I dislike this Fellow. He’s cocky and arrogant. He does not have a rapport with the patients, or the nurses, for that matter. He walked into our room, exclaiming “Whoa!”, in that damn that boy looks bad kind of voice. Not the voice you want to hear in reference to your own child. Maybe I am overly sensitive. Maybe he just rubs me the wrong way. But he is the one I have to deal with, the one who will intubate Capt Snuggles, yet again….
I knew when I woke up, that David would be intubated before the day was done. It wasn’t that he was breathing 100 times a minute, not so much, anyway. That seems to be the norm for him these days. It was the way he was breathing, like his whole body was gasping for air. The Fellow called it Disorganized Breathing, he was inhaling twice, exhaling once. Inhaling once, exhaling twice. It was very hard to watch him struggle, not knowing the cause of his erratic behaviour.
The whole day was rough. He needed a blood transfusion. He needed the remaining dose of campath. He needed Cidofovir (treats Adenovirus). He needed a fluid bolus before and after the Cidofovir. All this in addition to his daily regimen of 5 different IV antibiotics, steroids, Protonix (protects the stomach from ulcers), IV nutrition, pain meds and fluids. Factor in the frequent blood draws and his dance card was full, full, full. Take a number and wait your turn. It was going to be a long day.
He was in such obvious pain from all the open blisters now covering his little body. And no matter how much pain medication they threw at him, it wasn’t enough. Somehow we got through the day. But by evening, he had spiked a fever, his blood pressure was sky-high, his heart rate low. While his blood work indicated he was processing oxygen adequately, it was obvious by looking at him that he was struggling.
We encountered a set back with his central line, somehow the hub came loose and was leaking. It needed to be repaired. This meant for about 6 hours he was without one of his access points. IV nutrition was turned off. The line needed to fixed and quickly. The risk of infection from a hole in the line is incredibly high. An infection his body is no longer able to fight.
The decision to intubate was made around 11pm. Ready, set, GO! Such a flurry of activity~ 3 doctors, 3 nurses, 2 respiratory therapists and a slew of helpers in the hall ready to get items as needed. It’s a bit like a sci-fi movie, all the scientists gowned up – ready to dissect the alien.
The Fellow does the actual intubation, the Resident assists. The 2nd Fellow supervised. One Nurse charts, one Nurse pushes meds, the other Nurse does, well, everything else. The RT’s keep him breathing.
Fortunately, the Fellow didn’t have any trouble with the actual intubation. It was a struggle to get the ‘tube’ taped in place, though – both of his cheeks had multiple blisters and the skin had peeled away where the existing tape had been removed.
The RT and the skin-care nurse brain-stormed and came up with a way to dress the open wounds and still fasten the breathing tube in place. All the while, the 2nd RT kept him ‘bagged’. They couldn’t hook him to the ventilator until they figured out how to secure the tube.
It’s mind-numbing to watch someone squeezing that little bag, manually blowing air into his little lungs. I wanted to scream for everyone to Shut-Up – so the RT could concentrate on what she was doing.
squeeze release squeeze release squeeze release squeeze release
Now the hard part ~ getting him sedated. If he’s not fully sedated, he runs the risk of pulling the breathing tube out. Sedation is an on-going event. He can require adjustments to the med doses on an almost hourly basis for days to come.
After the intubation, his blood pressure dropped, requiring epinephrine to stabilize, his body temperature went down to 93.4, his heart rate was elevated. His electrolytes, his potassium in particular, were off kilter probably because the TPN had been stopped. He needed another blood transfusion, his platelets dropped to 30.
I say ‘after’ only because, time-wise it was after. Intubation would have become an emergent need if they had waited much longer to do so. Some of the reactions were related to the campath, some to the sedation meds, some to his overall diminished state.
The good in all this is that his pain is better managed. They were able to dress all of his open wounds, essentially treating him as if he were a burn patient. They inserted an arterial line to constantly monitor his blood pressure and provide another access for blood draws.
It feels like we’re back to the beginning, though. This roller coaster ride isn’t over yet.
I’ve always hated roller coasters.