Pulmonology, Week 1, Day 3

Today I witnessed a patient passing away ... this is the first time I have ever been present to observe a person approaching the end of their life. But let's start at the beginning of the 3rd day of my Pulmonology rotation.

This morning Arthur and I met with Eva, a respiratory therapist. She explained to us that her job was to resolve both respiration (oxygenation) and ventilation (breathing) problems and that the goal of respiratory therapy was to wean patients off of mechanical ventilation and to ensure that extubation is successful. After a review of some respiratory physiology concepts and a quick introduction about positive airway pressure and negative airway pressure we went down to the ICU to observe some of the patients on mechanical ventilation. Eva and another respiratory therapist explained about the machines and calculations they do to monitor the patients, but to be honest, I did not understand very much. We were in the ICU during the family visiting hours and I saw family members doing whatever they could to help the nurses care for their loved one.

Then, Eva took us to the Respiratory Care (RC) unit. This floor was much quieter than the other floors, as there were fewer patients and visitors. All the patients in this unit are long-term mechanically ventilated patients and some have been in the unit for many years. Most patients were considered to be brain-dead and were described as having "no consiousness". Patients stay here because nursing homes are not equipped to care for these patients. It was explained to us that the culture in Taiwan contributes to families deciding to keep patients on mechanical ventilation for many years. The culture revolves around respecting your elders and caring for them until the end of their life, and to take them off mechanical ventilation is disrespecting them and essentially killing them. It is not seen as ending patient suffering and ending their poor quality of life. So we observed patients who had been in this ward for over 10 years. Eva told us some families leave their patients here, and only visit about once per year, but there was one patient with Amyotrophic Lateral Sclerosis (ALS), sometimes called Lou Gehrig's disease who had been in the unit for 11 years, whose husband visited every day. We were in the room during his visit and he doing the usual daily exercises with her. It was touching to see the devotion this man had for his wife, especially after hearing that other families rarely visited their patient. The level of family involvement in long-term patient care is greatly contrasted with the acute care patients.

This afternoon we met with Dr. Huang in the RC unit. He informed us that he would be performing tracheostomy tube changes today, which they do once a month. 

Patient 1: Dr. Huang and 2 nurses began the process of changing the tube and then the machines started beeping, so more nurses rushed in. Eventually we were asked to stand in the hallway. After he was able to insert the new tracheostomy tube, Dr. Huang came out and explained to us that after inserting the tube, he checked the tidal volume, which was much lower than expected, thus signaling that the tube was not inserted into the trachea, so he had to insert another tube. He told us that if the second attempt did not work, he would have had to perform an endotracheal intubation. Then, he told us that if this situation happens, we should not be scared, but we should continue to remain calm and keep going in a step-by-step manner.

Patient 2: The changing of the tracheostomy tube went smoothly.

Patient 3: This patient resided in the same room as Patient 1. She had been in the RC unit for 10 years. As the doctor was in the process of changing the tube, the machines started beeping, like with Patient 1, so we took this as our cue to exit the room. We stood in the hallway facing the room and tried to observe as much as we could. Nurses rushed in and out of the room, bringing in machines and and other things. Since neither of us speak or understand Mandarin, we did not know what the doctor and nurses were saying. Then, Dr. Chieng (from Day 1 of the rotation) came into the room. After a while, one of the nurses came out and asked us to bring "your teacher from this morning." We rushed to find Eva in her office and told her that she was wanted in the RC unit and we followed her back to the unit. By the time we returned, the machines had stopped making noise and we waited in the hallway again. Eva went into the room, briefly talked with Dr. Huang, and left because she was no longer needed. Dr. Huang came out and told us that the patient had "expired". He told us that they had called the patient's family and the family understood the situation and decided against intubation. Thus, the he did not perform the intubation and the patient passed away. 

I think that if I could have understood what the doctors and nurses were saying, I would have had a better idea of ​​what was happening with this patient, because I was not expecting to hear that the patient had expired. I guess I was expecting the same result as Patient 1. When Dr. Huang first exited the room, he said "This is not my day," and I wondered what was going through his mind. He told us that we had to be very careful when doing this procedure, but even if we were very experienced and had done the procedure 1,000 times, this situation can still occur. And that perhaps this allowed the patient and her family to end any suffering they were experiencing for the past 10 years. This has been the most intense situation I have encountered thus far in my short journey in medicine. I wish peace to the patient and her family.