Ronibats.PH Stories of a Filipino neurosurgeon, teacher, and writer

When Things Go Wrong As They Inevitably Would

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Maternal instinct sent Ofelia Reyes running to their backyard when she heard the loud thud that disrupted her Wednesday afternoon. And for good reason. Lying on the ground, beneath their santol tree, was her 16-year-old son Eric. He would have been in school if he were in college, but his family being unable to pay for tuition, he had joined the population of out-of-school Filipino youth who become tambays in billiard halls, walk shirtless in main roads to heckle street drivers, and climb trees to keep themselves preoccupied. The experience would teach Eric to look for more productive ways to spend his afternoons. As his neurosurgeon, I would also learn from his fall: he was my first re-op.

I saw Eric at the emergency room ten hours after his injury. With a markedly swollen right eye, he was barely awake. He could only express his pain by grunting, unable to say a word or follow my simple commands. I checked his eyes; his pupils were unequal – an ominous sign. His cranial CT scan showed an epidural hematoma, a large blood clot that was compressing his brain. Eric needed surgery fast.

“Nanay, kailangan po nating operahan ang anak ninyo,” I said. “May namuo pong dugo sa loob ng ulo niya. Naiipit po ngayon ‘yung kanang bahagi ng utak niya kaya hindi siya gising na gising. Papayag ho ba kayong ipaopera siya?”

“Hindi po ba iyon delikado Dok?” Ofelia asked in return.

“Siyempre delikado, kasi operasyon po iyon sa utak. May 10% pong chance na magkaroon ng komplikasyon; wala pong doktor na magbibigay sa inyo ng 100% guarantee na magiging successful ang kahit anong operasyon. Pero kung hindi po kasi natin siya ooperahan, pwede ho siyang ma-comatose at hindi na magising.”

“Sige po Dok, gawin po ninyo ang nararapat.”

There was no fear in her voice. Perhaps anxiety, but mostly resignation.

As I habitually did, I explained to her in layman’s terms my contemplated surgery, pointing where to expect the surgical incision and where I intended to place the tube drain that would be sticking out of his scalp after the operation. I discussed the possible complications of the surgery and how much money they would need for operating room needs and post-operative care. Early on, my senior residents taught me to go through these things in detail with the patient’s family before any surgery —Β  no matter how simple or complicated the operation seemed. The habit would pay off that night.

In an hour, I was in the operating room evacuating the blood clot that compressed Eric’s brain. This is going to be a good case, I remember telling myself. I had done the same procedure unsupervised many times before.

There was a lot more blood than the CT scan showed; as I suspected, the bleeding inside his head had not yet stopped. Fueled by the adrenaline rush of a life-saving surgery, my every move was cautious and calculated, from the moment I cut his scalp until I stapled my incision. I was able to remove the entire blood clot and my anesthesiologist was able to extubate him, letting Eric breathe on his own without the need for a mechanical ventilator. I brought him to the recovery room satisfied — to say the least — and proceeded to fulfill the day’s obligations.

Eleven hours later though, Eric was still drowsy in the recovery room. He could now lift his arm and bend his knees when told to do so, but he still kept his eyes shut and could only utter inchoherent sentences. He should have been fully awake at this time. A feeling of unease began to set in. After referring the case to my senior residents, I brought Eric down to the Radiology Department for an emergency scan.

The CT scan monitor showed that I had completely evacuated the blood clot on the frontal region of his brain; the part that was originally compressed had now begun to expand. The bad news, however, was that a new blood clot had formed, albeit smaller, just next to where the original one was. It was this new clot that kept my patient from regaining full consciousness. Immediately, our service made the decision to re-operate and remove this new blood clot.

Being the primary neurosurgeon, I would have to do the re-op.

In the elevator on my way up to the recovery room, a thousand thoughts bombarded my head. How could this have happened? What did I do wrong? Could I have averted this from occurring? Did I take too long? Did I do it too fast? I’m sure I checked my bleeding parameters, but could I have overlooked something? So what’s the plan now, neurosurgeon?

I kept playing and re-playing the entire surgery in my head, each cut and each tie I tried to remember in an attempt to figure out where I faltered. It didn’t help that my neurons and my heart muscles were racing against one another.

Ofelia was at her son’s bedside when I arrived.

“Nanay, kailangan po nating operahan ulit ang anak ninyo,” I looked at her in the eye.

“Bakit po Dok? Mas gising na po siya ngayon kaysa kagabi.”

I showed her the films and the new blood clot.

“Pasensya na po ‘Nay, gaya po ng sabi ko sa inyo, minsan hindi po talaga natin naiiwasan ang mga komplikasyon na ganito.”

My voice was trembling but I tried to suppress it. That was not the time to appear weak and unsure, not in front of my patient’s mother, who probably only drew strength from the belief that experienced health care professionals were taking care of her son.

“Sige po Dok, gawin niyo po ang nararapat.”

Exactly like the first time.

“Kayo na po ang bahala sa anak ko,” Ofelia said as I wheeled her son back to the operating room.

I could only pray that I be guided to make the right decisions to save her son’s life.

A re-op, I would learn that night, is ten times harder than the initial surgery. I knew what to expect. I knew what to look for. I knew exactly what to do depending on what I saw. I even had a senior resident assist me this time. Still, every hand movement was being weighed down by thoughts of my patient becoming severely disabled after the operation, or worse, dying on the operating room table. I had to constantly remind myself: focus. Even after the operation, there was no reprieve — only the anxiety of waiting, wondering whether my patient would wake up.

Or not.

Twelve agonizing hours later, he did.

“Eric, taas mo nga kamay mo.”

Quickly, two arms were held up in the air.

“O baluktot naman ang tuhod.”

He bent his right knee and, to my relief, his left.

“Okay, very good! Hinga lang malalim ha, kapag kaya mo nang huminga nang sarili, tatanggalin rin natin ‘yang tubo sa bibig mo.”

“Salamat po, Dok,” Ofelia said.

“Wala po ‘yun ‘Nay.”

Eric stayed in the recovery room for one more day, during which time he was weaned from the mechanical ventilator. He was subsequently transferred to the wards awake, conversant, and following commands.

“Alam mo Dok, masama ang loob niya kasi hindi niya nakuha ‘yung santol,” Ofelia confessed during one of my visits to them in the wards.

“Eh ‘di sa follow up mo, dadalhan mo ako ng santol?”

Two tubes sticking out of the M-shaped incision on his head, Eric grinned.

“Hindi ko na po uulitin, Dok.”

“Eh ano munang pangalan ko?”

To my surprise, instead of answering, Eric turned to the side of the bed where I was standing, grabbed the hospital ID that was dangling from my neck, and attempted to read my printed name.

That was when I knew: after the humbling, heart-racing, nerve-wracking experience, all is well.

About the author

Ron Baticulon

Ronibats is a pediatric neurosurgeon, teacher, and writer. In 2018, he won a Palanca award for the title essay of his upcoming book, "Some Days You Can't Save Them All" (UP Press, 2019). You can follow him on Twitter @ronibats.

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By Ron Baticulon
Ronibats.PH Stories of a Filipino neurosurgeon, teacher, and writer

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