In the Desperate Hours

Simple solutions may offer hope....

The first year of a physician’s practical training program is called Internship. So named because, traditionally, the trainee was literally interned in the hospital. Many of these giant municipal medical centers had living quarters in the building or on the grounds. In those dark days of classical medical education fledgling doctors were purposefully subjected to the kinds of intellectual, emotional, and occasionally physical abuse suffered by the military in basic training. We were expected to “see one, do one, teach one” in evaluating and treating patients correctly even after 36 hours or longer of duty. Repeatedly, in the same week. At the massive county general hospital where I voluntarily imprisoned myself for that year, much of that work was scut—functions that normally would be done by nursing, therapists, lab techs, or even custodians. Money was adequate to staff our 19 story 2500 bed hospital with interns and residents (physicians in training who merely “resided” at the hospital and actually might leave from time to time), but not for enough of the accessory staff. Since we chose to be there, and had to be there, much of that other work seemed naturally assignable to us. We transported patients, moved them from gurney (a stretcher on wheels) to bed and back again, drew blood, started intravenous lines, catheterized patients, evaluated urine and blood samples under the microscope in small labs on each floor, provided occasional breathing treatments, conducted simple biopsies of various organs at the bedside, tapped spinal fluid, and did other simple surgical procedures not requiring the strict disciplines of an operating theater. Sometimes we could negotiate with the vastly understaffed nurses to do one patient procedure for us in return for some other relief to their workload. Here and there we would slip away to eat something at the doctor’s cafeteria--open almost 24 hours daily of necessity--or a bathroom break. Small “sleep rooms” were available on each floor furnished with bunkbeds almost wall to wall that we used as “hot racks”. I might be able to lie down for an hour or so, then one of my teammate physicians would roust me out for his/her turn. Everything except one’s personal welfare came first. That was the core of our rite of passage.

The toughest rotation (4-8 weeks working on a particular ward or specialty) was general internal medicine. Each “team” of doctors was composed of a resident and two interns. Each team would have twenty to thirty or more patients under their care daily and nightly on the ward. Twice weekly, or occasionally more often, the team would receive admissions over a twenty-four-hour period, while continuing to oversee their current patient load. Often an intern might admit, evaluate, and begin treating up to 10-15 patients on one of those nighttime invasions by the desperately ill. The folks came directly from the Emergency Room, whose main functions seemed to be stopping the process of death and then sending the patient to the appropriate general or specialty ward, or directly to surgery. The nursing desk, where we sat filling out paperwork, smoking cigarettes, guzzling endless cups of coffee, and commiserating, was directly across the hall from an elevator whose sole use was bringing up patients from the Emergency Room. New general medicine admissions were rotated amongst three floors, three different teams on duty. Many nights the elevator seemed to disgorge the sick so rapidly we doubted there had been time for it to return to the ER, load other patients, and deliver them to the other two floors. The people judged to be critically ill (virtually no one went directly to an Intensive Care Unit without first being admitted to a medicine floor) arrived as “Red Blankets”. In past decades they were easily identified on their gurneys with a fully covering red blanket. Years of wear and tear and diminishing resources had reduced these to large red handkerchiefs. Just as each intern on the team alternated taking charge of each elevator arrival, so we alternately took responsibility for red blankets as they arrived.

That responsibility began the instant the elevator doors opened. The ER forewarned us of each red blanket arrival, with good reason. Often the gurney was pushed by one person, with the other doing CPR or providing other life-sustaining therapy during the ascent of six to eight floors. They would verbally brief us on the situation as we took over while crossing the hall to the admitting rooms next to the nursing station. There the intern, and the resident if not otherwise occupied, would examine the person from head to toe over a minute or two, while trying to simultaneously digest the often sketchy information from the ER chart and, if possible, question the patient as to what had happened, what their prior medical history had been, and how they had responded to what had been done for them so far. Sometimes the ER chart had almost nothing except vital signs, brief lab and x-ray findings, and observations. We had to try to figure out what was going on from the inert breathing body before us.

One such case I caught was Paul. He rolled off the elevator with his transporter and an Emergency Room respiratory therapist, both frantic to get back downstairs to a very active firefight with an overwhelming number of illnesses. The therapist was “bagging” Paul, meaning he had a large facemask pressed firmly on Paul’s face over mouth and nose, attached to a large stiff rubber bag. He would firmly squeeze the bag until almost collapsed every five seconds or so, thus ventilating, or breathing, for Paul. I took over the bagging as we rolled Paul into the red blanket room. He had arrived by ambulance, again being “bagged”, with the only history of having chronic lung disease and respiratory arrest. He was not conscious but on superficial exam did not appear to have any clear neurologic signs of stroke, and his EKG in the ER had not shown any signs of acute heart attack or rhythm problems. Blood gas tests had shown the typical pattern of a chronic lung disease patient, very low oxygen and very high carbon dioxide, with an acid/base balance indicating that had been going on for some time. A not uncommon situation from nicotine addiction. My first order of business was to get better control of his breathing situation; bagging lungs that had been massively expanded and partially destroyed by emphysema sustained his life, barely, but provided no way to change that status.

Putting Paul on a ventilator-a controlled breathing machine- was not the clean easy process shown in modern medical dramas. I had to intubate him, meaning place about an 18 inch “hose” down his throat past his vocal cords under direct vision. In the admitting room with several other patients no expectation of privacy, or of the cleanliness of an anesthesia or operating theater, existed. I had seen this procedure several times and had done it a couple of times (initially on someone who had already died), so my resident, after listening to my intentions, left me to it. I grabbed the pre-packaged sterile intubation tray off the cart holding medical supplies for extreme situations, opened it up, put on a face mask (more to protect me from any sudden explosions of fluids from Paul’s lungs when the airway was inserted), put on sterile gloves and unfolded the special “lever” and flashlight-a laryngoscope-to insert down his throat to see the vocal cords. Paul’s head had already been tilted back at an extreme angle to straighten the airway, or trachea. All my actions had to be frantic and precise, as I had to stop bagging him prior to and during the intubation process. I inserted the lever down his throat pressing his tongue up and forward out of the way and put my face as close as possible to his widely open mouth so I could see down the trachea. Proper technique required tilting the laryngoscope to open the airway without pushing against the upper or lower teeth, which might break. First one had to get past the epiglottis, a sort of trap door that protects the trachea or airway when you swallow food or fluid down the esophagus, the stomach tube, behind it. Then I could see down the trachea, a tube with a series of internal rings of cartilage. Imagine looking down the interior of a large garden hose or small vacuum cleaner hose. Just a couple of inches beyond the end of the lever I could see the vocal cords, two vertical stripes of white blocking the lower trachea and held next to each other by controlling muscle tissue. The end of the intubation tube was blunt but angled so that I could push it through the opening in the vocal cords to the trachea below. The end of the endotracheal (intubation) tube had a collapsed balloon around it. Once I could see that this portion was past the vocal cords, I pulled the laryngoscope out and used a plastic syringe to inflate that balloon with enough pressure against the inside walls of the trachea to both hold it in place and prevent air from leaking around the tube. I then taped the long tail of the tube outside his throat to Paul’s face so that the tube would not slide up or down. To know the tube was properly in place I listened to his chest as I pushed air via the bag-which could be attached to the tube by the same fitting used for the facemask-through the tube. If the tube was too far down, only one of the two lungs would inflate and deflate. If I had mistakenly pushed the tube down the stomach tube, the esophagus, I would hear air over the stomach. Proving the tube was in proper placement required a chest x-ray, but in those days at that type of medical center we did not waste time, money, and effort on getting a chest x-ray. Now that I had a “controlled” safe airway for Paul, the next part of the process was attaching a breathing machine or ventilator.

That many decades ago, ventilators similar to what you see in television and movies today did exist, although much simpler in their functions and safety. However, they were only available to patients deemed sick enough to be in one of the various general or specialty intensive care unit beds. These beds were always fully occupied, and any new possible transfers to those units had to await morning rounds, where new candidates on the admitting wards were evaluated and those currently in place considered for sending to lower levels of care. Paul and I had passed midnight together, my other new patients being watched over by the other intern and my resident given my necessarily intense attention to Paul. I went to the supply and equipment area and brought a “Bird” to the gurney-side. These green plastic boxes, about eight inches square, were on a rolling stand and had several dials and fittings on their surfaces. The internal workings were visible through the translucent green plastic. Birds were used mostly for giving breathing treatments with various mists of drugs to patients with acute and chronic lung conditions but had originated as a primitive type of ventilator. When needed they could still serve this function although with risks. “Birds” were “volume” ventilators. I could change the rate they would pump air (and supplemental oxygen), and the volume of air delivered to the patient’s lungs with each breath, or ventilation. I measured that volume by placing a collapsed plastic bag on a port of the machine, watching it expand timed for 1 minute. The long clear plastic bag would unroll and had markings along its length to indicate the approximate air volume delivered over that minute. Approximate, close, and good enough under the circumstances. But not entirely safe. No “pressure” settings were possible on the Bird ventilator, only volume. If I guessed, from a formula based on height and body weight and sex and what I estimated his diseased lung capacity to be, too high a delivered volume with each machine breath, Paul’s lungs might rupture. Too low and, although he might get plenty of oxygen, his carbon dioxide level would rise too high pushing him deeper into coma and perhaps even a fatal heart rhythm from acid/base imbalance in the blood. Meanwhile the rate of machine breathing and/or the volume might need to change, as moving his oxygen and carbon dioxide blood levels too quickly towards normal could also cause an acid/base problem in his bloodstream. In an intensive care unit this process and progress might be monitored several times a day by drawing arterial blood for “blood gases” to guide the changes in therapy, but this was not possible on an admitting ward. I had to make my best educated guess on the settings that would keep him stable and alive for several hours till morning rounds. My resident physician might come and check Paul’s overall status sometime in that period, but without hard measurements on an ongoing basis the resident physician had no greater ability to modify the process. And there was always the individual nature of each patient to consider in setting the Bird as a ventilator.

Paul was a pink puffer. That means he had advanced emphysema, a destruction of lung tissue most often caused by cigarette smoking. With less functional lung tissue and more “empty space” in the lungs, the chest tends to hyper expand and not deflate well. The chest becomes permanently expanded, and the diaphragms, the dome muscles at the base of the lungs that drive air in and out of the lungs, flatten and lose their function of pulling air in and pushing air out of the lungs. Breathing is really two functions. You inhale air with its oxygen, and in the lungs’ microscopic grape-like clusters called alveoli, the oxygen is exchanged for carbon dioxide from the blood. That carbon dioxide is then exhaled. Emphysema destroys much of this “exchange” tissue, and Paul’s blood oxygen was low, and his blood carbon dioxide was typically high. Either one of these could kill through a variety of means. What I wanted to avoid at all costs was a cardiac arrest—a sudden stopping of his heart rhythm due to lack of oxygen or too high a carbon dioxide. If I had to do CPR-cardiopulmonary resuscitation-on Paul, my first compression of his chest wall to push blood “through” his heart would break his sternum and ribs like crushing a Styrofoam cup. Reversing this imbalance on a ventilator, whether “Bird” or more sophisticated, happens very gradually in a carefully controlled manner. Depending on the degree of damage to the lungs and the physical pumping mechanism of the chest and diaphragms, that could be a long process before Paul could be taken off a ventilator and his breathing tube removed. And his best “baseline” status off a ventilator might be very poor and very fragile. All that was not my concern. Getting him on the Bird machine as a ventilator, getting his breathing settings stable, and seeing that no problems occurred till morning rounds, was my focus. After several prior sixteen-hour days and another night duty that same week, my focus was blurry at best.

Nonetheless, after several hours of gurney-side attention to his vital signs, his lung sounds, and his initial set of blood gases, he seemed likely to survive till morning rounds. We did have one heart monitor on the admitting ward, a suitcase sized device with a four-inch oscilloscope screen on it, and his heart rhythm and rate were stable. That “heart monitor” was nothing like those seen now. No alarms were present. And other admitted patients on the ward needed it more due to their severity of illness and likelihood of survival. The nursing staff would come into the red blanket room every hour or so, depending on our total admitting activity, and check Paul’s blood pressure and pulse. But in between I had to monitor his breathing status. My other patients were relatively less ill and stable till morning rounds. So I could place my full attention on Paul’s status with brief checks on others.

But my full attention, as often happened in those training trials of supramaximal effort, was already spent. By two a.m. that morning I was barely able to walk, or think or speak coherently. Physical exhaustion happens from lack of sleep and continuous exertions; mental exhaustion can accompany it and endangers decision making. For that reason, the two admitting interns often would see the supervisory resident physician go to the sleep room for two or three hours between midnight and morning rounds, as someone had to have had some rest if a new life-threatening emergency occurred or arrived off the elevator. That could not help me monitor Paul. In my desperate mental fog, I had to know if Paul continued to breath on the Bird. Just as no heart monitor was available, so too there were no “respiratory monitors” in that day. What to do?

My simple solution to two contradictory problems was typical of how many of us solved issues outside the box of what might otherwise be considered acceptable medical practice. I pulled another gurney up next to Paul’s, locked its wheels, lay down on it, placed my arm and hand through the siderails of both gurneys onto Paul’s chest. I could feel my arm rising and falling in rhythm to the Bird’s ventilations. As I all but immediately passed out to an exhausted dreamless sleep, I forced myself to think, over and over, “if my arm stops moving, I will wake up”. And so there I lay, in my Dr. Kildare whites, an unconscious but living monitor to the breathing of a living but unconscious patient. Those desperate hours of near-death for any illness, between two and six a.m., passed.

My resident awakened me at six a.m. by gently raising my “monitor” from Paul’s chest and pulling it back through the siderails. He said nothing other than rounds would start at seven a.m., as usual. The other intern told me, after I got up from the gurney and began to attend to our other mutual patients, that the resident had called him into the room about four thirty that morning to point out what I was “doing”, and that it provided them both with a good energizing laugh. They had immediately understood the purpose of and need for the strange, silent demonstration in front of them. The concept of makeshift medicine was only too familiar to them both.

Since I had been successful, no mention was made of my methods during morning rounds, and after our requested review of Paul’s case by the Critical Care team, he was transferred to the Medical Intensive Care unit where he could be sustained with a “real” ventilator. Our resident followed his care by the intensive care team for continuity, but Paul immediately left my mind, displaced by all my other current and new patients and the restoration of a few hours’ sleep. I frankly don’t remember what happened to Paul, whether he survived or eventually left the hospital. And my unorthodox solution to his and my needs was not the only unusual method I used during my training under the lean and mean conditions at that giant county medical center. But for forty years it has been my most remembered. Under the most stressful of conditions, I had identified the core problems, the critical needs, and found direct and simple solutions in the desperate hours.