FOLLOW DR. KO: Medical Mission to Haiti – Paul, the patient who couldn’t breathe
Paul was a thin and frail-looking man in his sixties. He walked into Hôpital Bernard-Mevs accompanied by his teenage nephew on my first shift volunteering in Haiti. He was complaining of worsening shortness of breath for the past couple of days. He suffered from asthma, he told me, and confessed to a history of heavy smoking.
From Paul’s barrel-shaped chest and his long history of tobacco abuse, I thought chronic obstructive pulmonary disease, or COPD, was more likely than asthma. However, definite diagnosis would require a pulmonary function test during which the subject sits in a chamber connected to a spirometer that measures various pulmonary parameters such as lung volume during expiration and inspiration. One major difference between asthma and COPD is that the former responds to a class of medications called bronchodilators, whereas COPD does not. Also, people with COPD are usually accustomed to having a higher than normal level of carbon dioxide (CO2) in their body. That elevated level of CO2 serves as their respiratory drive, reminding their body that it needs to breathe. As a consequence, giving these patients high levels of oxygen could actually be lethal as oxygen suppresses that CO2 respiratory drive.
Since the initial treatment in asthma and COPD is similar, I went ahead and ordered the medications. Unlike back in America where I would simply click a few buttons on the computer, in Haiti I had to write down every single medication I wanted, including the route of administration and the dosage on a prescription pad. The patient, or a family member, would then to take that script to the pharmacy, pay for the medication, and bring it back to me so I can administer it to the patient. And if I wanted a repeat dose, I would have to write another prescription, and so on. No money, no meds. Of course, in cases of emergency where it’s a matter of life and death, Hôpital Bernard-Mevs would still treat, but the bill would somehow have to be settled later.
I wrote albuterol, ipratropium bromide and methylprednisolone on my prescription pad for Paul’s nephew to take to the pharmacy. He hung onto my every word and executed my orders like I was someone important. I guess to them I was; I was all they had. A shooting near the hospital distracted me away from Paul for a while (see previous blog), but I quickly came back to him, because he was obviously in respiratory distress and not improving. His lungs, which wheezed loudly on auscultation in the beginning, were now almost quiet. This could misguide a clinician into thinking that the patient is improving, but it is actually an ominous sign that the patient is fatiguing and about to crash.
If this were back home, I would sedate the patient, put a breathing tube down his trachea and connect the tube to a ventilator to breathe for him. Paul was getting tired and I didn’t think he would be able to maintain his airway on his own for long. But I had never intubated someone without the supervision or at least the blessing of an attending physician, and there, I was by myself. Should I just make the call?
Just when I was hesitating, it was time for shift change, and the local doctor who was on duty came to take over. I was relieved to hand off the patients to someone more senior, and voiced my concern about Paul to this doctor.
“He is using his accessory muscles, his oxygen saturation is slowly going down, and I already gave him three rounds of nebulizer treatments, magnesium sulfate and steroids. I think we need to intubate him.” I reported, as a resident would to an attending.
This attending, however, was not impressed. “He doesn’t need to be intubated,” she retorted, “Just take him back to the ER and put him on oxygen.”
Although I did not completely agree with her management, I did not want to overstep my boundaries. After all, it was possible that due to lack of resources, Haitian doctors had a higher threshold for intubations and other more aggressive approaches. Just because I was used to doing things a certain way, didn’t mean that everyone practiced medicine the same.
A few hours after I had finally slipped into slumber from a tiring and eventful evening, a volunteer Critical Care nurse who was also one of my bunkmates rushed into our room to grab her Ambu bag, a device used to manually ventilate a patient who is not breathing. “They are tubing the patient, Melody. I came to get my Ambu bag because they couldn’t find one in the ER.” I jumped off my bunk bed, and still in my pajamas, ran out to the ER which was right across the volunteers’ rooms. Paul’s oxygen saturation had gone down to 70%, while a healthy person’s saturation should be more than 98%. He looked exhausted and distraught at the same time.
Kicking myself for not standing my ground, I wanted to remedy the situation as quickly as possible. I asked the nurses for etomidate, an anesthetic agent commonly used prior to intubating a patient. They didn’t have it. “Give me propofol then, do you guys have propofol?” They had a vial somewhere but couldn’t find it now. They finally brought some ketamine, an anesthetic agent, and succinylcholine, a paralytic drug. The nurses infused both medications into Paul’s intravenous (IV) line and I waited for him to fall asleep and stop struggling so I could intubate him without a fight. But Paul did not close his eyes, nor did he stop gasping for air. He was neither adequately sedated nor paralyzed. We probably didn’t have enough medications to put him out completely.
“You can go ahead and intubate now.” The attending instructed.
I could not believe that I was going to do an awake intubation. But it was either that, or Paul was going to asphyxiate.
It was a traumatic experience for Paul and for me. I saw him stare right into my eyes with horror as I propped open his jaws and pushed the endotracheal tube down his throat. The image of Paul gagging and gasping for air will forever be edged in my memory. So will the image of his feeble smile one week later when I told him that he was going to be discharged from the ICU (intensive care unit) and celebrate the New Year with his family. But that’s another story for another time.