I’ve been thinking of writing the story of a man who came in struggling so much for breath, that Les and the other doctors didn’t think he would make it. But as I typed the title, I thought it also described the start of 2020 for us…waiting for our visas! Many of you know that the hospital agreement with the govt expired on Jan 15. We did get a 6 month extension, however, that didn’t automatically translate into new visas for the expats. As we prayed, sent documents to Kathmandu, and waited for word, it really was a rather breathless time! Would we get to stay? Have to go to a tourist visa and stop working? It was unsettling! But – thanks be to God, we all got visas stamped into our passports on Jan 15 – the day the old visas expired. Last minute answer to prayer – but we are sure in God’s eyes it was just at the right time. Please continue to pray for the hospital agreement which needs to be completed soon!
Our good friend, Steve, from Australia, wrote up his version of what happened the night the breathless man came into the hospital. He is an anesthesiologist who spends a year in Australia working to earn money to support himself here for the next year. He and his wife have been doing this for probably 10 years now (or more) and we are so thankful for them. And we miss them when they are not here. I hope you enjoy his version of events. (This does have medical terms and explanations, but I think the story is still interested to non-medics, too!) After reading his, I didn’t feel I could say it any better. (Les thought he was spoken of too highly in this version – but I thought it was right on target!)
“My phone buzzed at 4.30am. My anesthetic staff asked could I come to the High Dependency Unit (HDU) to help intubate at patient with Acute Respiratory Distress Syndrome (ARDS). ‘Dr Les had asked.’
I had been deeply asleep and couldn’t put two thoughts together. Dr Les, however, is a walking legend who never asks for anything from anyone, and who can be trusted in that way where you just start assuming whatever he’s asked for is a good thing. The default position is trust and you can discuss it later. I was not in the position to discuss anything – I could barely remember my own name.
The temperature was about 42 outside and probably all of 50 in my bedroom. I fumbled about trying to dress in the dark and not wake Ana. I couldn’t find clothes, I couldn’t make my rapidly cooling body work, I nearly left without glasses without which not a single thing, near or far is in focus. I eventually left the flat and managed to negotiate the 2 padlocked gates, and 50m of downhill cobblestone that separate me from the HDU.
Every day for the previous week, we had had a one hour ‘class’ on HDU. There are only 3 of us in the hospital prepared to care for a ventilated patient, and we are trying to increase that pool, just as I am about to depart it for another 12 months. We have an old ‘home ventilator’, a Puritan Bennett LP6, from the 1980s maybe. While fancy touch screen Evitas have been donated and another old German machine has been donated, it is the LP6 that has outlasted them all. I have lost count of the number of successful snake-bitten patients we have seen through their paralysis with it. We jerry rigged a way to enhance the oxygen intake by attaching a reservoir to the air inlet. It did 5.5 weeks non-stop for Govinda the Guillain-Barré Syndrome patient. It’s proved to be a good choice for our setting – running on electricity not compressed gases, with dials, not electronic controls, with a simplicity and durability that suits our ABG (Arterial Blood Gas) free hospital.
The classes focused on the ventilated patient in our hospital: our protocols, our habits, our successes and failures, our budget and indeed, our LP6 specifically and how to get a healthy but paralyzed patient through the 2 to 6 days that they are ventilator dependent due to their snake bite. The first minutes of the first class were about ‘Who to ventilate’ and I had been pretty blunt in saying we didn’t have the equipment or staff for people who had bad lungs. In fact I admitted that we ended up giving most of our snake bite patients pneumonia anyway, despite them starting off with good lungs. Sure, there was room to change the rules, and the new mother I had ventilated just before the Dashain holidays for 3 days, was a good example. In her case she was badly hypoxic, but all other organs and functions were working well. She was previously well with no diseases – and she was a brand new mom. But the general rule was: Good lungs, single organ or system disease, and for learners: snake bites only.
Dr Les had been in those classes all week. The cold air woke my brain enough to wonder, as I skipped from torchlit stone to torchlit stone, why Les thought it OK to intubate and ventilate a patient with ARDs, and how he had become involved since he wasn’t on call anyway.
My phone rang again – ‘Are you coming?’ – and a few minutes later I arrived to see an older man, breathing like a train, hypoxic, cyanotic, with a good spO2 trace on the monitor behind him, a reliable trace reading 60%. He did not appear to be conscious, did not respond to my voice and had small pupils that were asymmetrical and sluggish. Surrounding him were the medical and surgical juniors on call, the senior medical on call, who was also an HDU class attender, and Les, and the junior anesthetist on call…plus a bunch of family members. He was not only breathing, but he was being bagged – somewhat synchronously by 2 of the junior doctors.
The history was that he was normally healthy and had suddenly become short of breath at 12.30am. It seemed to come out of nowhere – he had been fine the evening leading up to it. In a time-unconscious society, it was interesting that the family could name the exact moment it all started. He had been transported quickly to the hospital, en route, completely inconsolable and tearing his clothes off in the freezing cold air, desperate to breathe. He’d already failed CPAP, and now was failing being bagged in time with his breathing.
I felt a bit of a failure as a teacher. He didn’t look remotely like a patient I said was suitable for ventilation in our little hospital. His brain was not working, his lungs were not working, he was older and as for ‘should have a good chance of recovery’ – he appeared to have no chance. He didn’t look like someone who was going to last the night, or even the next hour. Add on to that a chest Xray that looked like a big heart with some early failure, his ECG a resting tachycardia to 130 with widespread ST and T wave changes – and current BP of 170/70 … I assumed he was dying before us. I suspected a big PE or an AMI. I suspected that an attempt to intubate him would see him die from his profound hypoxia turning into complete anoxia, while the tube was finding its way to the right place. I said: “No. He is not going to survive, and he might not even survive the intubation.”
I don’t like saying no, but we have been down these roads and the implications for the patient, the family, the next patient to land in the HDU, the hospital in general, the morale of the nurses and the 3 of us willing to look after a ventilator and the patient attached to it … no one gains anything except practice in grief. The medical on call had done the right thing I had taught in the ‘class’ – “the decision to intubate and ventilate is a big one and should be shared between a minimum of 2 senior doctors – this is especially helpful when the decision is not to ventilate – you don’t want to make that decision alone – share that grief.” So he was the one that had called the ever helpful Dr Les out of bed. I had also taught: “the anesthesia service is excellent and can intubate your patient for you in the HDU – they are on call 24/7” … which is why the junior partner of the anesthesia on call team was present … it was her, that had called me. I guess at least some of the things I had taught were learned and being put into practice.
I trialed CPAP again and made the patient worse. I drove the O2 sats down to 40% with a good trace and a color that matched the numbers. I sat him up, put on an oxygen mask, the non-rebreathing type with reservoir bag, and he returned to 60% with huge breaths, a very long expiratory phase, wheeze and he remained deeply unconscious. The sats didn’t fall and the medical on call told the family yet again he was not likely to live and we couldn’t ventilate him. I left and returned to my day off, as the sun was threatening the horizon.
The next day I asked Dr Les how fast the man died – Did he make it to ward round a few hours after I left? Les said, he did not die, he in fact was about to have a trial off oxygen altogether! I went to the HDU, about 28 hours after I had condemned him to fade away without what I assumed would be a cruel and fruitless intervention, if he was to in fact survive its commencement; – and here he was sitting up in bed, smiling, with a healthy look, easy breathing on room air with saturations in the mid 90s.
If I was a failure as an HDU teacher, then I was an abject failure as a prognostician.”
Just a note to say that Steve is not only a great teacher, but also a great doctor. He (along with Les) is but one of the doctors here who serve with a humility that never fails to touch my heart. And – these doctors give thanks many, many times for God intervening to save those patients who we feel are beyond the help we can offer here. To Him be the glory!!