This is an MRI film of my patient R. Terribly ruptured and protruded intervertebral disc pieces sit deeply on nerves between L4,5 and L5, S1. Non-stop excruciating pain and muscle spasms, multiple unhelpful surgeries that worsened the pain to a higher level, and tolerance to opioid painkillers made him come to our clinic for help.
But none of those matter anymore. R committed suicide two months ago.
I still remember it took us almost a good hour each time to finish all the needles. PONAMS, ear, and scalp acupuncture had to combine to calm an Indian man who showed up with muscle spasms, profound sweating, and screaming. It was until he started telling us about his story, making jokes, and even inviting me to spend some late-night happy hours at a bar that we could be sure his pain had gone and could be released from the session.
The late-night happy hour had never taken place before he passed away. R wasn't the first patient I had had who died of illnesses. However, he is the only one who ended his life by committing suicide. Looking back, my heart was shaken as the lost lives were stirred up.
More than three decades ago, I was assigned to a terminal cancer patient when I was an intern doctor in the oral surgery department. She had multiple distant metastases of cancers that made her condition worse. Palliative care became the only intervention in her last phase of life. The family and patient agreed to not suffer from more treatment, be kept alive with all the tubes in her, and leave the world without dignity.
My supervisor asked me to keep a very close eye on her critical condition, for it can change dramatically in the blink of an eye. So, for that, I went back to her room to check up on her in the afternoon.
Without any warning signs at all, she started vomiting blood as I was going through her chart. A massive amount of blood disgorged out of her mouth and nose one after another and covered all over her chest and sheets.
I rushed to the door and shouted to the nursing station for emergent assistance.
Before the help came, there was almost nothing I could do about what I saw. The truth is, I was petrified of how the scenes played out in front of a rookie. I watched her pouring mouthfuls of blood one by one. Then, when she gasped for breaths and choked on the blood, more blood ejected out vigorously and sprayed as if no one cared.
She got choked in a vicious cycle of coughing blood, and coughing more blood got choked even worse. Her body bowed, eyes popped, and face twisted as we tried our best. Finally, she left the world in extreme suffering.
My supervisor was right. The change was dramatic, and it happened so suddenly that I couldn't prepare myself in time for losing a life in the 3rd month of my internship.
From the surgical department to internal medicine, you couldn't hide and run away from the fragility of life.
A few nights before I finished my internship at the infectious disease department, we had a critical patient about to stop living. Somehow, a faint voice in my head drove me to seize the moment for her.
I kneeled on the mattress next to her, doing CPR. I guess I lost time and never stopped until the resident pulled me back one hour later.
"That's enough. She's gone. You need to stop now. The time of death is…." He said it as if he were reading a statement that has been practiced millions of times.
I sat exhaustedly in a chair with a chart before me, not knowing where and how to start. So many mixed feelings surfaced and sank alternatively in my mind that I couldn't distinguish one from another. My brain went totally blank and refused to think straight.
I couldn't face a lost life the same unconcernedly as the resident had shown. Yet, should and will I become one with time and experience? When nothing else is left but routine rituals, or even worse, not disturbed by patients' sufferings, are we still qualified to be doctors and practice medicine?
After she was transferred to where she should have been, the late-night shift nurse told me the sheet was spattered with a lot of blood, and it seeped to where I knelt. I pulled up my pant legs and saw dried blood on my kneecaps and shins.
"You have tried, young man. Now, learn how to let go." The nurse handed me a wet towel and said.
The two lost lives affected how I treat patients and taught me to do things in a way that can ease patients' hearts and mine with a clear conscience. As a result, I always encourage my patients to try all the options before giving up on their dental problems. So, yes, I am a firm believer that an opportunity arrives only when you try and prepare for it.
There was good news on many occasions by overturning a bad situation after a tough fight, while a lot of times, I couldn't. Therefore, patients and I had to start all over again to find other solutions. I held the same attitude and persistence for R as I treated his challenging pain.
The crushed disc fragments that pinched into the nerves and scar tissues from multiple surgeries made his pain more resistant to the treatment. We were able to gain temporary relief each time, with no hope of curing in sight, regardless of how many acupuncture techniques combined. When the pain disappeared for the first time, it lit up a spark in the dark for R to keep returning for more hope.
R's pain battle looked the same as today's ongoing scenario of coronavirus and COVID-19 vaccines. Such a virus, insignificant in size and visible only under specific devices, has thrashed the world badly. We couldn't stand back up on our feet steadily for so long and had to form a shield to avoid direct contact with it. We may defend better with vaccines, but the virus always runs ahead of us and invades us when exposed to a new variant. R's disc fragments, like the coronavirus, may be under control for a short period but never stop attacking no matter how hard we fought for him.
Among all the medical interventions that R had gone through, each of them may have provided temporary relief, but none could cure it for good. His pain seesawed up and down with more flare-ups than relief. The chance of winning? I have to say the light had never appeared at the end of the tunnel before he quit on himself.
In those days of enduring excruciating pain and spasms, gasping for breaths after endless torturing, and surviving each attack that withered him inside out, R asked me with tears in his eyes for a simple and honest answer about his treatment—What improvement have I seen after months of efforts? Can I stop the pain or not?
The atmosphere turned silent around me, and pairs of eyes stared at me. I looked straight into R's eyes and told him nothing but the truth.
I spent my entire adult life learning and practicing various medical systems. No medicine is perfect, and there are risks and uncertainties that come with all interventions. I believe that there were several talks with doctors about his treatment as R struggled with pain. I wonder how many equivocal replies R had to listen to in the past years? How many attempts had those doctors made to placate R and not leave any trace of evidence that might be used against them someday?
Say you go to a doctor with a dagger in your thigh. The doctor says that he can stop the pain and make you walk and jump like an average person without pulling out the knife, and, "Everything is gonna be okay!" Would you believe him? Those words may be comforting for some people. But, unfortunately, the truth is that it is a statement that 100% ignores the medical facts and, even worse, a baseless lie with no common sense—not even a white lie.
I understand the dilemma and awkward situation the doctors were in when potential troubles could be caused by their own words. However, when a patient is well aware of what happened to him, asking for a straightforward and honest answer from his doctor, what would you say? Placating him again?
To PONAMS, the progress made in R was plodding and limited. In his first session, the meridian linkage was the only step that did not cause him more pain. After that, both "Tonify Assisting Element (TAE)*" and" Tonify Parents (TP)*" soared the pain drastically to the level where violent muscle spasms were so intense that needle insertion became impossible. Three months later, TAE can finally be incorporated into the protocol without flare-ups. R's response was the only case I have ever seen in the whole course of PONAMS treatment since it was innovated. What lies behind the pain is a structural deformity that will not disappear through any of the acupuncture techniques.
What could TCM and acupuncture do about a tangible and visible object that cannot be cleared after multiple surgeries?
Do I see any progress in him? Yes. Do I see any upcoming chance? Yes. When can the pain stop? I don't know. I told R that those were the facts I saw. There were possibilities for more progress. But the question is, can you live with a slow course like this?
R looked at me, nodded in approval, and said, "Thank you!" He then closed his eyes slowly, and the corners of his lips turned upwards.
A few weeks later, R decided to discontinue treatment. His wife, emotionally burdened and overwhelmed for years, burst with anger and argued with him. Things ended up with her leaving their son and getting a divorce.
I met the wife sometime later in a gathering to celebrate my doctorate graduation. She told me R wasn't well and that her son had to help him with almost everything. Aside from that, her son had stopped R several times for suicidal attempts.
I was surprised when R showed up in the clinic that day. He grabbed my hands firmly, wanting to express his appreciation for all the efforts I had made. His talking was so calm that it raised a medical red flag immediately. Fifteen minutes after leaving the clinic, he complained to his ex-wife, who rushed to the house to check up on him, about me not minding my own business. Ten months after I left the town, R finally made it happen. He replaced the pain with his life for good.
Which one outweighs the other? Life or illness? Different as perspectives can be, the answer is in every living soul as they go through their paths.
Someone once said, "You hold nothing as you make a tight fist; you have every possibility when you release it."
Before it entered my life, I never hesitated or doubted a practitioner's vocation to fight with patients and get them well by all means. But, on top of a doctor's responsibility, I believe that hope comes along with actions.
However, I got confused after being "enlightened" by it.
After I tried everything and couldn't get the desired results we wanted, I often asked myself, "Did I push it too hard? Or should I let it go with the flow in the first place? How can I sleep well at night knowing I did not reach out to what could have been saved?
I used to try my best to save lives, yet lives slipped through my hands ruthlessly. I had done everything I could to help those who needed me. Still, I couldn't conciliate my helplessness when things did not happen as I anticipated. Now, I still dedicate myself to fighting the impossible—without being tied to any expectations. People come and go in your life like a party; some come early and some late. But in the end, they all leave you when they are meant to be.
Many years later, I liberated myself, and so did R. When life was compelled to an end with no choice, was there right or wrong? What delimits it? For a medical practitioner, what should we hold on to? And what shouldn't? Are we holding the same happiness or pain as we think it is? Would we unintentionally release lives and hope that could have been kept?
What we should be adhering to, as a doctor, is the responsibility of our patients. Then, free our minds on those taken over by their destiny.
* "Meridian linkage," "Tonify the Assisting Element (TAE)," and "Tonify Parents (TP)" are the three treatment protocols for intractable disorders in PONAMS. In short, the meridian linkage provides an alternative route to resume the flow immediately. TAE is for increasing the number of lanes to expedite decongestion. TP initiates the healing power to speed up the repairing process and resume flow on the blocked meridian.
Restoring meridian flow rapidly and massively may reduce pain instantly on a chronic, long-term blocked meridian. However, it also causes a "rebounding phenomenon" manifested as even worse pain on the lesion site. The best example of the rebounding phenomenon is straightening the crooked and sleeping arms and legs and experiencing a transient yet overwhelmingly pins and needles sensation before returning to normal.
Advice and suggestions:
Though it may indicate a good sign as a rebounding phenomenon occurs, the flare-ups can be too intense to endure. In addition, there were times when patients withdrew from the remaining treatment, particularly those with pre-existing neuropathic pain or other forms of excruciating pain. Therefore, patients need to be well-informed and prepared for what's about to come. For instance, magnets application or ear needles to prolong the pain relief period, taking painkillers as needed, and allowing them to return for emergent care.
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