Battling Bile

Here is the entire 7-part series I wrote on Medy's battle with bile:


Terrible, Marvelous Year (Philippine Star, 11 December 2008)

I write this in violation of William Wordsworth’s precept that writers should write of emotions only as recollected in tranquillity. At the moment, I am far from being tranquil, but I plead the joy and pain of writing in the middle of things.

2008 was the worst year of my life, but it was also the best. This year, I came face to face with mortality, with the fragility of human life, with the strengths and the weaknesses of human beings, with God. This year, I found out, as one friend of a friend put it, that I had friends I never knew I had.

2008 was the year my wife died and was born again. 2008 was the year I died inside and was born again.

2008 started like every other year in my life, with the previous year’s New Year’s resolutions largely unfulfilled, with a half-hearted intention that I would do better the coming year, with a vague hope that I would remain in enough good health to finish all the teaching, writing, organizing, and social commitments I had made.

Before 2008, I prided myself on not being absent a single day from class. Except for the rare times when I was too sick to get out of bed, I had taught every class day for the previous forty years in various universities. I was a stickler for punctuality and attendance, as far as I myself was concerned, and had gained a reputation for starting class even if only one of the students was in the classroom when the opening bell rang and for starting a workshop even if there were only a handful of the participants in the room.

In 2008, I not only was often late for my classes, but was even absent so many times my students started complaining.

Before 2008, I prided myself on remembering names and faces and even approximating Brother Andrew Gonzales’s penchant for associating people with their research projects or academic studies, nagging them to get on with their professional careers.

In 2008, I often found myself at a loss when greeted by former students who would say with a smile, “I was in your class, sir,” then walk away totally disappointed upon seeing my blank stare of unrecognition.

Before 2008, I prided myself on never missing my writing deadlines, whether those of this [weekly] column [in the Philippine Star] or those of scholarly articles or books. I also always came to my public lectures prepared, not just with written papers that I could give to sponsors to be distributed to the audience, but with fancy PowerPoint presentations with animated clip art.

In 2008, I missed all sorts of deadlines, leading two of my publishers to partly replace me in two very large book projects. I found myself giving speeches off the cuff and seeing, on the faces of my listeners, that I was merely wasting their time. I had PowerPoint presentations that were full of text (a no-no for experienced presenters) or even just downloaded pages from the Web (an even bigger no-no).

Early in 2008 my wife Remedios “Medy,” my daughter Luna, and I bought plane tickets to spend Christmas with my daughter Emily, her husband Brett, and their son Carter in Silicon Valley.

Since I was going to be in that area anyway, I registered for the annual convention of the Modern Languages Association to be held in San Francisco during the Christmas holidays. I planned to give two books to my friends attending the same conference – one book (edited by my star student David Jonathan Y. Bayot) anthologizing many of the articles I published outside the Philippines, the second a festschrift in my honor (also edited by Bayot), containing articles by many of the biggest names in international literary theory (Gayatri Spivak, Marjorie Perloff, Catherine Belsey, Christopher Norris, among others).

That trip was cancelled, and the two books will be published only after this year [2008].

The root cause of my total disorientation in 2008 was what happened to my wife Medy. This is the story of Medy and her battle with bile.

The Bile Lady (Philippine Star, 18 December 2008)

Of the two of us, my wife Medy was, before 2008, far and away the healthier. She would hit the treadmill an hour every morning, go on low carbohydrate and other types of diets, use brown rice and brown sugar, and avoid desserts. In contrast, I had (and still have) a sweet tooth and, despite all my resolutions to stay healthy and slim, would devour ice cream, candy, and cakes practically daily.

Before 2008, Medy had never been hospitalized, except for childbirth and a minor polyp operation. In contrast, because of hypertension, I had been brought several times to the emergency rooms of various hospitals, in Manila, Cebu, even Poland while attending a conference. In the middle of one of my speeches in Baguio while I was in DepEd, I became dizzy, had to stop, and was revived by doctors in the audience. I took a term off undergraduate studies for medical treatment, was operated on much later in Iran, had to be nursed back to health in China, and in general, even allowing for hypochondria, was the more likely to get into serious medical trouble.

Instead, in 2008, Medy stayed 47 days in Makati Medical Center, 10 of those days in ICU, another 4 days afterwards in the same hospital, and 11 days at St. Luke’s Medical Center. In the process, she lost almost 30 pounds, had two near-death experiences, and is alive today only because of a miracle wrought by prayers.

How could someone so healthy end up staying that long in hospitals? The long and short answer is bile.

Sometime in the first few weeks of 2008, Medy was diagnosed with cholecystolithiasis, a medical term for gallstones, or more precisely, cholesterol stones in her gall bladder. The condition is fairly common, occurring in up to 55% of all adult women in the world. That means that one out of every two women you know probably has gallstones.

Often, gallstones are not serious enough to require surgery. In fact, there are a number of non-medical cures for gallstones (perhaps merely urban legends), involving massive doses of virgin coconut oil, probiotics, or even just plain water.

Scientifically speaking, there are some non-surgical ways to remove gallstones, such as endoscopic retrograde cholangiography, endosonography or magnetic resonance cholangiopancreatography, percutaneous transhepatic cholecystoscopy lithotripsy, and endoscopic sphincterotomy. I have no idea what those are, since I am not a medical doctor; all I know is that they are mentioned in recent medical journal articles. (Did I hear someone mention that a little learning is a dangerous thing? With the Web, we have all become amateur physicians!)

In her case, Medy was medically advised to undergo surgery to have her entire gall bladder removed in order to avoid the possibility that one or more of her numerous tiny gallstones would move out of her gall bladder and into her pancreas, where they could do major damage.

Let us pause for a moment to review what we learned in school about human anatomy.

What is bile? Here is a description from MedicineNet: “Bile is a yellow-green fluid that is made by the liver, stored in the gallbladder and passes through the common bile duct into the duodenum where it helps digest fat. The principal components of bile are cholesterol, bile salts, and the pigment bilirubin.”

Inside the liver, bile begins its long journey by flowing through numerous small ducts, like branches on a tree, that come together to form a large common hepatic duct, like the trunk of that tree. This common hepatic duct connects with the cystic duct that comes from the gall bladder to form the common bile duct.

As long as nothing obstructs the flow of bile, the digestive system works very well (after all, we all know Who designed this system). The intestine signals the gall bladder that it needs bile to digest fat, the gall bladder releases the bile it has stored from the liver, and the liver continues to produce bile to be stored in the gall bladder. Even if humans tamper with the divine design and the gall bladder is removed, there is minimal disruption, because bile can go directly from the liver into the duodenum as long as the common hepatic duct is not cut.

What is the duodenum? The duodenum is the first twelve fingerbreadths of the small intestine (duodeni in Latin means twelve) or about ten inches at the front or top end of the intestine or small bowel (botulus in Latin means sausage).

Since many of our friends already had gall bladder operations with no serious complications, Medy decided to have her gall bladder removed. She turned to a close friend since childhood, one of the country’s leading cancer surgeons. Since the surgeon could routinely remove microscopic cancer cells, there was no reason to think that he could not remove a huge thing like a gall bladder.

Unfortunately, there is Murphy’s Law that states that, if anything can go wrong, it will, and in Medy’s case, something went very wrong.

1 out of 100 (Philippine Star, 25 December 2008)

On May 18, to remove her gall bladder, Medy underwent a laparoscopic cholecystectomy (lapchole or LC, for short), a surgical method developed in 1989.

This is the way Medterms describes LC: “Removal of the gallbladder (cholecystectomy) by laparoscopy. LC is performed through several small incisions. The laparoscope, a small thin tube, is put into the abdomen through a tiny cut made just below the navel. The surgeon can then see the gallbladder on a TV monitor and do the surgery with tools inserted in three other small cuts made in the right upper part of the abdomen. The gallbladder is then taken out through one of the incisions. LC permits a shorter hospital stay and shorter recovery time with less pain [than an open or traditional cholecystectomy]. Possible complications may include bleeding, infection, and injury to the bile duct, intestines, or major blood vessels. Although the rate of common bile duct injury appears increased, this rate is still sufficiently small to justify the use of LC in the treatment of symptomatic gallstones.”

An accident (called a “cholecystectomy surgical misadventure”) during an LC occurs roughly once out of every hundred operations. (The rate varies between 0.55 to 0.94 percent or less than one in a hundred cases.) This rate is “still sufficiently small,” unless you happen to be the one out of the hundred.

During Medy’s LC, the surgeon placed a drain or tube as a precaution, to ensure that any unwanted fluids left would be removed. This was the first sign to me that God was paying special attention to Medy. The drain was a wise decision on the part of the surgeon, even if it went against an October 2007 article in the British National Library for Health, claiming that such a drain was unnecessary: “Drain use after LC is controversial. This review [of all randomized clinical trials worldwide until March 2007] found that the drain use after LC increases wound infection and delays discharge from hospital. Currently, there is no evidence to support the use of drain after LC.”

For the next nine days, Medy had bile leaking out of her body through the drain. Initially, the surgeon thought the leak merely came from “liver weeping” (a medical metaphor for “extravasation of protein-rich lymph on the liver surface”), not a real cause for concern.

In fact, having received an assurance that there was nothing to worry about because the leak would soon stop by itself, I spent the nine days giving three public lectures, hosting a dinner, going to my three offices, and coordinating a national workshop for journal editors. That was the last time that I would ever be that busy and also the last time I would not be camping out in a hospital.

On the tenth day after LC, the bile leak dramatically increased.

In the afternoon of May 29, Medy underwent a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) to find out what was going on inside her body. What the doctors discovered was chilling. Medy’s common hepatic duct had been transected (i.e., cut transversely or perpendicularly). In other words, there was no connection between the liver and the duodenum, which meant that the bile coming out of the liver was going everywhere except where it was supposed to go.

The December 2008 issue of the ANZ Journal of Surgery contains a study of such accidents. According to the article, “Bile duct injury is an important unsolved problem of laparoscopic cholecystectomy, occurring with unacceptable frequency even in the hands of experienced surgeons. Underestimation of risk, cue ambiguity, and visual misperception (‘seeing what you believe’) were important factors in misidentification. Delay in recognition of the injury is a feature consistent with cognitive fixation and plan continuation, which help construct and sustain the duct misidentification during the operation and beyond.” In other words, all over the world, even with the best surgeons, LCs go wrong.

That evening, the doctors decided to have an emergency operation early the next morning. I was asked to obtain at least two units (or bags) of type A+ blood, Medy’s blood type. Unfortunately, Makati Medical Center had run out of such blood in stock.

During times of crisis, you get to know who your friends are. Responding to our calls for help, Luna’s friends immediately came over to give blood. Employees of China Banking Corporation, where Medy worked, came trooping in to give blood. My friends who were corporation managers or school administrators asked their employees and students to donate blood.

Not everybody, however, who wanted to give blood could do so. There were all sorts of restrictions (infections, colds, fever, hypertension, diabetes, tattoos, menstruation, anemia, underweight, and so on). Would-be donors kept getting rejected.

It did not look like we could get the blood through donations; we had to buy it. Near midnight, Luna went to the Philippine National Red Cross office in Quezon City, where she found a long queue of people asking for A+ blood. Time was running out.

Agony in the Hospital (Philippine Star, 1 January 2009)

Close to midnight on May 29, 2008, Luna was able to buy two units of A+ blood from the Philippine National Red Cross, whose personnel, used to personal and national emergencies, were very helpful, courteous, and efficient. Meanwhile, Makati Medical Center accepted two blood donors, one from Luna’s gang and another from ChinaBank. By early morning, we had four units of blood ready for the emergency operation Medy had to undergo to repair the damage done by the laparoscopic cholecystectomy.

At noon the next day, as soon as one of the operating rooms became available, Medy was wheeled in. The team of surgeons warned us that the operation was going to be, in their words, “technically very difficult.” I had not yet started searching the Web nor asking my doctor-friends then for medical information. It was just as well, because my heart would not have been able to take the long wait, had I known what I found out later.

The operation took nine hours, not counting recovery. Luna and I spent the time just being impatient but not overly anxious. My sister Loree, her husband James, and my best friend Paulino even came to keep us company. Ignorance was bliss.

After the operation, one of the surgeons told me that they had just done a Roux-en-Y. I found out later that I should have been worried. When I asked around, my Filipino-American friends who were veteran surgeons in the US told me that Roux-en-Y was “a surgeon’s nightmare” or “looking for trouble.”

The full name of the procedure is “hepatico jejunostomy Roux-en-Y anastomosis,” simply known as Roux-en-Y (pronounced ru-en-wai by Americans and ru-zong-nee by Europeans). The Roux-en-Y is named after Swiss surgeon Cesar Roux, who first employed it in 1892, and the Y-shape the small intestine takes when pulled closer to the liver (in other cases, the stomach). Basically, it is a bypass process, bypassing the bile duct by moving the duodenum next to the liver and punching a common hole to connect them.

Medy spent the next day sound asleep in the hospital room. Alone with her in the room that night, I thought she was just asleep until, close to midnight of May 31, I noticed that she was gasping for air. I called a nurse, who immediately called a doctor doing rounds on the floor.

This was the second clear sign that God was pulling the strings. The nearest doctor turned out to be one of the country’s best nephrologists. Another doctor with a different specialization might not have handled the crisis as well. The nephrologist took command of the doctors that had gathered in the room.

I left the crowded room to cry in the hallway. The nephrologist came out and told me, “She is having acute renal failure. We will try to save her kidneys without dialysis.”

MayoClinic says matter-of-factly, “Acute kidney failure may be fatal. Death rates are highest when the kidneys fail after surgery.” In Medy’s case, acute renal or kidney failure was probably caused by dehydration, since she had fasted almost 36 hours for her ERCP and Roux-en-Y. In any case, eMedicineHealth says that “acute kidney failure occurs in about 5 percent of people who are hospitalized for any reason.”

In the hallway, I called up relatives and friends who were doctors. They all told me not to worry too much, because acute renal failure was reversible. Their reassurances helped me through the next few hours. At midnight, Luna rushed back from our home in Alabang. My other daughter Emily, who lives in Silicon Valley, arrived early the next day.

Afterwards, Medy told me that she had two near-death experiences (NDEs) that night. “Lord, into your hands I commend my spirit,” she prayed, but at the same time, she said, “No, I refuse to go.” Only Medy can be so contrary, but then, God made her that way. She prefers to keep the other details private, but I can say that her NDEs were similar to those documented in books such as Embraced by the Light or websites such as near-death.com.

On June 3, Medy was brought to the Intensive Care Unit (ICU), where she would stay for the next nine days. Infection was threatening to enter her bloodstream (called sepsis or blood poisoning, a life-threatening illness with a 30 percent chance of death).

Upon seeing her in the ICU, a well-known internist warned me that Medy might have only days to live.

It was time to call in the prayer warriors. I needed the Great Doctor. On June 3, I emailed everyone in my address book and I posted the same appeal on my blog.

“It will help a lot,” I wrote, “if friends storm heaven with prayers. My two daughters are holding up very well, much better than me, I have to admit. You might want to pray for us, too, especially me. I have never panicked this much before.”

Within hours, my Catholic, Christian, Islamic, and Jewish friends were asking God to give Medy a new lease on life.

Prayers work (Philippine Star, 9 January 2009)

For my family, 2008 was a roller-coaster year.

On the down side, Medy continually got into medical trouble. On the up side, every time she did, the Catholic, Christian, Islamic, and Jewish prayers of friends worked to bail her out. Perhaps most touching was the prayer of a usually skeptical friend who said, “I am praying (not something I do very often), so I hope my prayers are given extra force!” The prayers confirmed my belief that God does not give us sufferings we cannot handle nor problems we cannot solve.

After prayers helped them solve the problem of Medy’s acute renal failure, the doctors had to contend with one crisis after another, such as cardiac asthma, congestive heart failure, pancreatitis, anastomotic stenosis, diverticulosis, and a fistula (hole) in her small intestine, not to mention infection of all kinds, among them the life-threatening pseudomonas aeruginosa (which doctors dread because it is so difficult to fight). She was bombarded with several antibiotics, some of which were so new even non-specialists in Infectious Diseases had never heard of them.

Even after she was moved out of the ICU and into a private room, she had tubes going into and out of her body, at one point ten in and four out.

On July 3, after 47 days of confinement, even if bile was still flowing from her body through a tube, Medy was discharged, because a continued stay would have increased chances of hospital-acquired pneumonia.

She continued her medication at our home in Alabang. We were told to look out for signs that would mean immediate trips to an emergency room: high fever, chills, low blood pressure, vomiting, or worst of all, jaundice.

We asked Alabang Medical Center to send a nurse every day for two weeks to administer injections, to dress Medy’s wounds, and to measure the bile leak. We went frequently to the emergency rooms of Alabang Medical Center and Asian Hospital and Medical Center whenever she developed a high fever, needed more injections or another bile culture, or had to replace her ostomy pouching system (colostomy bag). We went regularly to Makati Medical Center for consultations and tests. This went on for more than three months.

The key problem was the bile leak. The second operation was supposed to have solved the problem of the bile duct accidentally cut during the first operation. The bile leaking from Medy’s body was assumed to have been spilled from the cut duct. That leftover bile should have already been totally drained. If the bile were seeping out of the small intestine through what radiology showed was a fistula, even that hole should have healed by itself. But the bile kept flowing, and she kept getting infections.

We started consulting doctors from other hospitals, not just in the Philippines, but in Singapore and the United States. The doctors were leading figures in their fields, many of them published scholars, a couple of them doctors of Philippine presidents. One liver transplant surgeon from Harvard Medical School even asked for copies of Medy’s MRI tapes.

A renowned hepatologist (hepatos in Greek means liver) from St. Luke’s Medical Center gave us a clear explanation of what was happening. This was a race, she said. The bile leak should stop by itself eventually, but that could take months. Meanwhile, the longer the tube remained inside her body, the greater the chance of infection, because the cause of infection was the tube itself. The worst possible case would be that infection could no longer be controlled because we would run out of effective antibiotics (since bacteria develop immunity to drugs); Medy would then go into sepsis, which could mean death in a few days.

The solution, therefore, was to have a third operation to fix whatever was blocking the bile flow to the small intestine. We asked several other specialists; they unanimously agreed that Medy needed a third operation.

Since Medy was shedding not just bile but weight (she had, by then, lost almost 30 pounds), we scheduled a third operation for Oct. 21 at Makati Medical Center. We contracted a leading liver transplant surgeon to do the operation.

On Sept. 28, the bile leak suddenly stopped. On Oct. 15 the tube was removed. Medy continued to have fever and even got readmitted for four days into Makati Medical Center for an IV-administered antibiotic, but the doctors theorized that the leftover bile had finally all been drained, the fistula had closed, the anastomosis was working, and it was only a matter of time before antibiotics would kill all the bad bacteria in her body.

Because it looked like Medy no longer needed another operation, we scheduled a Thanksgiving Mass and a reception in Makati on Dec. 1. On Nov. 25, however, friends noticed that Medy’s eyes were turning yellow. She had also started itching all over (medically called pruritis).

On Dec. 2, it became obvious that Medy had jaundice, which meant that bile had been blocked from flowing into her small intestine. Bilirubin, normally excreted in bile, was leaking instead into her eyes and skin. The race was entering its last lap.

Special Christmas (Philippine Star, 15 January 2009)

My wife Medy, my daughter Luna, and I were all set to leave on Dec. 20 for Silicon Valley to spend the Christmas holidays with my daughter Emily, her husband Brett, and our grandson Carter. I had also arranged for Stanford University Medical Center to take a look at Medy to check if her bile problem had indeed been solved.

We had standing instructions from our liver surgeon to rush to Makati Medical Center to have a third operation once Medy developed jaundice. Since she had had no bile leak for a month and a half, I was sure nothing could stop us from going to the U.S.

The reason for the standing instructions was, of course, bile.

All red blood cells break down after three or four months to be replaced by new cells; this is the body’s way of cleaning our system, something like a biological oil change. When the cells break down, they release a yellow-orange protein called bilirubin. The liver sends the bilirubin through bile to the small intestine for eventual excretion. If bile does not flow to the intestines, the bilirubin stays in the bloodstream and stains the eyes and the skin yellow. That is called jaundice. Since Medy’s original problem was the lack of a way for bile to move from the liver to the small intestine, jaundice was a visible sign that the original problem had not yet been solved.

Towards the end of November, some of Medy’s friends remarked that her eyes seemed a bit yellow, but because I was eager to leave for abroad, I was on denial mode.

On Dec. 3, her friends insisted that she had jaundice. I answered that the only way to find out for sure was to have a doctor see her. We called the liver surgeon to set an appointment. She was out of town and could not do the operation in Makati Medical Center immediately anyway.

We decided to see the hepatologist we had consulted four months earlier at St. Luke’s Medical Center. The moment she saw Medy on Dec. 4, she said, “This can’t wait anymore. We have to operate immediately. The risk of infection is too high.”

St. Luke’s Medical Center did not earn its reputation of being “a center for world-class healthcare in Asia” by not being proactive. If the race against bile was going to be won, it had to be won quickly. The hepatologist arranged for the operation to be done by one of the best Filipino biliary surgeons, who happened to have a day free in his busy schedule.

This was the third clear sign that God was directing the events. We learned from doctors later that, had we waited longer, Medy would not have made it. It was crucial that we got a free slot in an operating room with excellent doctors attending to her.

On Dec. 5, Medy was admitted into St. Luke’s Medical Center. That night, Emily arrived from the U.S.

After various tests, Medy had her third operation on Dec. 8. After the four-hour operation, the surgeon explained to us that, instead of merely repairing the earlier Roux-en-Y, he had done another Roux-en-Y with a larger opening, using a different part of the liver. He had removed three remaining tiny stones from the liver. He had moved a portion (the jejunum) of the small intestine close to the skin, to enable non-surgical repairs in case of future need.

“No one among my patients has ever had to use this safety measure,” he assured us, “but it’s better to be safe.” Should the bile stop flowing again to the intestines, Medy need not have another operation. All a doctor has to do is to extract through the port whatever debris may be causing the blockage.

During the seven-month ordeal, with bile unable to leave her liver (called cholestasis, from the same Greek root word as “static”) and scarring liver tissues (called fibrosis), Medy developed secondary biliary cirrhosis. (The term is misleading because it is not cirrhosis, which is chronic liver failure and life-threatening.) Damage to the liver is supposed to be irreversible and may eventually cause cirrhosis (the real thing).

We are not scared even a little bit about the irreversibility, because God has already shown extraordinary care for Medy and is not likely to let up now.

In fact, during our consultation last week, the hepatologist said that Medy’s latest blood tests showed that the biliary cirrhosis may be reversible. That would be another miracle, but who are we not to believe in miracles? In any case, biliary cirrhosis is a condition Medy can live with for a long, long time.

After the operation, Brett and Carter arrived to spend Christmas with us in Alabang. We still had a family celebration, though not in California as we had thought we would. God meant for us to spend the holidays in the Philippines. Christmas in 2008 was truly special for our family.

Lessons Learned (Philippine Star, 22 January 2009)

These are some of the lessons I learned from Medy’s battle with bile:

1. Prayers work. Even some of the doctors at Makati Medical Center admitted afterwards that they did not expect Medy to survive her stay in the ICU. The storm of prayers done by friends and friends of friends from all over the world (thanks to the Internet) moved God to intervene in the medical process.

2. Religion does not matter. Most of our friends are Catholic, many are Christian, some are Islamic, and a few are Jewish, and they all prayed to the same God (who is called by different names). I am sure that God does not much care if those praying go to different places of worship on different days of the week. God looks directly into the hearts of people, where it was clear that concern for Medy was foremost.

3. Always get a second opinion. We immediately agreed to the first operation when the doctor suggested it. Had we asked other doctors, we would never have gone through with it. Several doctors we asked afterwards said laparoscopic cholecystectomy was ill-advised, since Medy’s gall bladder was embedded in her liver. A senior doctor from the Philippine General Hospital put it this way, “You have to have done a thousand lapcholes to be good at it.”

4. There are doctors and there are doctors. Most of our doctors do not mind talking to us by cellphone and even giving prescriptions through texts to be shown to pharmacists. These doctors do not worry about their fees; they represent the best disciples of Hippocrates. There are a few doctors, however, who will talk to you only during their clinic hours and only if you pay for the visits.

5. American hospitals are not necessarily better than Philippine hospitals. This is what one American doctor in California said when we consulted him: “I recommend that you don’t treat her in the US, because she wouldn’t get better care here than in Manila. The US is a good option if we were dealing with the heart, the brain, or other cases that need advanced technology or advanced skill. But Medy’s case fundamentally requires skilled doctors and not so much high-tech.” The same doctor recommended going to St. Luke’s Medical Center, which he regarded as an excellent hospital even better than those in Singapore.

6. Money is not as important as life. Well-meaning friends have asked us whether we still have savings. The answer is the old saying: “Ang pera, pag nawala, pwedeng kitain muli, pero ang buhay, pag nawala, wala na” (Money lost can be earned back, but a life lost is lost forever).

7. Exercise to prepare for emergencies. Without her daily hour at the treadmill, Medy’s heart would never have carried her through the crisis.

8. Have friends. The more friends you have, the better. You need friends, as well as family, around you when you get desperate. All our friends and all their friends responded quickly to our calls for prayers. Friendship, however, is always a two-way street. When your friends get desperate, you have to rush to their side. Drop everything you are doing and do what they have done and will always do for you – make their personal crisis the center of your life.

9. Trust your doctors. They are human, just like you. They make mistakes, just like you. But they have trained long and hard to do what they know how to do. They will always do their best to keep you alive and in good health. They know much more than you do. Follow what they say. Do not second guess them.

10. Trust God. You cannot depend completely on human talent and wisdom. In the end, God calls the shots. God did not create you just to make your life miserable. God is always looking out for you. God is always doing what is good for you. Nothing that happens to you can ever be really bad for you. God has a reason for everything, and your puny human mind cannot possibly comprehend the divine design.

Thank you to the MDs (in the Philippines, the U.S., and Singapore) who helped bring Medy back to life, whether by joining the medical teams or offering medical advice or moral support on the sidelines (in alphabetical order): Alipio Abad, Salvador Abad Santos, Nolan Aludino, Jimmy Aragon, Ramon Arcadio, Elizabeth Arcellana, Benjamin Benitez, Frances Bernardo, Hermin Calma, Marianne Cayco, Juliet Gopez-Cervantes, Dennis Damaso, Dina Diaz, Romeo Diaz, Jackson Dy, Christine Fausto, Filologo Felix, Ma. Tarcela Gler, Godofredo Godoy, Erwin Gomez, Jonnel Lim, Juan Madariaga, Karl Morales, Carol Narvacan, Ruben Ortega, Elmar Perez, Willie Pulido, Eugene Pulmano, Jesus Relos, Ramon Santos-Ocampo, Romeo Saavedra, Menandro Siozon, George Soo, Remedios Suntay, Ma. Milan Tambunting, Jaime Galvez-Tan, K. C. Tan, Catherine Teh, Annabelle Vergel de Dios, Alex Yap, and others. Thank you also to the countless non-doctors (especially Robert F. Kuan, chairman of St. Luke’s Medical Center, and the nurses of four hospitals), who worked, prayed, visited, and watched with us through the long, dark night of Medy’s battle with bile.