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Friday, October 19, 2007

When it's asthma it's personal for me

(Two weeks ago)

"I can't breathe! I can't breathe!"

I did not recognize her as Leanne because she looked so miserable. She sat on the edge of the bed, all 300 pounds of her, with her arms to her side holding her shoulders up. She was extremely labored. She was literally gasping for air like a fish out of water.

My first instinct was to get her in bed because I could just see her coding and falling to the ground. Nurse Boo helped me set the bed up and put her feet in bed. Then I started a treatment.

"Go get your biPap," the doctor said. BiPap on an asthma patient? I had heard of it before, but never tried it. I know some asthmatic RTs who contend they would never let someone put a BiPap on them when they were SOB.

It was a rental doctor I had never seen before. "Let's try BiPap!" he ordered again.

He was impressed because I just happened to have my LTV 1200 plugged into the wall right next to the bed. Within a minute I was holding the mask on the patients face. I figured if I attached it to her head she'd feel even more trapped and claustrophobic. In other words, I had a good feeling this BiPap wasn't going to work.

"Put that thing on her!" the doctor ordered, and he grabbed it from me and put the straps around her head. She isn't going to tolerate this, I thought. To my amazement she made no attempt to yank it off.

That was when I realized this was Leanne, and she's only a couple years older than me. She had a history of asthma and did wear a BiPap at home. So that would explain why she tolerated it so well. She also had a history of fluid retention, so I was thinking CHF. And, considering she had audible upper airway congestion, that's kind of what I was thinking.

The doctor disagreed with me. "This is status asthmaticus, he said, "I want you to keep the treatments coming; just give continuous." I did. I set the treatment inline. Nothing we were doing seemed to be doing any good.

"She's really bad," nurse Lee said. "We're going to have to intubate."

I knew from past experiences with nurse Lee that she has a tendency to get over excited in intense situations, and I see too many doctors jumping the intubation gun. I also knew from past experiences that I did not want this patient to be intubated. It was personal. This patient had asthma. I have asthma.

"Let's just be patient," I said, knowing no one was listening. The doctor was already leaning on the airway box. Stay away from that, I thought.
(Nine years ago)

It was in my first year at Shoreline Hospital. Her name was Erin. She came in with status asthmaticus. I knew her personally as a nurse and because she took care of me when I had my asthma attack and had to stay the night. Her Internist happened to be here that day, gave her all the essential medicines like Epi, Steroids, bronchodilator, etc., and sent her to CCU despite the fact she was still quite labored.

Thirty minutes later she was doing much better, "Looks like she escaped the tube this time," Dr. Peterson said that day.

Two weeks later Erin came back in. She was equally as labored as her last visit. This time, however, Dr. Peterson was unable to come in. Dr. Samson ordered the essential medicines like Epi, Steroids, continuous bronchodilator, etc, and decided to intubate.

Wait!, I thought. Don't intubate this patient. Let's be patient and give her time to recover. Let's give the medicine some time to work. It worked 2 weeks ago when Dr. Peterson was here. I was a new RT at this time. I did not say what I was thinking, what my gut instinct told me to say. I regretted this for years to come.

Erin got intubated. It was a horrible intubation. She fought vigorously and turned blue when we sat her back. As soon as I placed the mask on her I could see vomit building up under it. We set her on her side. She vomited all over the side of the bed. Since she was overweight, she was an awful intubation.

In CCU she fought the vent like no patient I have ever seen since. Dr. Peterson ordered a tidal volume of 700, but the vent breath stopped at 300. The high pressure alarm blared with every breath. I turned the tidal volume to 250, and the high pressure was still barely under 60.

Dr. Peterson was not happy. More than likely I was new and hadn't earned his trust. "I ordered 700."

"I can't give 700."

"Is something wrong with your vent."

"No." I had intensely been studying my machine and nothing was wrong, I was sure of it. The vent was doing its job, I was certain. She was in severe bronchospasm. She had asthma. She was tight. She was airtrapping. She needed low tidal volumes. Why the hell is this doctor insisting I give her 700 tidal volume?

He paralyzed the patient. Still, a low tidal volume was needed. Dr. Peterson was insisting something was wrong with my vent. I was sweating.

I went to the nurses station and called sagacious Jane. I explained the situation. "What do I do," I said. She assured me what I was doing was correct, and then came in to help me.

She ended up doing a 1 on 1 with Erin the rest of the night, that's how bad she was. I felt bad because I wished I had told the ER doctor my recommendation that we not intubate. At least if I had said something and he still intubated, I wouldn't have this on my chest.

She ended up spending a month on the vent. At one point we were told she might have brain damage because we had taken all her sedatives away and she wasn't waking up. It was very sad. We were told she might not make it.

Then one day I walked into her room and her eyes were open. The next day I was explaining to her the weaning process.
The doctor decides to intubate Leanne against my wishes. It was actually an easy intubation despite what I had expected. I set the LTV 1200 up to give ventilator breaths and did a blood gas. The ABGs read: pH 7.24, CO2 56, PO2 90 (on 100% FiO2), HcO3 25.

According to this ABG she was starting to fail. That's when I realized the nurse and the doctor were probably right about intubating this patient. I was basing my decision on not to intubate on emotion rather than experience and knowledge. And she was so panicked she might not have turned around had we not intubated. As it was, we had no choice but to intubate.

I suppose we can't be perfect all the time. Two days later she was off the vent and back to her usual cheery self.

While the ER doctor assured me she was "a classic case of status asthmaticus," and I agreed with him, I still suspected a CHF component too, although she wasn't treated as such until she was up in CCU and I was at home sleeping.
(last night)

In report I was told she had been crying. She was scared about going to pulmonary rehab. By the time I enter Leanne's room to give her a treatment she's her usual cheery self, however I see the pulmonary rehab packet on the bedside table.

Leanne had been a regular patient since she spent time on the vent two weeks back. I always tell people working at a hospital is no different from working at a grocery store, you have your regular customers.

She asked me if I read any good books lately, and so we discussed our favorite books. Then somehow we ended up discussing a show she was watching on the history channel and, before we realized it the treatment was no longer misting.

"Oh, I guess that's done," I said. "When I have fun patients I try to make this thing last longer." She smiled. I proceeded to put the neb away while she talked.

I grabbed my clipboard and was standing by the door. "You know," she said, "I'm really leery about going there. I have a 17-year-old at home. I don't want to leave him."

"You know," I said, "I can relate to you here. When I was a kid I was a regular patient, kind of like you right now. I'd spend at least 2 weeks a year in the hospital. When I was 14 I got so bad my doctors didn't know what to do, so they shipped me to an asthma hospital in Denver."


"Yep. Only I didn't get to go for just 18 to 24 days. I was initially scheduled to be there 6-8 weeks. It ended up taking them nearly 6 months to straighten me out. And it really wasn't that bad really. I learned a lot about my disease. You see they did all the best asthma research in the world there, and they put me on all the most up to date asthma medicines at the time."

"Wow. That must have been hard to be away from your family at such a young age."

"Really it wasn't so bad. Somehow I knew that making this small sacrifice now was going to make the rest of my life better. And you know what?

"What?" She smiled.

"I didn't go back to the hospital for ten years after I got out.
(This morning)

"You know," Leanne said this morning as I was finishing up her treatment, " I feel much better after talking to you last night. I really think this is the best thing to do."

I said, "I really think this will benefit you."

"I think it is too."

I wrapped up the neb. "Anything I can get for you?"

"No." She hesitated, then said, "I really like you guys and all, but I hope I don't have to see you again for a while."

"In a grocery store. If I see you again I want it to be in passing."

She smiled.

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