“Sir, regarding patient Ofelia Reyes, inform ko lang po kayo na nag-mortality na. Mother was firm with her DNR status.” I was sleeping on the couch in the Neurosurgery office when my message alert tone woke me up. It was 1:42 in the morning. Our resident mosquitoes were feasting on my ankles, where I had forgotten to put my insect repellent lotion out of stupidity and exhaustion. Though the news was not unexpected, it took a full minute to register in my head: my patient had just died.
I picked up my glasses which had fallen to the floor, used my palms to flatten the hair strands that had stuck out in all directions, and put on my shoes. After checking that my keys, wallet, and phone were in their respective pockets, I closed the office and made my way to the Pediatric ward. I had one last task to accomplish for Ofelia.
Eight hours earlier, I did rounds on my one-year-old patient and noted that her condition had not improved significantly since she went into cardiac arrest for six minutes the previous day. It was time to discuss the prognosis and options with her mother.
“Mommy, hindi po maganda ang lagay ng anak ninyo. Hindi pa rin po siya gumigising. Ang mga gamot sa suwero lang po ang nagpapataas ng blood pressure niya.”
There was no reply. Only a gentle, steady streaming of tears from both eyes.
“Pasensya na po, Mommy. Mukhang nag-impeksyon po talaga ang shunt na inilagay natin sa kanya. Naaalala mo ba ‘yung napag-usapan natin noon tungkol sa mga posibleng komplikasyon bago ko siya operahan?”
A nod, and a muffled cry.
I wondered, how much did she remember? Did it even matter?
Four weeks earlier, Ofelia lay in almost the same state: hooked to a mechanical ventilator and hovering between stupor and coma, the effects of excess cerebrospinal fluid accumulating in the brain from tuberculous meningitis. I explained to her mother that we needed an emergency procedure to insert a ventriculoperitoneal shunt, that would divert the excess water out of her brain and relieve the hydrocephalus that was keeping her unconscious. I discussed the risks, too, and made it clear that the benefits outweighed the former in this case.
Ofelia’s mother gave consent, but expressed apprehension because she and her husband were unemployed. They would not be able to afford the cost of the operation. Thus, I had to wait as the Neurosurgery and Pediatric services looked for sponsors who could shoulder the cost of the shunt.
Twenty-four hours later, we obtained the funds we needed and brought Ofelia to the operating room. My patient made rapid recovery and was discharged seven days later.
Her mother, most of all, was happy, being able to bring Ofelia home awake, breathing, feeding, crying, moving briskly on her own. Being the surgeon, I also felt satisfaction and pride, having been able to save a child from dying.
As it turns out, the good news was short-lived.
Ofelia was brought back to the emergency room three weeks after being sent home because of fever and seizures. More worrisome, the shunt’s valve had eroded through her scalp.
Initial laboratory workups confirmed what I had feared: the shunt had become infected. She had signs of pneumonia, too. The infection had overwhelmed her immune system, causing her to stop breathing and her heart to stop beating just as she was waiting to get a CT scan. She was revived after six minutes, but from then on, she had become too unstable to be taken out of her hospital bed, even to obtain x-rays. Only the mechanical ventilator and intravenous medications were keeping her respiration and heart rate within normal limits.
Reviewing my patient’s chart, I was disheartened to learn that the parents had signed a DNR waiver. They would no longer want to facilitate laboratory workups and they would only want the nurses to administer whatever was left of the medications (almost all of which were obtained from donors). If Ofelia went into cardiac arrest again, they would not want her resuscitated.
“Ipapaubos niyo na lang daw po ang mga gamot niya, Mommy? Kapag itinigil na po natin ang mga gamot, titigil na rin po ang paghinga niya at pagtibok ng puso…. Kung ganoon po ang mangyayari, hanggang dito na lang po talaga tayo. Wala na po kaming magagawa para sa anak ninyo.”
“Dok, kung meron lang po talaga kaming panggastos, gusto pa po naming ituloy para mabuhay pa po ang anak namin, pero walang-wala na po talaga kaming pera.”
She continued to cry.
“Ok po Mommy. Pasensya na po, pasensya na po.”
Eight hours later, I made my way back to Ofelia’s bed. Her mother remained seated where she was when I last spoke to her. She had never left the bedside.
“Mommy, tatanggalin ko lang po ‘yung shunt ng baby ninyo. Kung OK lang po, lumayo po muna kayo saglit para hindi niyo na po makita.”
She nodded and stood up. She had stopped crying, but by now both eyes were red and swollen.
Ofelia’s body was wrapped in hospital linen, but her face was exposed, noticeably pale but almost beaming as it reflected the ward’s dreary fluorescent light. All the tubes had been pulled out and all the micropore tapes removed. I began to unravel the linen and was surprised to see that she still had earrings on. She was clothed in a multi-colored floral dress. She could have been just sleeping, peacefully and enviably still amidst the chaotic world in which she’d soon grow up.
But no, she was dead. She was my patient, and she now lay lifeless. It seemed I could only cheat death once for this kid. The scene reminded me of a painting I saw in the National Museum a couple of months earlier: that of a dead infant, eyes closed but smiling, donned in a flowing white dress, and surrounded by flowers in bed.
I turned Ofelia’s head and upper trunk to the right side, the same position I put her in when I did my first operation, except now it was easier because her body had begun to become stiff. There was no resistance at all. Her skin was cold against my gloved hand. I extracted the shunt with ease, pulling it out by grasping its exposed valve through the eroded skin. I sutured the skin and was done in a minute. I had probably spent more time looking at my patient. Contemplating on my mistakes, what I had done and what I had failed to do. Then I prayed.
Only when I looked up did I realize that the mother did not go away as instructed. She merely transferred to the other side of the ward and had observed the entire procedure through the glass-and-wood dividers.
I beckoned to her.
“Tapos na po, Mommy. Pasensya na po talaga…. Salamat po.”
I proceeded to the nurses station to write on the chart. Then I walked away, specimen bottle containing the shunt tip in hand, head down and gaze on the floor, each step successively heavier than the last, overcome by grief, frustration, disappointment, and anger.
I wanted to run.