Today, was a rather slow day for Christine and I. In the morning, we met with Eva, a respiratory therapist, to talk about ventilators and intubation/extubation. She was very insightful and told us the goal of a respiratory therapist is to help a patient improve his/her ability to breathe comfortably by a variety of methods such as using equipment, rehabilitation, and of course, patient education. Many of the patients we saw were either on a non-invasive ventilator or IPPV (invasive positive pressure ventilation). She explained that since many are on mechanical ventilators, they depend on this invasive equipment to enable them to breathe. Hopefully, one day, they would be able to wean off and be extubated successfully. She kept telling us about this equation that is the holy grail for their profession, the equation of motion: P = V/C + (Q × R). This describes the pulmonary mechanics and also gives them the ability to manipulate certain components, such as the airflow or pressure of the ventilator to provide adequate ventilation. Her strategy involved using this equation to initially optimize ventilator settings to keep a patient stable. As time goes on, she would try to wean them off and using a weaning profile, she would be able to determine the success of an extubation and act accordingly. I found it fascinating that the basic respiratory science that we learned during our first year of medical school was very practical.
In the afternoon, we met with Dr. Huang, who was doing a couple tracheostomy tube changing procedures. We met in the Respiratory Care Ward, which is essentially a palliative care facility for elderly patients or those who cannot breathe on their own anymore. Many were on mechanical ventilators and were comatose for many years.
Case 1: This elderly male had been in this ward for the last decade. Dr. Huang explained that he has had complications before and his family had signed a DNR. It is common practice to change a double lumen tube each month to prevent the development of granulation tissue around the tube and tube blockage from excessive secretions. Other indications include substituting for a different type of tube to facilitate weaning and tube damage/obstruction. This is when the complications ensue. Failure to recannulate or creation of a false lumen is possible during this changing process. As a result, there will not be an adequate seal and thus, the patient will soon be in respiratory distress. Dr. Huang intensely checked the tidal volume to ensure it was in normal range. If it is not, he says "Do not be scared. Follow the procedure step-by-step." He pulled out the tube and Ambu-bagged the patient (for manual ventilation). He would then check the oxygen saturation and if it is stable, he would try to re-insert the tube a second time. If it still fails, an endotracheal tube is indicated. However, since a DNR was in place, if it got to this point, Dr. Huang would not intubate (due to legal reasons). This was not the case and the re-insertion was a success.
Case 3: This elderly female was neighbors with the patient in Case 1 and also, lived in the hospital for the past decade. This time however, re-insertion failed and Dr. Huang had to call the family to check if they were still honoring the DNR. Unfortunately, they said yes and Dr. Huang was unable to intubate the patient. She expired shortly after. Dr. Huang walked out of the room and told us,"Today is not my day." He explained that even if a physician did this procedure 1,000 times, it was common for this to occur. He did everything he could do legally and at the end of the day, he was still frustrated that he could not do more. Maybe it was for the best.
Personal Note: The DNR seems not to be as legally binding as in the US. For example, if a patient goes into cardiac/respiratory distress and a DNR is in place, the doctor in charge will try to contact the immediate family to confirm the DNR orders. If the family says no (even if it is one family member out of many) or is indecisive, the doctor will then perform intubation or CPR to stabilize the patient. This would not hold true in the US and would be legal grounds for a lawsuit. Even though DNR is a relatively new concept in Taiwan, many physicians see it like any other piece of paper. In addition, many Taiwanese people do not fully understand the intent of the DNR. In the US, in addition to the DNR, the family can also sign a DNI (Do Not Intubate). This order essentially dissuades the medical staff in cases of a medical emergency. Although it is commonly not recommended, a patient may opt to have only certain interventions done in the cases of distress (DNR but okay to intubate). The take home point is that if this order is well-conducted, it will make a more fluid experience not only for the patient and his/her family, but also the medical staff. The discrepancy of communication may lead to undesired patient outcomes and unnecessary distress for all those involved in this matter.
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