Suffering and Courage

"Are you going to--oh my gosh, what's the matter?" Ginger, one of the ICU nurses, interrupted her own question with a look of worried concern.

I'd had my head down as I was looking over my patient's chart. I thought I'd gotten the last of my tears out in the nurse's break room a few minutes earlier. But as I looked over the chart and glanced over into "Jimmy's" room, I couldn't stop more from shooting from my eyes. Jimmy has been my patient for the past month. He's been Ginger's patient since 7 o'clock this morning, when she arrived for work.

Jimmy is barely in his 20's and has cystic fibrosis. He happens to be a really sweet Catholic kid who doesn't show much distress on his face when he's struggling to breathe. "I guess I'm just used to it," he told me once during an exercise walk around the hospital hallways. I always have to ask him directly if he wants to change anything we're doing in physical therapy. If I don't, he doesn't complain.
All the nurses love him. All the hospital visitors from the local parish love him.
But the fact that he's a sweet kid is beside the point.

The point is that his breathing has been getting more labored, and that despite increasing breathing treatments and physical therapy interventions, he's been needing more and more supplemental oxygen over the past few months. But he was getting better. The Pulmonary Team was going to discharge him from the hospital earlier this week, but he opted to stay "until I get my transplant."
His status on the lung transplant list is "active" -- meaning, he's waiting for the phone call that notifies him when matching lungs are available. "Good" lungs are not abundant. Organ donors, even with the same blood type and tissue type, don't always have healthy organs when they pass away. "Dry runs" are the rule, not the exception--a dry run being, when a patient is all prepped and ready in the O.R., only to find out that the long-awaited lungs are "bad."

Last night, a Rapid Response was called to Jimmy's room up on the Pulmonary floor of the hospital. A Rapid Response is a hospital-wide overhead page that calls for immediate medical intervention by a specialized on-call team. Jimmy's oxygen saturation was dropping. That is, there was not a sufficient amount of oxygen being carried through his body by his blood. This sometimes happens to people when the inner walls of the lungs become so congested or fibrotic, that no matter how much oxygen is sent in, there is too much of a barrier between that oxygen and the blood that is trying to pick it up on its way through.

Jimmy ended up being transferred to the ICU, where he was intubated. This means that a tube was sent through his mouth down his airway, to deliver oxygen to his lungs from a ventilator. The ventilator does the work of breathing for him, so that he does not have to use up his energy on an activity that we do without thinking. He won't become exhausted trying to get enough oxygen, and the Respiratory Therapists can monitor how much flow of oxygen he needs. Because people are not naturally designed to have machines "breathe" for them, it's a scary, agitating condition to be in. So people who are intubated are generally also sedated.

When people with cystic fibrosis are intubated, it is a serious event. It is not done lightly. Their lungs are already in sub-optimal health, so the chances of recovering breathing function with their own lungs is slim. It is difficult enough for people with healthy lungs (who need to be intubated temporarily because of other injuries) to wean off the ventilator, nevermind those with diseased lungs. For people like Jimmy, their primary hope is for transplant: for "good" lungs to become available sooner rather than later.

One of the Physical Therapy Technicians paged me while I was sitting in my team's meeting at 8:30 this morning, to tell me that Jimmy was intubated in the ICU. Upon reading the text message on my pager, I turned and whispered to Allison, our Pulmonary Senior Therapist, that I "hate pulmonary" (my current team assignment); then I completely lost control and had to excuse myself to the restroom to let myself cry for several minutes. When I arrived at the ICU 45 minutes later, I stood with clenched teeth and prayers to my guardian angel for strength, while I stood with the medical students, the interns, and the residents, and listened to the Chief Pulmonary resident on rounds give her report of Jimmy's status to her attending physician. I tried to numb my mind to much of what she said, "desatting into the 70's on non-rebreather mask ...tachycardic in the 150's ... PCO2 of 109 ... chest x-ray films ... worse ... hopefully he'll move up on the transplant list ...".
After I clarified with them that they did want us to continue chest PT (manual percussion on the patient's chest and back to help physically shake excess mucous from the walls of the lungs) I retreated to the nurse's break room for another semi-breakdown while I prepared my note for his medical chart.

And then I was standing outside his room, listening to the "click"s and "sigh"s of the ventilator, and hoping he was sedated enough that he wouldn't open his eyes and see my red ones looking back at him.

"Are you okay?" Ginger asked. "What is it?"

I motioned to Jimmy's room.

"Do you know him?" she asked.

"He's been my patient for the past month," I squeaked. "I'm sorry. I guess I'm just not handling this well today."

"We all have days like that," she assured me. "I hope yours gets better."

I thanked her, wrote my note, and left.

Another patient of mine with C.F. just moved to the ICU earlier this week from the floor. He is a staunch Christian and has been refusing to be put on the lung transplant list for years: he's waiting for a miracle. Yesterday he was lying in bed with his eyes closed, an oxygen mask on his face, his heart racing. His wife was reading to him from the New Testament. As I reviewed his medical chart outside his room, I heard her strong, steady voice read the story of the man born blind that Jesus cured on the Sabbath, and the Pharisees summoned his parents to ask if he really had been born blind.
Then I entered the room and reviewed the plan with her for continued chest PT treatment. I know the team is considering intubating him--but since he is not on the transplant list, that would mean he would be intubated ...indefinitely...? I hope he gets his miracle.

Last week, one of the young women with C.F. that I have as a patient experienced the "dry run." I had stopped into her room that morning, had congratulated her on "getting" some lungs, and had promised to pray for her that night as she went down to the O.R. The next morning, she was still on the floor. In that case, it was bad news that she was still on the floor. "The lungs were bad" was all I heard.

This morning, I looked up a patient in the computer, and saw another patient with a similar name listed one row beneath --and this other patient is one that I know: a young man with C.F. that just left the hospital this past week after several weeks' stay and a hard fight back to his prior level of health. I walked by his room this afternoon, saw that he was on the phone, and waved. He smiled and gave me a shrug.
I'm sure he'll be on my schedule tomorrow.

Thankfully, when I opened my email this evening, I received the timely encouragement of a message that Dad sent today to all of his children:

"We rejoice in the hope of the glory of God. Not only so, but we also rejoice in our sufferings, because we know that suffering produces perseverance; perseverance (produces) character; and character (produces) hope. And hope does not disappoint us." (Rom. 5:2-5)

and

"Courage does not always roar. Sometimes it is the quiet voice at the end of the day saying, "'I will try again tomorrow.'"

"We all have days like that," Ginger told me today.

Hopefully, tomorrow will be better.