Originally Posted: 6/18/2011
A few weeks ago, I took care of an adolescent who developed sepsis after chemo. Although her initial low blood pressures improved, she was now bi-pap dependent and from the first night I had her, I knew she was getting sicker. I was not surprised to find out that she had been intubated when I arrived to work several nights later, and when the nurse giving me report brought up her chest X-ray, I immediately recognized something all too familiar- severe ARDS. The same thing that my Dad had.
I knew the treatment all too well- low tidal volumes, high PEEP, manage the infection, and pray. I was unfazed when I suctioned and saw the tell-tale bloody secretions, and chuckled a little to myself when the oncologist called to check on her in the morning and told me he wanted to talk with the ICU team about starting steroids due to her persistent neutropenia (low white blood cell count) and fevers. (This was a huge battle with my Dad, as his ICU doctors were adamently opposed to using steroids on an ICU patient because one of the side effects is increased risk for infection; however, his oncologist saw it as the only way to treat his persistent high fevers and help him to engraft after his stem cell transplant. His oncologist finally won- and we all believe that adding the steroids were probably one of the turning points in him getting better).
I was not surprised when I returned to work two days later to find that, after she initially appeared to be improving and they were able to wean her vent settings and even starting to wean sedation, she now appeared to be much worse- requiring pressors to keep her blood pressure up and a neuromuscular blockade due to requiring increased PEEP on the ventilator. (PEEP- or positive end expiratory pressure- is pressure given by the ventilator to help keep the airways open, thus improving oxygenation. It is common for patients with ARDS to require high amounts of PEEP because their alveoli are so clogged up that gas exchange becomes difficult. However, increased PEEP can also be uncomfortable for the patient, so generally patients requiring a PEEP of greater than 10 require neuromuscular blockade- drugs that result in temporary paralysis. At one point, my Dad was requiring a PEEP of 18- the highest the vent will provide, and we are still not sure how they managed to not cause a collapsed lung, a common side effect of high PEEP). My Dad had gone through a similar stage- he too appeared to be getting better after the first few days, they were able to wean his sedation, and he started to respond by squeezing our hands and raising his eyebrows. I felt comfortable enough that night to return to work. At 4AM, I received a phone call from my Dad’s nurse, saying that he had gotten much worse, was again requiring 100% FiO2 and increased PEEP, and they had had to re-start the neuromuscular blockade and pressors. So in some ways, I was able to understand part of the Mom’s sadness that she had decided to go home and sleep instead of staying at the hospital the night before when my patient was a little more awake. I recognized the feeling of regret- What if I missed my only chance? What if she never wakes up again?
I mentioned these similarities to the nurse who I was giving report to the next morning. “Yeah, but was your Dad this sick?,” she asked me.
He was, in fact, even sicker. Requiring high FiO2 and PEEP for weeks, on nitric oxide for over a week (Nitric oxide is an inhaled gas used commonly in infants and children in the ICU as a vasodilator, thus increasing oxygenation in patients with pulmonary disease. It is seen somewhat as a last resort in adult patients, and my Dad was on it longer than any other patient that his ICU had seen). Looking back, I am amazed that they were ever able to wean him off the vent, and that he is now trach-free and appears to have very few respiratory complications. I had breakfast with a friend of mine who works in the ICU where my Dad was, and she said that she felt comfortable telling me now that no one there thought that he would survive. And that one of his primary nurses cried when she saw a picture of him now.
I realized then that I have a unique perspective to share with my patients and families. I know what it is like to have a family member that is so sick that no one thinks it possible to survive. As a co-worker told me yesterday, “That Mom needs you. You’ve lived this before.” Yes, this child is critically ill, and may not survive this illness. But I also know that miracles happen every day. I am lucky enough to have one in my life. Happy Father’s Day, Dad! You are truly my hero.