A Patient's Worst Enemy: Time
Her only enemy was time. There was too much of it. As my
patient lay in her bed and slowly suffocated, each tick of the clock brought a
desperate battle to stave off panic.
Ms. M had dealt with her difficult lungs for years. Without
explanation, the delicate tissues and air sacs had hardened and scarred; they stiffened
and refused to perform their vital function. For a while the fibrosis merely
hampered her life, stole the small joys and the ease of her breath. But now my
patient's disease had reached a critical point and one thing was clear: her
lungs were killing her.
She arrived in our critical care unit and fought to buy us
time while we worked on the one solution that might save her: a lung
transplant. She lay in bed and gulped air while we ordered tests and requested
imaging. She panted for breath, night and day, while we consulted the
transplant specialists and put a neat little checkmark in every box the massive
surgery required. She gasped for oxygen while we finally listed her for a new
set of lungs.
Lung transplants use a special score, called a lung
allocation score (LAS), to determine the need and urgency of each patient
eligible for new lungs. The highest possible score, indicating the greatest
need for transplant, is 100. Ms. M scored a 95.
Ms. M couldn't help but panic. She had suffered from anxiety
forever but the combination of stopping her usual medications and the struggle
to breathe was too much. She tossed in her bed; the fear burned even more
oxygen. Her nurse gave every medication that was prescribed and called our team
when nothing worked.
When my PA colleague and I entered the room, Ms. M was in
distress. A large plastic mask covered her face from the bridge of her nose to
her chin. The device, a non-invasive positive pressure ventilator, pushed 100%
oxygen into her body with each breath. Under the mask her mouth opened wide and
her lips flapped with the force of flowing air. Her chest, belly and shoulders
heaved and she occasionally flopped her limbs back and forth as if some new
position might relieve her agony.
My colleague explained that any extra movement raised her
oxygen requirements and made her shortness of breath worse. It would help if
she could calm down. She wanted more anxiolytic medications. More drugs could
sedate her and diminish her impulse to breathe, the PA said, and if she didn't
get enough oxygen on her own we would put a tube down her throat to breathe for
her. We need to avoid that at all costs, he said, because an intubation would
severely hurt her chances of a successful lung transplant. She nodded as her
whole body shuddered.
Before we left the room her wide eyes darted to mine. "You
can do this," I said. She held up one hand with the index and middle digits
intertwined. Fingers crossed.
As I walked to the parking garage at the end of the day, Ms.
M continued to fight for air. She struggled while I stopped at a grocery store
on the way home. While I slept in the next day and later went out for dinner,
Ms. M bought herself one more second of life with each terrified gasp. The
seconds became minutes and the minutes became hours and no new lungs arrived.
I was still enjoying my weekend when Ms. M had enough.
Without news of a matching organ, she and her family made a merciful decision.
She removed the breathing mask and died.
This story isn't about a horrific mistake or an unexpected
tragedy. In fact, similar situations occur every day in the ICU. Instead, it is
a reminder that at the end of the day, I clock out and go home but my patients
do not. This doesn't mean I carry every worry of the day home with me. If I do
my job right, I don't have to. But it is worth remembering that even when I take
off my white coat, my patients are still working to stay alive.