stories to share in this update!  We have enjoyed a few months at home after finishing our tour of the 13 original colonies (you can find some pictures from our trip at the bottom of this post).  We had an enjoyable time traveling from Dallas to Maine and enjoyed seeing dear friends and family members and some amazing historical sites.  We enjoyed some amazing ethnic food at several hole in the wall places in New York, Boston and Washington D.C. and had fun hanging out with Kris, Melissa's sister, who joined us for about half our trip.

We spent Thanksgiving with my family where we had almost 70 people come to my parent's home for the annual flag football game, Thanksgiving meal and post-meal Cowboy game watching - accompanied by plenty of cheering courtesy of my aunts!  The kiddos took their annual break during the time we were traveling up the East Coast but have since resumed their homeschooling.  Karuna continues to amaze us with the vigor with which she devours books - often requiring multiple trips to the library each week to keep up with reading material for her!  Luke has started working on learning to read which has been exciting for him since he desperately wants to read now that Karuna is always reading.  Vivek of course tries to destroy the house as Melissa works with the older two in their schooling.  We have also enjoyed this past month because Melissa's sister, Kris, moved down to stay with us at the end of November as she is searching for a new nursing job in Dallas - the kids have definitely enjoyed having their aunt here and enjoyed her two dogs and cat.

After much prayer and discussion we decided in the last few months to commit to serving at Duncan Hospital in Bihar, India with the plan to return to India in the latter half of 2013 after my board certification process is done along with student loans being paid off.  We are excited to have committed to Duncan Hospital because it gives us a greater sense of direction as we prepare for our return to India.  We felt that strategically Duncan is located in a part of India where we can be part of a team to help train young physicians while at the same time use the hospital as a platform for sharing the great news of Christ by providing compassionate and loving care to the poor in northern Bihar and southern Nepal.  Our next task will be to find a language school we can join when we return so we can gain fluency in Hindi prior to starting work because it is critical to our long term ministry in India to be able to speak Hindi fluently so that we can relate spiritual principles to the people we work among without having to rely primarily on translators.

Over the past year I have been writing about different patients I have met over the years in the ER and I wanted to share a story where some things didn't go right - the despair of doing everything possible but in the end realizing that God had called them home.  In the next post I'll write about something a little more encouraging - an unexpected save.  I'll start with the story of a middle-age man I met during the third year of my residency.  What struck me about this patient was how quickly things progressed and how helpless I felt even though I was surrounded by all the things that modern medical technology could offer.  Around noon, a 4o year old Asian man and his wife checked into the ER I was working at.  The  ER was full that day and his chief complaint was vomiting and because he was not actively vomiting he waited in the waiting room for about 45 minutes.  The triage nurse went back to check on him and because he appeared really pale decided to bring him back to be seen sooner since something just did not sit right about how he looked.  One of the junior residents picked up the patient and soon realized this man was much sicker than what was initially thought and soon he was a in a critical care room and the resident asked me to assist him.  This man, in broken English, explained that he went to bed the previous night feeling fine but woke up not feeling well and he started throwing up.  His wife tried to nurse him at home that morning but because he continued to vomit and feel worse and worse, she drove him up to the hospital to be seen.

As soon as we walked into the room and saw him we knew something was quite wrong.  He looked off - he was pale and looked yellow.  We started asking about clues that might lead us to a diagnosis.  Have you traveled anywhere?  No.  Diarrhea?  No.  Fever?  Maybe, felt a little chilled.  Hepatitis or gallstones? No.  Anyone else sick?  No.  Ever been to a hospital before? Not in at least 20 years.  Blood was drawn and labs were sent off as we started resuscitating this man.  His blood pressure was initially normal but within about 30 minutes his blood pressure was in the low 80s.  We started fluids and antibiotics thinking that because he appeared jaundiced this was perhaps due to ascending cholangitis.  About 30 minutes later he started complaining that he was having trouble breathing - his oxygen saturation had dropped into the high 70s - we kept going up on his oxygen but even with a nonrebreather mask we just were not making any progress.  I tried to keep his wife informed as best as possible but her understanding of English was basic and more complex medical terminology was going over her head but thankfully the man's sister and brother-in-law, who both spoke great English, had come to see him.  About an hour after we started treating him he was intubated because of how low his oxygen was.  Then we started getting calls from the lab - the blood we sent was hemolyzed.  Nothing new there...so we sent another sample.  Again hemolyzed.  After the 3rd sample came back hemolyzed I personally called the lab to find out what was going on.  "Doctor, we don't know what is going on.  Every time we get the blood it is just black and because so many of the tests we do use spectrophotometry we can't get any results back." "What do you mean?  This man is getting sicker and sicker and you can't tell me what is going on inside his body?"  "No, we are calling in the lab director to see if there some other way to do these tests but right now we can't tell you anything more."

By this time his jaundice seemed to be getting worse and so we decided to do a bedside ultrasound to see if we could get any more clues.  We put the sonogram over the liver and I saw something I had never seen before - bubbles of air going up through the venous system of the liver.  This must be ascending cholangitis - what else could cause air to form within the biliary tree - I called the general surgeon and the GI doctor.   Of course they were incredulous, "You are calling me with no labs and no formal sonogram?  How do you know what is really wrong with the patient."  I responded, "I think he's got ascending cholangitis and I need your help - this man is getting sicker and sicker as we wait.  Would you at least come down and take a look at the patient."  By this time, his blood pressure kept dropping despite the several liters of fluid we had given him and so we placed a central line and started norepinephrine and because that was not enough also started vasopressin.  The consultants arrived to see the patient and they saw that by this time blood was coming out of the endotracheal tube and around the central line we had placed in his groin.  Now what?  This man was bleeding from every orifice and I still did not even know what his hemoglobin level was.  We checked a bedside hemoccue and it came back at 4.  Clearly he was now going into DIC (disseminated intravascular coagulation), a condition where the body can no longer clot properly.   We called for unmatched blood and within 15 minutes we had 4 units of blood in along with FFP (fresh frozen plasma) using the level 1 infuser.  I could see how gravely afraid his wife was getting and so I took her to the side and asked her how she was doing.  "I'm scared, is my husband going to die?"  "I don't know, he is very sick and we are trying everything we can and have called in multiple other people to help us but we're are not making much progress.  Do you have a faith community you and your husband are part off?"  "Yes we go to an Asian church and my sister called the pastor but he is not here yet."  "Can I pray for you and your husband?"  I implored God, "Please let this man live.  I don't know what is wrong but you are in control and if it is your will you can bring healing."  I was back at the patient's side and watched as his heart rate dropped from 110 to 30 - "Oh no...he is going to arrest, open the crash cart!"  I checked for a pulse, there was none, I started compressions while the nurses pulled the drugs: 1 mg of epinephrine, sodium bicarbonate, calcium gluconate...anything we could think off.  He got a pulse back - 10 minutes later, another loss of pulse.  He coded 9 times in less than an hour.  By the last few times I went back to the family who was waiting at the back of the room, "We have tried everything, I don't think we'll be able to get him back."  His wife and sister were crying - they finally said it was okay for us to stop.  Time of death - 4:05 P.M.

He walked in alive at noon - having never been to a hospital before and four hours later he was dead.  I must have been at his bedside constantly  for the last 3 hours of his life.  I went back and prayed with the family - I didn't know what to say except they could see my eyes were tearing up.  The husband and wife along with the rest of the family were Christians and so I spoke with his wife and sister about Paul writing in 2 Corinthians 12:9 where Christ speaks to him and says, "My grace is sufficient for you, for my power is made perfect in weakness."  At least I feebly offered to the wife that her husband was in the presence of the Lord (2 Corinthians 5:8 - "to be absent from the body is to present with the Lord") - away from all the heartache of this fallen world.  I finished my shift a few minutes later and I wept bitterly on my drive home.  Lord, do you not care?  Why did you allow this young family to go through this?  Was there something I did wrong?  The words from Psalm 46:10 came to mind, “Be still, and know that I am God; I will be exalted among the nations, I will be exalted in the earth.”  There was no easy answers - just tears before the Lord.  A few weeks later I called up the coroner's office to find the autopsy results - clostridium perfringens sepsis.  I read up more about this because I had never heard of c. perfringens in the bloodstream - there were 10 care reports in the literature - average mortality rate between 80-90%.  And an explanation for why I never got any labs back - the bacteria produces an alpha toxin that punches holes in red blood cells and thus the reason why all the blood I sent off looked black - everything had hemolyzed because the bacteria had torn open all the blood cells.  If you are interested in reading another case report very similar to our patient take a look at this article in Clinical Oncology, "Intravascular Hemolysis As a Complication of Clostridium Perfringens Sepsis."

Next month a more uplifting story of a 34 year old woman who was saved just in the nick of time.  Finally below are some pictures from our trip up the East Coast - Atlanta and Durham, North Carolina.  Have a blessed and Christ-centered Christmas!