small beginnings

recently i caught up with an old friend. the day i started studying surgery he started in internal medicine. he is now a fancy prof. i was amazed and impressed. he really was, and i assume still is, a really great guy. yet even great people must start out small. i remember the first day we met.

i was on call in the surgical icu. i had been part of the surgery department for a full two days and was still unsure about pretty much everything. so when the internal people phoned asking if we had a bed available for one of their patients i called our prof even though there was one bed empty. the prof was a good man and told me we were obliged to help them even though the pressure on our beds was usually great. i phoned the internist on call and told him he could bring his patient.

some time later a patient was wheeled in. the first thing i noticed was that she was blue, a colour i have often said doesn't appeal to me. the next thing i noticed was that she was just barely breathing. being astute even though inexperienced, i concluded she was in the process of dying. at that moment the physician walked in and introduced himself to me. he had just started in internal medicine two days previously and was also pretty unsure of himself. after whizzing through the formalities of greeting, i pointed out to him that his patient wasn't breathing too well and that she needed intubation and ventilation soon. otherwise one could only hope her policies were all paid up. he looked at her. it was abundantly obvious i was right.

"yes, i see what you mean," he said after a moment's thought. "i'm just quickly going to call my consultant. i'll be right back." and with that, before i even had time to express surprise, he was gone. the sister and i looked at each other with bewilderment on our faces. it just seemed that intubating the patient was at that very moment more important than finding his consultant.

"well, we know what to do." i said, "get the patient into a room and let's intubate. without any further delay or looking around for wandering consultants we soon had the endotracheal tube in position and the patient connected to a ventilator. soon the blue hue was replaced by a more encouraging pink colour. not totally unlike the patient, we all breathed a sigh of relief.

after a short time, the internal registrar returned with consultant in tow. by that time the icu staff and i had settled down and were even making coffee. then i put the story together.

the registrar had been out of clinical medicine for a while doing some or other form of research. he was not confident enough to intubate the patient and just assumed that i also would not be. he therefore felt he needed to get his consultant there as fast as possible to place the tube. it was the best he knew to do at the time. unfortunately it would not have been good enough for the patient. i had to intervene. i was not the patient's best hope. i was the patient's only hope.

well, all's well that ends well.

catching up with the esteemed prof after so many years made me realise how even the mighty have humble beginnings.

dignity

he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.

in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.

the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.

then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.

he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.

i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.

i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.

maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.

but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.

tube

i mentioned a possible series. i thought i better at least try. so lets talk about another tube incident.

i was in my icu rotation. our icu was 23icu. but there were about another 4 icu units in the hospital and we had a number of patients spread out throughout the hospital.

late one night i got the call.

"hello, it's sister x in 54icu. could you please come and tube mr y?" i had no patient at that time in 54icu. 54icu was the internal medicine icu.

"who's patient is mr y?" i asked.

"he is internal medicine's patient." she replied.

"well then call the physician on call for icu." i suggested.

"he is here and he asked me to call you." it was time for my standard question.

"should i run or can i walk?" 54icu was about 500m from 23icu and it was an uphill route. i hoped for a gentle walk.

"i think you should run!" i set off. en route, i thought about what i would encounter. an internal medicine registrar was asking for backup in an attempt to tube a patient. i got ready mentally to do a tracheostomy.

i charged into 54icu and what a sight i met. the patient was blue, a colour that in my humble opinion, did not suit him. he was lying in a puddle of blood and vomit. there seemed to be a flurry of activity around his bed, but not much was being done. i decided to attempt to tube him once before i turned to my trusted friend, the knife.

the intubation was quick and easy. once i had done it i couldn't help wondering what all the fuss was about. the patient regained his pink colour before i regained my breath. if i thought the guy was capable i might even have asked the physician to intubate me. i thought better of it though.

"thanks a lot!" he said.

"no problem." i replied. i thought of making some witty comment about needing the adrenal rush or that the sprint up to 54icu could only do me good, but i was still too out of breath. all comments i thought of in that moment were more than one syllable.

"can i just quickly ask you something?" he continued.

"no problem." i repeated. (i was tired.)

"when you intubate, is the trachea anterior or posterior of the epiglottis?" i did not let my face betray what i thought of the question. i just gave a factual answer. he at least had the guts to ask. at least i knew why he had struggled.

resus fun.
cuban resus.
resus with hands tied behind my back.