It’s 4:30am and I wake to the bright overhead lights being turned on. Either something’s wrong or our overnite Chaperone is being a pain. I squint towards David’s bed and see the Fellow standing there.
A half hour earlier, David’s heart-rate dropped suddenly into the 40’s, his oxygen level had also dropped suddenly. Blood was being drawn for his daily 4am labs, so the nurse waited until they came back before sounding the alarm. She said he was pale and lethargic.
His blood gas came back awful. So bad they had to max out the ventilator settings. That’s right, there is very serious talk of putting him on the oscillator, as it is really called.
I prefer the life-support machine.
Maybe yesterday’s episode wasn’t isolated, maybe the bleeding did more damage than originally thought. His chest x-ray shows marked deterioration of his left lung. Upon exam, they can hear that his left side is ‘down’, even with the vent setting maxed, he’s not moving air through his left lung very well.
The Fellow is unsure, he doesn’t want to put David on the oscillator, he’s afraid his body won’t tolerate it, he would require deep sedation and additional lines for closer monitoring. What I hear between his words is that he doesn’t want to be the one to commit him to this machine – to be the one to say there is no more hope.
So we wait for the Attending.
Of course, being Sunday, it seems like forever before the doctors arrive for rounds. They repeat his blood-work prior to rounds. A dose of sodium bicarb and the increased vent settings seem to have straightened him out for the time being. While the Fellow is certain this episode is an indication of his lungs getting worse, the Attending feels it is all related to the blood he aspirated yesterday.
Something we can support him through, rather than throw in the towel and wait for the inevitable.
So the vent was re-adjusted. Now we wait to see what his numbers tell us. Given that he’s been intubated for the past 2 months straight he has developed an underlying lung disease, causing a fibrosis or thickening of the lung tissue. This isn’t an infection or a pneumonia, something that can be readily treated. The Attending thinks his lungs are as stable as they will get for a while. It may take months into years for the damage to repair itself – if it can be repaired.
His upper GI bleeding has increased again and his 10am labs indicate the need for another blood transfusion and more platelets. Everything else looks relatively good. His kidney function has improved, his liver is holding it’s own, his heart is still strong. The three main contenders are the gut, the lungs and the adenovirus / GVHD. The adenovirus/GVHD get lumped together simply because we can’t tell which one is really the culprit in destroying his gut – so we treat them equally.
If we could get the adenovirus/GVHD under control, his gut could start healing. If his gut could start healing, he could be extubated and his lungs could start healing. If his lungs started to heal, he could start being a baby again.