Saturday, September 13, 2008

Missing a Lung

This is another early essay:

There is no training in nursing school that addresses how to go about giving information about a patient’s condition to a patient or their families, or about what they need to know or should know and what they should not. Neither was there, for me at least, anything in my hospital orientation that gave any guidance on the matter. For me personally, this is good because I have strong opinions about it and the absence of a defined role gives me a lot of discretion to act according to my own sentiments and intuitions. It gives me an opportunity for personal expression and allows me to help my patients and their families in a very meaningful way in spite of physical conditions that are often insoluble. I feel very strongly that patients and their families should be as aware as possible of their situations and should have all of the information necessary to make all important decisions. This becomes even more important, in my estimation, when death is imminent.

There are, however, other points of view and for whatever the reason it is often found that patients and their families are not given information promptly and in such a way that it enables them to make the big decisions with their eyes open.

The story of a not atypical workday illustrates: I arrive on the floor of the MICU at 7:00am to take report on my two patients for the day. The night nurse tells me about my first patient, he is suffering from pneumonia and has already had his entire right lung removed because of cancer. I look up from my note sheet to check the monitor and see the patent’s sats are in the mid 80’s. Without waiting to hear more I get up and go into the patient’s room to turn up the oxygen on the patient’s face mask. As I get closer to the flow meter the night nurse calls in “It’s already at 100%.” The night nurse is calm and obviously aware of the situation, so I come back out of the room to finish report. The night nurse explains that he has spent the night trying to keep the patient calm and encouraging him to take slow deep breaths. In this way he has kept the patient off of mechanical ventilation through the night, but the patient has started to slip more as the morning has come. The night nurse, who has years more experience than I, emphasizes the patient’s vulnerability due to only having the left lung (the left side is smaller because of the heart). He summarizes saying, “If he gets tubed (placed on a ventilator) he’s toast.” Then he adds that the family does not realize what is happening and expects him to be home by the end of the week.
There is not much time. I first go to the patient to try to calm him and encourage him to breathe deeply, but he is barely conscious and gasping for breath. All he can do is nod and his sats are not rising above 86%. The patient’s son is in the room. I find the fellow and ask him if the patient’s prognosis would make it appropriate to refrain from intubation and to allow the patient to expire naturally. The fellow answers in the affirmative and his tone encourages me to talk to the family. I tell the son as gently as possible that I have heard that his father has almost no chance of surviving intubation and that the time to make a decision which could spare him a lingering death with a plastic tube shoved down his throat is now. The son replies nervously that he cannot make that decision without his mother and she has just gone to the cafeteria. I encourage him to bring her. He leaves quickly.

The patient’s sats are now in the low 80’s. There is no question of calming him down now, he just cannot breathe. There is no room to delay. I find the resident and tell her about the patient’s current status. She comes directly to the room, looks at the patient and the monitor and calls for anesthesia to be paged for an intubation. I hustle to bring supplies and prepare the patient. By the time the patient’s wife returns with her son, two anesthesiologists are setting up shop, the respiratory therapist has brought the ventilator and the resident, who is standing at the bedside simply tells the patient’s wife that the patient requires help breathing and that he is going to be placed on a ventilator.

Intubation is a violent process. Families are generally asked to step out. Even if they are not asked, they always leave. A sedative is administered followed by a paralytic that leaves the patient unable to resist the impending violation. The paralytic also renders the patient entirely unable to breathe and a mask with an ambu-bag is used to give breaths until the ventilator is in place. When the patient is judged to be best able to tolerate a period without air, the mask is removed and a metal blade with a light on the end is inserted into the throat. The doctor stands behind the patient’s head and lifts up on the blade to visualize the patient’s vocal cords. When he sees them he takes the endotracheal tube (ET tube), which has a metal rod inside to make it rigid for insertion, and aims for the trachea. If all goes well (it is not uncommon for several attempts to be necessary), the tube is placed, the rod removed, the balloon at the end is inflated to make a seal, the Ambu-bag is attached directly to the tube, a carbon dioxide indicator is used to verify that the tube is in the lungs and finally the ventilator is attached and the machine begins to give breaths. The process is always somewhat intense for all involved, and when the patient’s oxygen levels are already low to begin with there are bound to be some urgent exchanges.

As I come out of the room I see that the patient’s wife and son have stayed nearby. Having heard the process going on the wife is disturbed, worried and crying. She glares at me, “He is going to be fine.” her eyes say, “why are you making us worry like this?”
I do not remember speaking with them for the rest of my twelve hour shift. I had another intensive care patient to look after also. I probably tried to say something encouraging like “I hope everything will be alright,” but I do not remember. A week later I heard the doctors explaining to the wife that there was nothing more to do. The ventilator was turned off and the patient died shortly thereafter.

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