Thursday, July 29, 2010
Black Triage part II
That's a picture of a CT scan. Please excuse the box labels you can see through it; and the florescent lights behind it.
That's the neck of a 20-year-old man with a huge mass in his neck from the bottom of his jaw to the top of his collarbone; his airway is at the upper left of the picture--and that's at it's widest point. At its narrowest, it was about the width of a coin slot.
He came to the ICU from the "Catacombs"; the medicine ward where he had been languishing for months. He had a PEG tube through which he was fed, but was having a lot of pain and his airway was obviously diminishing--you could hear the stridor from across the room. The tumor was starting to come through the skin of his neck.
We had no hopes of doing anything for this guy; we were waiting for an obligatory consult from ENT--for a week. We were in the process of shutting down the ICU because the hospital management had decided to take back control of their facility; we had already pulled out of the ED, leaving it to the Haitian doctors and nurses. Hospital administration stated that they didn't have the staff or the desire to keep the ICU, and so we stopped taking admissions. This young man was one of our last three patients left.
We gave him IV fluids--he was convinced that there was some "medicine" in there that prevented pain, so we ran fluids slowly, continuously. His family fed him gruel through his PEG.
It was obvious that this kid was going to die. So over dinner we had the most macabre conversation I have ever had in my career: What are we going to do when his airway finally fails, or a blood vessel in that vascular tumor bursts? What do we do to help this kid for the five or so minutes until he dies?
This was not a hypothetical question.
One nurse who worked in ENT and had seen this sort of thing before suggested Versed, which was nixed because we didn't have a lot of Versed, and we couldn't waste the little we had on this. Morphine? No. So what we finally decided on was Etomidate, 20 milligrams. Sort of like a Rapid Sequence Intubation without the intubation part. The next morning we taped a vial of the etomidate and a syringe next to the bed.
Because we were closing down the ICU, there was no need for all of us to hang out there; people were needed to pack up our headquarters and redistribute our supplies. We took turns sitting with this kid and his family. When it was my turn, I listened to his every breath whistling in and out of they tiny opening that was his airway and prayed that that eensy slot would hold up. Would I be strong enough to do what had to be done when the time came? I was pretty sure I was--but I've never had to face this before, at least not with a human.
At last, the ENT surgeon came to evaluate the patient, and of course, after seeing the CT, declared that it was hopeless. Even in the United States, a tumor that bad would be inoperable--but it would have been caught long before it became inoperable.
So this was another one we sent home.