Monday, January 30, 2017

Sa PGH lang may Toxicologist


              The phone kept on ringing on the other end , until an automated voice prompted "The number you have dialed in now unattended. Please try your call again later". I kept calling anyway. I tried five times. I was calling East Avenue Poison control , a phone number listed over the internet.

           I caught a glimpse of my patient's mother. She was distraught. Tears were continuously flowing out of her eyes and I knew she wanted to howl like a wounded dog. She was trying to be super nice to the utmost of her ability... I think she was afraid that I might just give up doing what I was doing.

          I inhaled deeply and sighed... I dialed another number ,National Children's Hospital number to coordinate the transfer, but was refused  because they said that they don't have a toxicologist.

          I asked mother if they had twenty thousand pesos right at that moment, before the transfer. It was easier to transfer to a private hospital if they had cold cash. The mother gave me an utterly confused look on her face....then , I knew...

           I knew twenty thousand pesos was exorbitantly expensive amount as of the moment. And I was pretty certain that the receiving hospital's admitting section would ask for minimum of fifty thousand pesos deposit  for an intensive care case upon their admission.

          (Hell. If only I can transfer my patient anywhere near the hospital where the freaking antidote can be would be I think it would be  fantastic... at best, it would be life saving.)

          The nearest medical center was Dr Paulino J Garcia at Cabanatuan City ,but I knew they didn't have the medications the patient needed .

          It crossed my mind to send them there anyway. It was convenient to just send them away to anywhere, but it was, not only, just not right,  it was disturbing.

          An hour earlier, a 5 year old female child accidentally ingested a silver jewelry cleaner placed in a used  sprite bottle. Shortly afterwards, she was noticed to have difficulty in breathing. She was quickly brought to the emergency room. The family literally flew to the hospital.

          She was in respiratory arrest when she arrived at the emergency room.  A tube was immediately placed in her airway and oxygen was pumped into her lungs. She was not breathing. Then, she started having seizures. Anti convulsants and other medications  were given.  She did not have burn marks of silver nitrates inside her mouth, which was what we initially thought of.

Pictures of children with tubes on their airway look like (taken from the internet)

          After initial stabilization of the child, I called up Poison Control at Philippine General Hospital. I spoke to a female toxicology doctor on duty. We exchanged status and vital signs of patient. She said that there were two types of silver cleaner: one had organophosphate and the other had cyanide as active ingredients.

          I suddenly wished it was organophosphate poisoning... that would be easy I thought. I glanced sideways and saw my patient...this couldn't be that. It must be cyanide...

          "By the rapidness of course of the illness, it is safer to assume cyanide posoning", the doctor on stated. ( Naloko na, dalawang doctor na kaming nagsabi.)

          She said I had to give the antidote..."What is it?" I breathlessly cut off her sentence midway . " Sodium nitrite and sodium thiosulfate" she said. Then she quickly added "Does your hospital have them?"

         "No. No, we don't have them here ...or in the entire province," I said. The admission was so shameful, that it made my face reddened.­čśľ

          "Is there an alternative?" I asked. And she said that i can put half nitrate patch on the anterior chest wall now. She was about to say something again when i interrupted..."Can you hold on a minute please?"

          I went to our nurse and gave him additional instructions.

          I came back... she gave me a long list of laboratories I needed to check on... She explained that the patient really needed the antidote ,and ,at best ,she needed to be where the antidote can be bought ,or, be at least near where the antidote can be taken...but at the same time, and we need to go through the same route like all patients... pass through the emergency room unit!

           (I wondered if I can send my patient beside this doctor whom I was speaking to. She had calm soothing voice. Perhaps , she's the perfect doctor for my distraught mother too.)

          After hearing from the toxicologist that it was best for the patient to be near where the Poison Control unit was , it only meant..."TRANSFER!"... to Metro Manila­čśú... to Philippine General Hospital ( it's after all, the most dreaded hospital to transfer to... their emergency room is run by genuinely overworked temporary workers who whine all the time.Nayks.)

             But there was always hope, nothing was hopeless... and transferring to Philippine General Hospital without knowing anybody...hay, eto na... I couldn't help it , I felt a squeeze of hopelessness­čśł and impending doom.

          Nevertheless, I will dare, I will risk , I will try .

        There was not a moment to lose. I gathered  my wits, and summoned my courage.


           I called up the Philippine general hospital  emergency room thrice, and got hanged up twice. I guess they were busy.

         But after a few more minutes... Dra Jolina finally answered. Hooray! Getting through by phone is one hooray moment...not kidding.

          I explained that the reason for transfer was because we don't have the antidote for  cyanide poisoning. "Huh, who told you it's called an antidote?"  She said with unexpected mockery in her voice. "It's just sodium nitrite and sodium thiosulfate ." She added.

           Awwww. And I was expecting to get those comments at least half way through the referral. That was so soon.  

        I interrupted her "Doctora, I already called poison control, they called them antidote. Do you mean the doctor I spoke to was lying and they should not be called antidote?" (My gulay, what a bully , I thought. I was being nice, diplomatic and nice...)

          She explained why it shouldn't be called antidote. I wondered why would not calling it an antidote mattered at this time.

          I told her patient information, history, physical exam, interventions done and vital signs.

          Soon enough, she started questioning me ...and it was suppose to sound like the comprehenssive oral or revalida exam,  the ultimate exam before  graduating medical school...

           And... I deduced that because she was an emergency room doctor-in-training from a huge hospital , she felt that she was the better doctor than I was. And that this exchange of academic questions and answers were necessary before accepting patients for transfer.       

           She was insisting on hooking the patient to dopamine, and I kept on telling her, blood pressure was normal.  And when I just had enough of her bullying, I said" Doctora ,I had been a doctor ten years your senior, and and I'm telling you, my patient has normal blood pressure and, pulses are bounding. She doesn't need dopamine as of this time."

          Sounding a little irritated she  then challenged me what the color of the nail beds were. I repeated  that oxygen saturation was 95 to 97% . Again, I wondered if she knew how pulse oxymetry worked. I was tempted to say " Doctora, if nailbeds were blue, do you think oxygen saturation will be 95%?" ,or, I should have just answered pink ,and kept it simple...

          She was trying to keep us out.. My patient was going to be one of those patients she had to explain to her bosses. No patient meant easier  work. (I know , I used to be a trainee too).  She was sending us away. She thought that perhaps if she made me  feel I was too dumb to answer her questions, there won't be a need to transfer my patient there.(...Hmmm...feelingera...)

          And as if our conversation about the patient was not enough, she managed to squeeze in her over worked sentiments "Duty ako dito bente kwatro oras." With acidic tone in her voice.


          I nearly laughed out loud. Was she expecting empathy from me, when she was so inappropriately impolite and corrosive. I was having an adrenaline  rush just by speaking with her.

          She now made me feel that the entire conversation with her was a complete waste of cellphone battery and load. She was simply on a different plane. I was trying to make a difference in one child's life, and she wanted to complain about total patient number on her 24 hr duty...whutdahell.

          The conversation was going nowhere. "Doctora, Please don't be sarcastic." I said almost in a whisper.

          She paused.

           All throughout the time I was speaking to Dr Jolina, my patient's mother was weeping in front of me. The mother knew that by the conversation I was having, the person on the other end of the line was a jerk. ( but not necessarily a doctor... baka admitting personnel..haha).

         Eventually, I asked her if she was accepting the transfer. She told me that she will call me and that I shouldn't call her back. She was going to ask her superiors if the patient can be accepted.

           ( Yayks, she was just the first obstacle. Oh my gulay! Time was of the's 5 to 6 hours from Baler  to Manila inside a flying ambulance  plus the waiting time for doctora's call back ,plus traffic, plus reassessment ,plus re history taking and physical exam, plus lab works, plus getting the drug ,plus administering the drug equals to one critically ill intubated child and a helpless family.)

          "We don't know if we will be accepted. We will have to wait for her call. " I announced to my patient's mother in all honesty.

         There must  be someone somewhere else who would accept us.

          I started calling up a few other hospitals. We were politely refused . Every emergency room doctor I spoke to said "Sa PGH lang may toxicologist."

          And that's that.   "Sa Philippine General Hospital lang may toxicologist" ,the phrase sounded like a vicious Kreb's cycle in my biochemistry lecture or like a Carly Jepsen song's Call Me Maybe, it never ceasingly echoed in my mind.

        While I have indeed spoken to the toxicologist on duty who was ,btw, nice... we still had to wait for  Dr Jolina the emergency room doctor's  call back  to confirm our acceptance.

           The light at the end of this tunnel just became a bit foggy.

          The seconds became minutes, then the minutes became  hours. We were like waiting for nothing.

           Decisions had to be made.

          Under the current situation, the parents were already resigned  but resolved .Their resolution was crystal clear.

           They would  rather stay with me with a known greater degree of uncertainty, than risk the transfer.

          It was not right ,but then again, there was no institution  who was willing to take them in.

          I called back Poison Control and told them that we were refused by three other hospital and , transfer to PGH where Poison Control was ,was highly uncertain... I also called up to know how to treat the patient.

          The parents did not know anybody from Manila, but, we had to obtain the antidote one way or the other.

          They called up a friend who has a friend in Manila and begged him to buy the antidote from PGH , Ermita and send it by Genesis Bus at Cubao.

           At half past midnight, three and a half hours after the initial call, Dr Jolina called back... she sounded more pleasant this time. I sensed that she felt relieved. She learned from their toxicologist that the patient was not transferring and that I already asked for the procedure on how the medication will be instituted.

          Meantime, the patient's uncle rode his motorcycle. He left before midnight to travel 115 kms away, Baler to  Cabanatuan to pick up the antidote from the bus terminal. He was meeting the bus halfway from Manila.

          I spoke slowly and clearly with the emergency room doctor. I did not want any misunderstandings between us, "Doctora, we are not transferring my patient anymore because four hospitals refused to accept the transfer. You refused to accept us."

          Like a jolt of lightning, Doctora Jolina's voice suddenly became ruffled. She spoke rapidly. She explained the pathophysiology why cyanide poisoning caused bluish finger tips.
           At this point, the information she was explaining was a complete nonsense. We were waiting for confirmation of the transfer from her. Whatever she was saying won't make any difference in the management of the patient.

          Listening to her chattering gave me an adrenaline rush. I can hear my heart beating pambihira.

          Was she trying to be impressive...I don't know. She spoke faster and longer, as if trying to convince herself of her  YOLO moment.

           And after a few more breadths, I learned very importantly that Doctora's name was not Jolina was Zolina and that I should refrain from addressing her Jolina... (adrenaline rush nanaman... hahaha) and that the patient was accepted for transfer.

          Wow. The patient's acceptance was so unexpected. Surreal.

          After driving non stop, Baler to Cabanatuan, then, Cabanatuan back to Baler, the  patient's uncle's motorcycle broke down 20 kilometers off the  edge of Baler.

          Another uncle of the patient rode his motorcycle from Baler to San Luis to fetch the antidote.

          My phone rung. The intensive care nurse just received the antidote.

         "Punta na 'ko."I said.

images and videos are taken from the internet... ate... i hope i made you happier.

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