Mr. Smith had a large blood clot in his brain. He had come to the SICU to be evaluated for an experimental procedure where a catheter would be advanced through blood vessels to the brain and a clot digesting enzyme would be injected directly into the clot. It did not take a brain surgeon to know that this would be an extremely high risk procedure. The enzyme, Alteplase, is used most commonly as an emergency intervention for heart attacks. The principal danger of using it is that it can cause head bleeds. The thought of injecting it directly into an area where there was already a bleed was giving me pause. I do not know very much about brain surgery though, and I was waiting to see how things would unfold. If the procedure was going to be done, there was only a 48 hour window after the initial bleed to do it in. Less than 24 hours of that window remained when I began taking care of Mr. Smith. He would need a CAT scan with injection of IV contrast to map out the blood vessels in his brain. This would require a good IV in Mr. Smith’s arm, but we had not been able to get one so far. I asked for help from the techs and nurses who were “good sticks” and they tried again and again, but no one was able to find a vein.
As the doctors rounded on Mr. Smith my suspicions seemed to be confirmed. The surgical Attending, the senior doctor on the unit expressed disapproval. Mr. Smith had left sided paralysis, but was mentally intact. There was some chance of making him a little better, but a good chance of making him a lot worse. The resident was undeterred in his enthusiasm, however, and I sensed the involvement of another team of surgeons who were not now present. Perhaps this was why the attending stopped short of calling off the procedure outright. One has to know the limits of one’s influence and choose battles wisely. His objection now registered, the attending shrugged his shoulders and moved on to the next case.
The resident now came to Mr. Smith to get consent for the procedure. He spoke in simple terms of the clot in his brain. Mr. Smith knew about the clot in his brain. The resident made his pitch, “What if I told you that I could get that clot out and all I would have to do was make a small hole in one of your blood vessels?” My jaw began to clench, but then Mr. Smith belted out, “No invasive procedures!” as if he was burping. The resident tried again, but Mr. Smith only repeated his mantra adding that he was an old man (he was in his mid seventies) and that he did not want to take any such risks. The frustration registered on the resident’s face and it was ugly. He shifted his weight from one foot to the other. It was as if he had spent $100 on dinner and his date was now refusing to even kiss him good night. He protested, “It would just be a little hole.” He held up his pinched fingers to show how small the hole would be. “No invasive procedures!” It was clear and final. The resident gave up and left the room. We would not need to get that IV any more.
I had refrained from expressing my doubts about the procedure to Mr. Smith, but I still felt the proud parent speaking to him after the resident had left. “That was an experimental procedure he wanted to try on you Mr. Smith. I think it was right of you to turn him down.” This was maybe saying too much. I was getting caught up in the moment. I was happy to finally have a patient with some sense of the dangers of doing too much and some capacity to accept the inevitable end of his life, but we had just met and I needed to be more careful. I would soon be in an awkward position myself. Mr. Smith accepted my words happily enough. “All I need is something to eat. They haven’t given me anything since I got here. I’ll feel much better after I eat.”
I told him I would work on it, but this was going to be a big problem for Mr. Smith and he did not realize it. The few pills I had asked him to take had not gone down well. He would need to have his ability to swallow properly examined. Small amounts of food going down into the lungs with every mouthful means pneumonia and death in short order. If Mr. Smith failed his swallow evaluation, as I suspected he would, he would most likely not ever be able to eat again.
I had the doctors put in for an evaluation, but it took a long time for the speech therapist to come by to do it. Mr. Smith complained of his hunger to everyone who came by. My shift ended. I was back again the next day and I called Speech Therapy to see what the hold up was, but my heart was not in the fight. Soon I would have to stop giving him even sips of water. They came and did the swallow evaluation and Mr. Smith failed. I told the doctors and they told me to place a feeding tube. This is a minor procedure that is regularly performed by nurses, so it also fell on me to explain the situation to Mr. Smith. I gathered supplies and went into his room. I told him how he would no longer be able to eat and that the doctors had told me to put a tube through his nose down into his stomach so that we could give him some nutrition. Mr. Smith’s face quickly became flat. His previously exuberant communication was replaced with small, difficult to interpret gestures. I told him I did not have to place the feeding tube if he did not want it, but that it was the only way to give him nutrition for the time being. I looked into his eyes and asked, “Do you want the feeding tube Mr. Smith?” I badly hoped he would say “no,” but how could he? He was not ready to starve to death. He let his head come forward just slightly in a nod of consent. I prepared the feeding tube with lubricant and began to insert it in his right nostril.
Feeding tube insertion is one of the most uncomfortable things nurses do for their patients. Judging by the distress it causes it is much worse than urinary catheter insertion. As the tube hits the sinuses even the most self controlled patient will jerk his head away and grab for the nurse’s arm. For confused patients three nurses are sometimes needed; one to hold the arms, one to hold the head, and one to insert the tube. Once the tip of the tube reaches the back of the sinus it has to turn at almost a right angle to go down towards the stomach, which is accomplished simply by pushing with some force on the tube at the nostril. This is the most painful part. After this some care has to be taken so that the tube does not go into the lungs. I pull Mr. Smiths head forward, tucking his chin towards his chest and order, “Swallow Mr. Smith! Try to swallow!” He complies. Tears glide down his face, but the tube goes in without too much trouble. I tell myself that it is good that I am doing this for him, that another nurse who does not know him might be rougher on him, but I am thinking, “I hate my job today.” With this little tube, so much is being taken from him. More than he can even realize. And it is me doing it to him. I have to do it. It is my job and if I leave it for the night nurse, she will only be angry with me.
By the time the X-ray tech comes to take the X-ray which will be used to check the placement of the feeding tube, Mr. Smith has already pulled it halfway out. I push it back and the X-ray is taken. I put a wrist restraint on his good arm and tie it loosely to remind him not to pull it and talk to him about it. His expression is totally flat now. He does not even nod. I regret my previous feelings of camaraderie with him. I am his prison guard now; his oppressor. He only has one good arm left and I am tying it down. I have no right to ask for his friendship. In an hour or so the tube is out again. I put it in again and call for another X-ray. I ask him again if he wants the tube or not. If only he would give me some negative sign. Nothing. I tie his wrist restraint tightly, so that he cannot lift his arm off the mattress. There is no other option. Those who say there is have never done this work. I wish it was not so. This will be his life henceforward. Maybe next time I will leave it for the night nurse to do.