Saturday, 24 September 2011

The Road Back?

Saturday Sept 24 12 noon: Miranda is being moved to bed 21 Ward 13B. Visitors are still confined to family and close friends. To avoid infection and being infected please sanitize and use mask. Note visiting hours: 9am to 9pm. Re-registration needed.

1pm: She has begun to cough more and clear her throat. But her eyes remain closed, quivering her eyelids. Is this the beginning of the road back?
2.00 pm: As they prepared for the transfer, W & L, A & M, M & I came around the ward and gathered for deep prayer, led by W. It was no sooner than a hour later that she settled to her new surroundings, with view of the large window, bathed in light. We gathered and coaxed her with greetings and salutation. 4pm:  She opened her eyes for the first time in 24 days! What a flash it must have been for her, ever so briefly, incognito. Thank God the next step is on the way for cognitive response! She should be encouraged with a dimmer surroundings. If you next visit her again, watch her flutter her eyes open. Like a miracle.

Sunday Sept 25 9am: Coughing and moving her jaws more often now. Neurosurgeon's view: Trachea-mask to remain until throat clears. Suction maintenance for next 2 weeks in the ward. Stoma may remain until a month further, till she is no more bed-bound. Preparing for home stay in 3 weeks. Yesterday's eye opening still an involuntary motion, according to Dr. EW. He lifted back both eyelids to reveal the left eye oriented this way and the right pointing another, unconnected - like what you'll see in a broken, bedraggled doll, upturned.

2.30pm: Her joints became very stiff, fingers curled into claws. V and E did basic physio on her limbs, as PTs are not available weekends. This is necessary, to avoid being a "foetal shrimp" (Neurosurgeon's words).

3.45pm: This time her eyes opened to a slit - V could see her right pupils through them. Her left eye was not so wide but L could see that she was trying to listen by the tilt of her head.

Monday Sept 26 9am: Trussed up against the pillow with her now misshapen head, her arms awkwardly askew, spastic legs kicking randomly once, one would not have guessed that she once played for the national netball team. She looks stern, severe, as if going to scold me again. Sometime the trachea-insert must come off. There is still lots of scolding left. Temperature 38C, being quite a spike so visitors now limited to family. Post-note: Trachea being weaned off by weekend.

12 noon: The sneeze awoke me at the couch nearby. To my surprise the trachy-mask is gone. She has been challenged to breathe entirely on her own. And maybe sneeze unhindered.

3pm: S and SE came just in time to see her open for a longer time focusing. This time the eyes seem coordinated or "connected". She tried to look. No even that seems too optimistic. The eye appeared fixated, in a daze as if trying to recognize your face. Then she appeared to try to talk and sit up. The PT did a thorough workout and clear some more throat congestion. When you visit, say your name slowly and re-introduce yourself again, let her gaze take time to recognize you.

Tuesday Sept 27 10.45 am: The PT did a courageous job of sitting her up, moving her head, neck and torso. Then she was left to hold up, even for a while. More exercise followed until she fully opened her eyes. Considering this a first time, her floppy body did well.

12.45pm: FC and a pastor friend came to pray and after a while she opened her eyes to look (yes, look) at me, pupils scanning as if to recognize me. This went on for 5 minutes, her hands clawing for assurance.
2pm: Colo-rectal surgeon concluded that tumor does not seem to exist as seen from colonoscope but suggested a final x-ray of bowel-prep before leaving for home care. (Note: Please comment if you have a view here.)
Cranietomy (bone flap closure) and closure of stoma could be done together after regaining full consciousness and progressed motor capability, possibly 6 months after home therapy.

5 pm: "Any more bad news for me?", the neurosurgeon could hardly hide a grin as I needled him. Apparently the worst have already passed:

1) She can be described as "being in a vegetative state with cycles of wakefulness and coma". Continuous coma for periods of about 2 years are termed vegetative.

2) As she is slowly showing progress, treatment will be considered in any exigencies for now. After 6 weeks from September 1, if her condition does not improve, or worsen, the back-off rule of treatment will be decided by me in consultation with informed family members or caregivers. The 6 weeks period itself can be revised based on physiotherapy and other progress of consciousness, in like consultation.

3) Plans are in place to have her discharged for home or therapeutic care in two weeks.

4) She is almost certain to be bed-bound upon discharged with full dependency care, but her progress does depend on her state of gaining consciousness and therapy.

5.30pm: She awoke during examination and she looked at me with both eyes. I can never forget the look.

"Kian, I am not afraid of death, but I really dread lingering suffering", that look made me remember those words from her during better times.

Wednesday Sept 28 3.45pm: The day is half gone and I have nothing to say.
6.30 pm: V arrived with children in tow to cheer her. Eyes opened aimlessly after physio done, despite Z's encouraging shouts. Looks like her conscious recovery flows and ebbs. Will have to wait for a better day. The corner to be turned seems a distance away.
                                   "We are waiting!  we are waiting!!"
Thursday Sept 29 11am: Neurologically impasse. However as she opens eyes fully during physio, it is really encouraging. Normally she enjoys back-scratching and she seems to like backslapping! More coughs and expunging and the trachea insert might be out even by next week. 11.30am: The PT put her on a chair. She seems contented sleeping there for 1/2 hour at a time. Sat for one and half hours unsupported. The nurses began laying her down.

2pm: Got back from lunch to see her back on bed, eyes opened. Seemed to scan the environment, though right eye still slanted left. I approached her and she scanned my face curiously for a moment, then shifted to the sunlight. Again I called her and she shifted back momentarily. Then both eyes now moved to the left ceiling. For 6 or 7 minutes she looked. Then it hit me. She doesn't know me. For now. The machine beeped. Sensor moved but the heart rate went up. To 114 bpm. ECG please.

Friday Sept 30 1pm: The PT worked her and told me her eyes opened. But when I got back from lunch with a visitor, she was seated unsupported, tired out and eyes shut, for a good hour. That remained so on bed for the rest of another uneventful day.
After-note: Got a call at 10pm that they were fully open when niece V&L, family doctors L&MY dropped in.

Saturday Oct 1 8am: All the prayers have enabled us to crawl out of debilitating September. She belongs to the group whose eyes open only after the 4th week. Good recovery prognosis for openers during the 2nd or 3rd week. There is hope yet, although the usual dark prognosis on left temporal damage came from the latest ct-scan. 3 weeks thereabouts to discharge.
11 am: She tires all of us out when we give her Physiotherapy. But she does not even open a slit to see AC and JB, AC and WW. However Si, KC and wife got a slit welcome. Then at 4pm more of us got tired exercising her and she rewarded us with more open eyes to greet ZeeCheah, grandson and J.

Sunday Oct 2 10.30am: Barium NMR gastrography scheduled for Monday to complete the colon exam. Also trachea weaning starts to complete Thursday. Miranda is unconscious and is likely to be discharged bed-bound in a couple of weeks. She will require frequent interactions during the wakeful cycles to regain speech and limited cognitive skills. Only with full consciousness will she be wheel-chair stable for motor rehab, etc. When will that be? The Lord knows.

3pm: Self-quarantine (flu)

Monday Oct 3 9am: Running nose stopped mysteriously to put me back on watch. I had watched her silently from the bedside, as if in deep sleep, mouth ajar, as she is wont to do normally. My mind flashed back to the early Friday meeting room, when the neurosurgeon returned after the miraculous recovery of her expanding brain and explained sullenly the risk of removing the huge clot - one outcome for my permission to proceed would be a vegetative state, exactly as it has turned out. I now realize that the neurosurgeon wasn't brain-washing me to be prepared for the worst. But at that compressed point in time was the most heart-wrenching decision I had to make in my life, leading her to something she may never want, now or in the future. It is, on hindsight, the right decision, I've left the door ajar, for God might yet do another miracle. Slamming it shut would be most convenient for me and others but it will leave me with nightmares of "what-ifs". So now we are still waiting...

2pm: Came back from lunch to see her lying there eyes open. Her eyes seem to have a pleading look, like she needed water for her dry throat, jaws grinding. But there was nothing I could do until swallowing is purposeful. Found out that earlier she had failed the trachea test - her BP went too low. Could it be the after effects of the gastrography? Results not in yet. For that she even missed her PT exercises. Heart-rate went 114 as her arms and fingers curled up like giant rubber-bands. Later (5pm) BP became low, and temperature high of 38. Not a good day.

Tuesday Oct 4 9.15am: The skies have been weeping too. I arrived late to see her lying there eyes fully opened. I hurried with the soaping. After drying my hands I frantically looked for her spectacles. As I placed her on she seem to be able to scan the scene, pausing here and there on the framed pictures and window outside. This time she looked for 25minutes. But her fingers tightened and her arms taut as cables. Heart beating fast but the fever spike subsided. She turned her head when the OT opened her fingers. The most disturbing was when she looked straight at me sticking her tongue and moving her jaws..there was nothing I could do for her dry throat, if only I could offer her the coke.
11am: The stand-in PT worked her with me, sat her on the bedside and got a good BP. Her head droopy she looked like a lifeless doll. But it was progress.
1pm: She opened her eyes again - the third time over 5 hours, peering through her specs. Visitors are encouraged to stimulate by interacting with her opened eyes. That seems to be the next avenue to advance her neurologically.
Looking at her shriveled left lobe I cannot help but wonder what part of her will we be missing. One finding says that "Left side lesions (in the left temporal lobe) result in decreased recall of verbal and visual content, including speech perception". Miranda is not an oratory giant, but her choice of words in clear thinking above muddled emotions have resulted in decisive leadership. Being a person of her word, her strength of character shines through them. I saw this in the visitors' faces the day after the craniotomy, when her left forehead was swollen bloody. The women had a rush of tears and some men looked with eyes welling up. Here was their confident leader with knowledge weaved into masterly decisiveness lying broken and vulnerable. And then there was her logical prowess, speeding along ahead of most. Now but a shriveled shadow. Her objective, deadpanned approach to multifaceted problems was definitely left brain. Whither has it gone? And then there was her memory. She would recall in amazing detail what we were doing on my first birthday of meeting her some 30 years ago. Directions of places where she only went but once years before, clearly etched on her mind. Then her commanding presence, confident when faced with a critical decision, backed up by her memory banks. Is it still there?
Husbands at critical points of life may ask "Who is this person I loved? And who is she now? Can I love her again? Will I?" It may be too early to ask. But it dawned on me that the battle has only just began. Or is it a long war looming? Then the words echoed - "Better or worse, in sickness and in health..." - we are commanded to love as He loves us - unconditionally. End of discussion.

Wednesday Oct 5 11am: The PT, OT went through their paces. Sat her on the bed, limp as before. But sitting on the recliner seem to be relaxing. Gastrography show discontinuity in lower intestines, but surgeon decided fleet enema will do, followed by Xray to complete the process. Trachea spigot challenge to resume next week.
7pm: Heard that V&L and children had a great 70 minutes interacting with opened eyes. What the neurosurgeon ordered. But I had no heart to remind them that she sees but not perceive.

Thursday Oct 6 9.30am: Before I could do my usual starting monologue she opened her eyes during feed. Then closed shut till the PT sat her up and did the thoracic turns. They then lifted her to the recliner where she will sit contentedly for two hours.
12 noon: Had my first lesson on diapers and stoma bag management. Miranda doesn't mind, at least from her reaction. After that I thought to myself - that was the most decent thing I could do for her now. I am aware that some friends of hers might be angry at me for not doing enough and letting her extend beyond herself to end up like this. To an extent I stand guilty. Because Miranda is not one to be led about if she has the means. Their anger and my guilt now do nothing good.

Friday Oct 7 9.30am: Again before I began she opened up, and it became less of a monologue. But after the workout and suction by the PT, her BP dropped even to 102/53. The recliner position was abandoned and she returned horizontal. A comatose person cannot tell you if she is dizzy. But suction fluid clear. Leaky stoma bag. Visitors note eye-opening times are 9.30,11am, 2.30 pm,4pm and 8pm, for now. A clarion call to stimulate her visually, as it will do what may not be done neurologically - "reconnect the brain". Wear bright clothes, she'll look you over.
1pm: Her right fingers straightened - the second time I've noticed happening, as if she was swinging a ratchet on her left hand.
5pm: V brought her children and little Z noticed two bits of dried blood no less than 2 meters away stuck on the opposite wall from her trachy spigot . Quite a shot.

Some visitors have said they came to visit me too. How was I doing? I recall the story of a dog lost during the March Japan tsunami. She had a mate that appeared dead next to her, but she stayed whimpering in encouragement. Ever so often she would run off, looking for scraps or something, but returned to his side, nudging to resuscitate him. Many times doubts and a pall of deep sadness are overwhelming. I had to be strong, the visitors said. And so I ride out doing the numerous errands - looking at beds, planning renovations, seeing the lawyers, insurance, checking bills, nurse-maids and banking besides catching the doctors in their rounds to make informed decisions. The caregiver seems to be the extension of the nurses too, ensuring no infections, helping and informing visitors. But I have helpers. Like that dog I return to her side every morning, hoping for wide-eyes. Theirs was a story of great fortitude, and it applies to all creatures. Be that knight with a blue shield, slaying dragons against her recovery.

Saturday Oct 8 9.45am: Sleepy head. Even after physio. Nothing today.
Sunday Oct 9 9am: The alarm shows a heart-rate of 114. Traces of blood coughed from trachea tube. Stoma bag filled into a cylinder with gas about to burst. Nurse please!

Monday Oct 10   9.45am: The skies to me are crying more nowadays. I sat there silently watching her - the top of the trachy-pipe making circular motions with her breathing cycle, her sunken skull gently throbbing. My mind drifted.

She is called a terrific person. Let me share what is it like to live near the fire.
She is in all points more likeable than myself. Everyone lauds her openness and generosity. Acutely aware of the feelings of every living being, she would be the restraining factor of my outbursts. But let me just say that her generosity has its limits. Miranda has her favorite persons. As well as her despicable ones. And she often roots for the underdog - worthy ones.

Last week,in the morning bus I could see people standing stoically, staring blankly at the moving windowscape. Rows of commuters each one with a CPU humming away in their skulls. It controls all life - from the vital breathing apparatus, the digestive muscles, the motor balance as they sway this and that way in traffic, among others. Most of all, it defines consciousness, cognitive awareness, recognition of a face they bump into and the instinct of avoiding danger. They were not zoombies, but could easily be. How fleeting, temporal! One weak vessel in the skull could hit you like a thunderclap and the entire body decommissioned. You would not even wish it on your worst enemies. The seconds of our life tick by but we think nothing of it - the brain ticks on, orchestrating the vital functions of breathing, feeling, seeing - all consciousness. Really really thankful for a ticking brain!

10am: It happened again - almost imperceptibly her left fingers moved, then her right arm lifted, clenched fists. What can we read in it?
4pm: I flew back to her side to tell her what I did today, correcting a mistake I made in choice of lawyers. Often I tell her of my misdeeds, quite reassuring. The MO came to change the spigot size to 4mm from the previous 7.5, one reason why she failed to wean it off this morning. They asked me to leave, sparing me the agony of seeing blood on her neck.

Tuesday Oct 11 9am: The taxi was determined to run me over as I struggled over the rain- drenched road. Must avoid sorrow upon sorrow, I thought. When I walked in she was awake, looking at the ceiling. Dropping everything I started conversing. It went on for nearly 40 mins. I whispered to her the new "toy" I planned to buy for myself next week at Funan. Then SC and later D walked in, pleased as Punch seeing her opened eyes. The PT, another new one came, exercised her and started the spigot test - 4, then 5 till 15 minutes. BP ok, heart-rate ok. With the trachy-pipe shut she is now breathing through her mouth and nose. Will try again this afternoon. Looking good - maybe we are on the right road back after all.
<to be continued> Starting Over

Monday, 5 September 2011

Restoring the pillar

Miranda Yap has been comatose since Sept 1 at Tan Tock Seng Hospital ICU. We follow her here to cognitive recovery as God has determined:

Monday Sept 5: 4pm
Praise God !! Now both legs are active and eyelids quiver. It takes an anesthetist like S to say that she is breathing mostly on her own, with minimum help!! But I would have no idea what those scope traces mean even if I can tell you how to make the oscilloscope.
Sedation is minimum and BP strong. Please go on - breathe well so that tracheostomy not needed. BP excitable so that nurse even now say visitors should slow down exciting her, but next days may be susceptible to infection. There are more hurdles coming. Independent breathing should be at the conscious level..she is God's work in progress!

Tuesday Sept 6: God deals with the outliers

Had my second nite of 3 hours uninterrupted sleep. I've been told that the chances of full cognitive recovery for her severity of hemorrhage is 20%. But that is statistics and some have done better. Come Wednesday (tomorrow) or thereabouts the team has to make the decision of tracheostomy (opening in the trachea to assist breathing). But I hope that will not be necessary. The doctors have to determine the risks of gagging without one, as she is not fully conscious. Also chest infections are notorious leading to life threatening situations. I would like to welcome expertise comments from you - please help me with an informed decision. We will deal with higher level thinking later. The real Miranda will have to re-emerge slowly, one step at a time. Ne Pas?

Tuesday Sept 6: 4.40pm "Did you see that? she's moving her jaws!" KG and L exclaimed. And her left leg has kicked itself up to the edge of the bed. The neurological GSC rating is M4 with M6 being cognitive active like "raise two fingers please...". So we must be patient as not to run ahead of Grace - she's has some ways to go before she knows who you are. But we'd like to believe she knows - something we call Faith. As if to back-pedal, her assisted breathing from the ventilator is now increased at night - just a precaution?

Wednesday Sept 7 3.20pm Here is more of the briefing I had from the Registrar on Tuesday. The attending Physician-Surgeon E is on leave till Friday:
Fever spikes are expected (last nite T=38.8C, today 36C) and antibiotics continued. Probably tracheostomy (throat toilet) will be pushed back till after neurosurgeon's return. Nothing planned for the 2nd aneurysm (which was found on the 2nd scan), as its size (based from a 1998 study) has v low chance (0.5%?) of rupture and its location not as threatening. Recovery status probably better than 5 on Friday. Tough cookie even pushing her right leg. Edmund, care to add?

Wednesday Sept 7 9.10pm Like two small leaves quavering in the wind, the shut eyelids are now quivering more as you speak. One would have hope that it becomes the last scene of "Avatar" but that is probably not how the neural synapses connect. Only God knows how the brain recovers, since that must be how they were formed when we became conscious and came into being. Quite an experiment to find out isn't it?
Note: From Steven Tan's comments on Prayer schedule blog:

For you created my inmost being; you knit me together in my mother’s womb. I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well.” Psalm 139:13-14

Thursday Sept 8 9.30am  Overslept but didn't miss chance to see her moving her head, ever so slightly, and some throat reaction. Everything else same. The call came at 10. Neurosurgeon E say better to have coiling done now, on the other aneurysm, since it is risk-compromised by other earlier rupture. Slot at neurological-diagnostic radiology (NDR) at 11am. After some more phone discussion the NDR surgeon came and was given a clear briefing, procedure, risks, results. Called with S and L and decided to proceed.
11am : She is now wheeled to NDR operating theater and under GA for next 2-3hrs. Please note no visiting until 4 or 5 pm. Watch this space.p

13.35 pm Got the call from NDR NeuroDiagSurgeon that coiling has completed and be back ICU. Visitor-ready in couple of hours. Some vascular spasms are seen that may derail things later, but risks from haemo-dynamic pressures are greatly reduced. So be guarded.
4pm Latest status from attendant neurosurgeon E: Angiogram shows good coil but brain spasm detected. Driving BP next so visitors will expect to see high readings. This dilated brain blood vessels from vasospasms. Another ct scan expected tomorrow to confirm progress. Need to guard unforeseen problems next. Visitors can start to pray for eyes to open next few days to 2 weeks (Yes!). But cognitive only. Have to wait longer for higher level activity response. Expect temperature spikes(sigh).
5pm: Stole away to play a bit of golf. Earlier looked lovingly at her bag where I had routinely and absent-mindedly loaded up with mine. Wonder how long she'll be able to walk the greens again.

Friday 9 Sept 9 am: Grinding her teeth? Probably another non-reproducible motion like the eyelids. She could "hold" my hand but motion not reproducible.
2.30pm Neurosurgeon E guarded prognosis:
Currently have primitive pain response, post-op CT scan OK
Two issues a) Vaso (vascular) spasm to be cleared : Next 5 days
b) Infection to be watched continuously. "There be dragons here."
Possible rehab 4 weeks, depending? for speech, motors, intelligence (dominant side). Next 2 weeks (?) in ICU to watch developments before next stage.
Longer term prognosis will be clearer within next 4 months (2-4 months)

Saturday Sept 10 10am: "Ring round the bushes and up the...", ML finger-walked up her left arm. Her face broke into a faint coy smile, Mona Lisa-like. I know she doesn't take to massage but she's certainly ticklish. Hope somebody can reproduce this! She is on a fuller course of antibiotics due to a low grade fever and the EVD tubing (brain fluid) needs to be replaced. If she can clear her throat more purposefully it will be more reassuring.

Saturday Sept 10 noon: Tracheostomy to proceed Monday and EVD tubing may be replaced to reduce possible infection (unknown). Vasospasm reduced to 5 from 8.5 Please note that visitors will be limited to family and close friends (very sorry) for next week or so. But if you consider you are close enough to visit please feel free to come cheer her up (such as what ML did) and I would vouch.

Saturday Sept 10 ?am: "Hello Sally this is Miranda", "Whoa where are you, you woke up?" S gasped on the phone. "I 've awaken long ago - was with you people around the ward. Technology in medicine has enabled me to make this phone call." Then S awoke.

Sunday 9am: "Miranda move your eyelids if you can hear me". She did. Then IC repeated the request after the eyelids were still. She complied. Three times.
12.30pm: HH and J came to speak to Miranda and J started to talk to her and stroke her left arm. Then a muffled sob, her expression appeared like crying.

Monday Sept 12 9am: Tracheostomy postponed for further observation. Pray that she can cough and clear her throat purposefully. Consultant neurosurgeon (CS) prefers her to breathe consciously. Fever spike. 4pm: More eyelid quivers for favorite grandnephew.

5pm: X-rayed the bloated abdomen. Wheeled for ct scan to ensure the bloated intestines are ok. Probably small irritation as still flatulent.

11:45pm: After swallowing the sleeping pill (hope I'm not addicted to it!!) the call came. The intestines are blocked and needed intervention. Not life-threatening. Watch this space tomorrow after the 8am meeting with the general surgeon:p

Tuesday Sept 13 7.45am Colon-surgeon gave a dark prognosis of what the lower large intestine block may be. As she's in coma best is a colostomy a redirect out to an external bag. Biopsy when she recovers. Tracheostomy and redirect of EVD (brain fluid) tube will be done just after the colostomy. Lord!
10.30am: Wheeled into theater operations to last 4 hours. Pray.
Medical notes: Growth "mass" located at splenic flexure restricting the lower large intestine. Too risky to remove or do biopsy or even colonoscopy. Question: Why no earlier symptoms of blockage when healthy? Why now? Post-operative biopsy and subsequent intervention is possible and colostomy "bag" collecting the diverted waste can be reversed and sealed. At the same operation the ventricle functional shunt tube that returns brain fluid to somewhere in abdomen, under the skin. That and the tracheostomy will last some hours. Nobody knows what the "mass" is, whether it is malignant, etc, until a biopsy is possible.

4pm: Completed colostomy with minimum blood loss. Starting to clear left & right of it. Tracheostomy took a longer time but finally in. EVD tube replaced.

6.20pm ColonSurgeon said she's still bloated so will review her case if persist. Cancer markers negative but real joy only from biopsy when she's ready. Using the stoma for colonoscopy or endoscopy.

Medical Notes: Drs S, L and M discussed about the blocking "mass" or swelling may be edema. Albumen was noted to be low. Comments?

Wednesday Sept 14 8.20am Faecal matter still stuck in Xray, advised to wait&see. But troubling signs on right lung. When vf shunt to be inserted next week(?) then perhaps an endo or colonoscope can be inserted around same area. An odd prayer request-that she moves her bowels. Will update what's happening in the lungs...

1 pm update: Xray artifact no pneumonia. Also vasospasm gone and BP now normal. Waiting for bowels to move.
5.25pm: CT scan came back normal so condition unchanged. "No news is good news for now". But neurologically this status quo cannot be good long term.

Thursday Sept 15 8am:
Gut Plan - gas is moving but time needed to move faecal matter. Bloating reduced but not completely decompressed. Stoma to be replaced and when intestinal walls stronger and rested will colonoscopy/biopsy be done (next week?)
Head Plan: Neurologically still hover between NSC rating of M4/M3 (slightly better than last rating). Left area of thalamus still not fully recovered, so she is not able to wake (open eyes). Since vasospasm is almost nil, BP will be slowly lowered. Everything human has been done, now only God can recover the brain. The worst prognosis is that she'll be completely bed-bound.
Protection: Still challenging the EVD tube (fluid draining from the brain) to ascertain its requirement. Infection very little signs so far - lungs are very clear (thank God).

9pm: The smell can be overpowering as you enter the room. Can only be good for her as decompression must have relieved her abdomen.  But if only I can relieve her dry throat as she sleeps mouth open. She moves her mouth but must still be dry as bones. Poor girl!

Friday Sept 16 10.30am: Her bowels moved and stool in bag! Thank God. At least now they can feed her normally, wait for intestines to settle and strengthen, then do investigation. Neurologically jury still out. She's moving her mouth and trying to clear her throat or wet it (don't know). More news at noon from neurosurgeon.
12.30pm ICU briefing: Breathing improved so "trach-mask" tomorrow without hose encumbrance. Hopefully rest of blockage released as faecal matter rather than "tumor". Regular gut feeding tomorrow. EVD challenged to 15 (equal is 20). If cranial pressure is normal at 20 then vp shunt ( another procedure) not necessary. Miranda wake up!

3pm: SE was with me next to her when we heard the sound and we broke out in praise. Decompression is on its way! EVD challenged to 25.

Saturday Sept 17 11am: Trachymask now - she's breathing on her own, moisturized throat. BP support drugs off so less tubes now into her. Still dextrosaline feed but regular gut feed tomorrow. Stomach distension soon reduced with more stools out. No infection, lungs clear. Colonoscopy Monday when guts are strengthened. Maybe HDU (high dependency ward) or even general next week. Neurologically still NTS-M3/4, so still no opening eyes yet, but EVD tube out today. Except this all the rest are good news. Thank God! Then ask that her eyes be opened!

Sunday Sept 18 3pm: Bereft of the plethora of tubes, wires and probes that goes in and out of her as well as the trachy pipe that stabbed menacingly right at her throat, she is now able to slowly shift her half-shaved head up on the pillow. On regular feed down her guts, she has started to move her jaws and appears to cough or move her tongue. Neurologically however she is on no-man's land - only able to quiver her eyelids and her upper limbs extended outwards in primitive distension. However her legs are more active and her hips could make limited upward movements.
5pm: She looks "angry" and perturbed - Is she becoming normal?

Monday Sept 19 10am: Still progressing as before. TPN feeding over to normal feed. Gut review tomorrow? Lower limbs are still more active. Temperature spike, but still low grade fever.

Visitor information: She is now relocated to bed 6 within the same ward. However as before you are advised to wash outside the ward if you intend to make contact.

Monday Sept 19 4pm: IC saw Miranda did her first yawn in 3 weeks!

Tuesday Sept 20 10 am: She is now in high dependency room 6 (same ward 3a). Neurologically still the same. Fever spike - 37C.
4pm: The possibility of a malignant gut tumor will be investigated soon sometime tomorrow by an anal colonoscopy to be followed by biopsy. The surgeons also felt that resolving this before transferring her to general ward would be better as they continue to observe her brain pressure. By now it is hoped that the intestinal swelling or edema has subsided and the gut stronger for the procedure. Pray for a safe result.
8pm: Meeting with colorectal surgeon.

Wednesday Sept 21 10.30am: Fasting has begun for 6 hrs before colonoscopy. Showed ICU team that her eyelids seem responsive to visitors' words and reproducible. This is encouraged. Wheeled away for brain ct scan to see effect of removed EVD tubing in terms of pressure.

10.45am Brain CT scan is ok so no need of vp shunt.
4.30 pm Waiting for colonoscopy to be done in bed 6
6.45pm  Colo-rectal Surgeon held up, procedure postponed to tomorrow, back to gut feed and fasting to begin at 2 am.

Thursday Sept 22 It has been three weeks to today, passing like a gale fluttering open pages of a book. Odds against full cognitive-ness are rising each day. Taking a hard look with the neurosurgeon yesterday...
11am: Colonoscopy postponed again to 12 pm. Hope she doesn't get gastritis!
12.30pm Colonoscopy result: No tumor no blockage no biopsy! Thank God!

Friday Sept 23 3 pm: Continuing with the hard look with surgeon yesterday here is the revised prognosis as a result of the absence of  colon-malignancy:

1). Miranda will survive this incident even if coma exceeds 4 weeks
2). Sometime within the next few weeks she will open her eyes, but incognito
3). The process of regaining cognizance will depend on therapy thence
4). She is likely to be bed-bound at the beginning of home care and fully dependent, on trained nursing maid, even up to 6 months hence
5). There is still danger of infection or relapse during coma, and after
6). Be prepared to see a different person from the Miranda we used to know, the progress to "near" normalcy depending on therapy. Unlikely to regain full cognizance because of damage to left thalamus.
7) How much is "near" depends on progress - from vegetative to some level of intelligence.
8) This prognosis may change as time progresses

Saturday Sept 24 11am: Transferred to "A" ward 13B bed 21 Note : All visitors still required to register before using the lift to 13th floor. Sanitation and mask for entry to room. THIS PAGE WILL END HERE. Blog continues in "The road back?"

How it happened

Calm before the storm

Monday 29 Aug: Played a robust 18-holes at Island (SICC) "Balmy weather - Wished you were here" she beamed to another as we trudged up the new clubhouse.
Tuesday 30 Aug: Course closed but "I want to go to the gym - with LL" She did the treadmill.
Wednesday 31 Aug: Played alone round of golf (I was at TMCC)
Thursday 1 Sept: Sumptuous Lunch at Mayim (Hebrew for water) West Mall with J. Someone was also lovingly scolded by her at work- she was in her element. 4.10pm I called her and she said 5.15 at the garbage, Bukit golf location. Her voice was somewhat nasal, as if a cold was coming.

The Incident

5.35pm Teed off Bukit front - nice finish on 1st & second hole. At the 3rd hole her drive was good. After her second shot (6 pm) she stopped walking at 200m point and said "Oh I have a very bad headache...need to sit down". I said "Sit away from the tree, you might have ants there". Then she went down limp, eyes closed - "Oh very bad headache...". Lets stop and I'll call the marshal to buggy us back, I said. "Wave to the golfers behind to pass", she said weakly, eyes still closed. After a few minutes the back golfers drove their balls and came towards us, while I ran ahead to retrieve our balls after calling the marshal for emergency. One golfer tried to lift her but she couldn't move. The marshal arrived as I ran back and carried her wholly onto the buggy. "I need someone to lean on", she barely whispered. 3 of us on the buggy and 5 minutes later the marshal had already alerted and arrived at the emergency treatment room, all this while she was immobile but limp. Another marshal on a buggy was heading back to retrieve our trolleys (her's manual and mine the remote controlled powered cylinder). As she was being carried on stretcher bed a volunteer doctor was already there. Dr. I John was formerly NUH (now living in UK) with his wife, a trained nurse. He had responded from the gym. He check her vitals and found her cold but otherwise normal, while she administered oxygen. 25 minutes have passed and he reminded me that the ambulance must be called. I ran out and found that the call was made at least 15 minutes ago! Must be traffic. When I ran back in the third time I heard her garbled voice about vomiting, not wanting to soil anything. After spilling it out she seemed better but her grim look tells a different tale. By the time the ambulance came (6.40pm?) she was semi-delirious and it was strenuous to see how hard it seemed to transfer her. I was allowed in the co-driver seat. "Neuro-care" must be the word given to the paramedic. It was a wild-ride of my life, sirens blaring thru the 6.45pm traffic. It was traffic! A little after 7.15pm we arrived at TTS, she vomiting most of the way in the ambulance (as I learned later, thank God there couldn't be another more suitable hospital) When I saw her transferred on the A&E stretcher her voice was becoming incoherent  "I want to vomit...OooOh headache" as she passed out. A little while I had to agree for her to be intubated. We languished at admissions for a further hour.

Historical Note: Miranda has no previous history of cerebral or coronary problems, other than the fact that her father's death started with a stroke. Her secretary attested that she has never taken a single day of medical leave and her medical screening would never suggest an impending rupturing aneurysm. What would? Even the brain scans earlier 2011 for her motor movement problems wouldn't. Three weeks earlier on National Day we grieved over PI who died suffering 16 hours from amoeba infection in the stomach. She's the most intelligent dachshund we ever had (I am still grieving).

Restoring the pillar

8pm (Thurs 1 Sept) The life-saving procedure of relieving cranial pressure had started. It would be a couple of hours of further waiting, then more scans. Around 10pm we were introduced to the consultant who explained the initial scans shows a ruptured aneurysm, where is it, patterns of occurrences, treatment and possible outcomes. Haemorrhage white blobs on the scan was still relatively small. After questions he left to work on stabilising the brain.

Snatched from the Jaws

Friday Sept 2: Around 1.15 am we returned to hear from him that the haemorrhaging had not stopped but actually worsened with extreme cranial pressures. In point of fact there was not much that can be done when both pupils were already dilating. We had to wait out the worse. Someone burst into tears. There was a hush as he left meekly to let it sink in. But not 5 minutes later he returned and said the pupils have responded to a drug (thiopentone?) and the brain has a "calming effect". "If there is a time to remove the major clot this is the time", was the pronouncement as he left the room for my deliberations. Please do not shut the door on the Lord, was S's prompting to me. I knew I had to rush out and shouted to proceed. But they were all ready, scrubbed and systems to go for the next 4 hours. By this time all sleep had fled.


Friday Sept 2: (5 am) I was not even in the front door of TTSH when I could hear the surgeon's voice on my hp. After he had sat me down he said all was done - the ruptured aneurysm is now clipped with 2 titaniums, the brain is starting to stabilize. There was actually another minor one "outside" the brain but that have to wait another day. She would be in deep coma now for who knows how long. (But God knows)        <I cannot remember rest of this day now>
Saturday Sept 3 (10 am): I could not hold back the rush of tears as I saw the bloated left eye bruised bluish. But that was the extent of invasive correction. She'd lost part of her scalp for now. But everything should start to normalize, physically. But how about neurally and chemically? God only knows, and He does. There is one more scan - radiation with computer tomography - a spin-off application from the FFT (Fast Fourier Transform) technology providing a non-invasive 3D image, revealing any physical defects deep within an object.
Saturday Sept 3 6pm: Given a recovery rating of 5 on a scale of 3-15
 Thanks HL!
Saturday Sept 3 (11.30pm) Ernest's phone call raised me from my bed. I called back the consultant-surgeon and received the first good news of the debacle: the CT scan visually shows no physical damage.
 The brain still swollen, has some residual clots - but this will go away. No infarct - enough to make someone joyful for the day. But what about neural and chemical - how it'll affect cognition? Only God knows - and He does. I slept that night.

Sunday Sept 4 (noon) Philip Y, who had just touchdown from Boston night before was thoughtfully pensive - "Brain vessel ruptures are becoming prevalent..." I had gleefully shouted at Miranda "Here's Philip - time for durians !" She must have heard. The rest of the day I must encourage her friends to talk to her - it could only be good.
4pm - Church elders came and pray - anoint her. Quite a crowd.
5pm - Someone thought she actually saw her eyelids twitched - but touch and talk must be the balm of the day. Nana's loving touch moved her the most.

Next 48 hours is crucial for higher level functions. The process of impaired cerebral recovery is not well known to science and is beyond medicine at his stage. No drug (outside China?) is known to speed cognitive recovery.


1. Please remember to sanitize if you plan to stroke her and mask when you speak to her. This IS encouraged as healing should begin from the left side. Correction Sept 5 - Somehow too much aural stimulation is not good.
2. Please share this site on with people who knows Miranda (she loves her enemies too) as there may be more medical info leaking in.
3. Someone found using valet parking cheapest for long term (4-5 hours), others use Novena Square if TTS overflows (often). For Wollerton study group members AP's place is only 5 minutes (he may charge a nominal fee!!!)
There will be 2 more upcoming blog posts: "Restoring the pillar" and then "The Road back" As the Lord develop events next week. (He has already heard us - so be it Lord)

Latest (Sunday evening) Running a fever - full sepsis workout/antibiotics now. Visitors please be vigilant. Thanks deeply.

Monday Sept 5 1 pm: Had to do the uneasy task of collecting her bone-flap (non-reusable scalp fragment, pate) from the mortuary. But it was properly wrapped of size 8cm triangular shape. Depressing! But who will throw a part of Miranda away?
Other Blog pages: Restoring the Pillar- The Road Back?- Starting Over- Turning the Corner?- Home Therapy