It’s a quiet friday night and i am covering the resuscitation room.
We get a paramedic pre-alert advising us that they are en route with a 38 year old man in acute respiratory distress.
When we hear his vital signs, i tell the nurse to get ready, call the inhalotherapist and prepare the intubation drugs.
In an emergency situation, i prefer to be well prepared. Too much preparation is much better than not enough when we anticipate that someone might die and that we will fight for his life.
I decide to stay and wait for this patient. The other patients will have to wait, they can wait. I want to be there for this guy. He is younger than me.
The paramedic rush our patient in the resuscitation room. At a single glance, i can tell that he is in critical condition: agitated, sweating profusely and breathing like his life depends on it. He can’t even talk. He can barely manage nodding yes and no with his head.
We have no medical record and no information on him. We’ll have to do without. Quick listen to his lungs: noisy breathing with difficulty breathing out. It looks like asthma. Do you take puffers at home? He nods yes. OK team listen to me: lets start with O2, monitor, cardiac workup and blood gases, EKG, chest x-ray, bronchodilators, venous access, bolus of fluid, corticosteroids.
Sir, do you have cough and sputum? The nurse shows me the greenish stuff he just spit.
Sir, did you have fever recently? He nods yes.
All right, we are getting somewhere. Probable pulmonary infection. OK let’s start him on Ceftriaxone, Zithromax and Tamiflu. Let’s also add sputum cultures, blood cultures and influenza screening. Quick look at his vital signs… pulse is 160. Let’s give hil another liter of fluids. I am confident we can save him.
Seems like an eternity but not 5 minutes have passed since his arrival. I write everything down for the nurses and i get back to the paramedics.
Do you guys know his past medical history? Not really. He’s on home oxygen. WHAT? Home oxygen at 38 years old? Ohh shiit… this is not your typical healthy asthmatic man with pneumonia, this is a guy with a chronic lung disease on home oxygen. He has no physiologic reserve to fight this. My confidence has taken a big hit. Can we save him? I dare not ask the question.
His wife and daughter arrive and tell me he’s followed in another hospital by a specialist. Some sort of rare lung disease. Has he ever been intubated? No. Have you ever seen him like this? God no. Ohh shiit. Ohh shiiit.
I am thinking we could lose him but i display this calm confidence. I have been doing this for 17 years. I know what needs to be done. Once we have the right diagnosis, the management is pretty straight foward. Before someone dies, we must consider the other diagnosis but i’ve done that, twice already. I am confident in my diagnosis of lung infection. Nurses confirm he has a fever of 40,2C. He got bronchodilators, steroids, fluids, antibiotics, antiviral, non invasive ventilation. The only things left in my arsenal is mechanical ventilation and vasopresors if his pressure drops. After that, it is not up to me. So this thought stays at the back of my mind.
An hour later, labs come in pretty normal considering his condition. Elevated white blood cells. Normal blood gas and lactate are going down on serial checkup so looks like we did a good job. Everything looks good on paper. He seems ready to be transfered to the intensive care unit. Everything except… him… he looks bad, agitated, sweaty, with cold pale extremities. He looks like he is in septic shock. His blood pressure goes up and down but mostly down. But the main thing is: he looks sick.
His wife comes and asks: Doctor, i don’t understand. Every week, he keeps getting worse, why? Come over. I’ll show you the x-ray. Look at this image. You see those lungs? They belong to that 87 year old lady lying next to your husband. Now these are his lungs …..(long silence). OHHH!! Do you understand now? Yes.
Back to my patient. He’s all wrapped up to go to the intensive care unit. Time to say goodbye… but i have this bad feeling…
I ask his wife and father to come with me in another room. I sit down. I take his wife’s hands in mine. I look in her eyes.
Your husband is really sick. I’ve told you that already.
Now we gave him everything he needed to fight this infection but and there is a but… I am afraid for him. I will be totally honest. I am afraid for him. I’ve been doing this work for 17 years now and i’ve seen people die. I am afraid that although he did get everything we could give him to improve, he might not get better and he might require mechanical ventilation. This is the only thing left that we can do and it’s not a simple thing to put someone like him on a ventilator… His lungs won’t like this. They cry. I hug them. I wish i could do more. They thank me for my honesty.
Before he goes up to intensive care, i call my colleague again. I want him to know that although the blood gases are normal, i feel he might get worse. We reassess his condition. His blood pressure dropped. He needs vasopressor, medication to get his pressure up to normal. So the diagnosis is not just pneumonia, it’s full blown septic shock. We consider the risks and benefits and we agree that at this point, if he looks that bad, let’s do everything for him and put him on a ventilator. Since this is a complex case, i call my colleague. I don’t have a problem intubating a 38 year old asthmatic man but intubating a 38 year old man in septic shock with lungs so bad he’s on home oxygen, this is a dance with death that he will prefer to do with the most skilled dancer in our hospital: the anesthesiologist. Before my colleague calls me back, i tell the patient: Sir, you are so sick…. we feel that at this point, mechanical ventilation is the last thing we can give you to survive this.
I don’t want to be intubated!
OK, are you sure?
I don’t want to be intubated!
I must tell you that this was not an easy decision. We propose this to save your life. We think you could die without it.
I don’t want to be intubated!
OK Sir, i understood. I will respect your choice. I know that there is the question of how long we live and there i also the question of how we live… It is your choice.
He is awake and alert. He is not confused. Repeat one more time to be sure and we all agree that this is his choice. His family heard the discussion, they will understand.
Before i let him go to the intensive care unit, i put my hand on his shoulder.
Sir, i want to tell you something important.
I gave you everything i got. You got everything in you to fight this infection.
I am afraid you might die… But you might also survive. There is a choice you have to make in all this. If you want to live, you have to fight this. If you give up, you will die. You can fight this if you want. Good luck.
I say goodbye to my patient. I tell his wife, daughter and father to stick around, the next few hours will be critical. It is a good think my shift is over. I head home and i have a beer while listening to music and i think about this man, his life, his fight…. And how lucky i feel to be healthy.
I wake up the next morning and i text my colleague. How is he?…. Breakthrough during the night, he’s much better this morning.
Original post Facebook, October 2017
Martin Pham Dinh 