Sunday, February 6, 2011

Weaning the Vent *Excerpt from Chapter 1*

“Assessment and plan,” declared Lesley, who was wrapping up her presentation to our small team of physicians. “Angelina Andriola is a previously healthy fourteen-year-old girl acutely ill with presumed sepsis of unknown origin with systemic inflammatory response syndrome. She is on day two of broad spectrum antibiotics – nafcillin, cefotaxime and flagyl. She is hemodynamically unstable… ” Lesley spoke with meticulous cadence, and I suspected that she was a meticulous physician – the type who arrived two hours before morning rounds and knew your patients even better than you did. Staring intently at her clipboard, oblivious to the imploring eyes from the corner of the room, she finished ,“…and is on an epinephrine drip to support blood pressure and on maximum ventilatory support with an oscillator ventilator. Since admission to the PICU, we have been unable to wean the vent.”

“Okay,” said our attending physician, Dr. Connor, in a baritone. “Here’s what we are going to do...” Dr. Connor – and as my superior I was expected to call refer to him formally as Doctor – was a bear of a man, stout through the chest and neck; not exactly the waifish, Mickey-mouse-tie-wearing pediatrician of my internal stereotype-oscope. He had a bushy goatee and the faint stubble of a receding hairline. I’d heard from other residents that Dr. Connor was an excellent clinician and tolerant teacher, who occasionally transformed into a volatile autocrat. “I want to turn Angelina over. Let’s get her off her stomach, flip her supine, and let’s see how she does. If she can’t maintain her oxygen sat above ninety, we’ll have to turn her back prone. And, let’s try and get a feeding tube down so that we can get her some nutrition. Now,” he said while rotating towards the girl’s parents, who were standing attentively nearby “Questions?”

“Yes, Doctor.” The girl’s mother started to speak but her father, a pale man with a grey speckled beard and intense red-rimmed eyes, interjected. I studied him for a moment and thought, oddly, of Richard Dreyfuss.

“Absolutely, I have questions,” he said. “You have to explain some of this in layman’s terms. What does ‘hem-o-dy-nam-ically unstable’ mean, and what about ‘su-pine’ and ‘prone’? What, exactly, does it mean that Angelina is on ‘maximum vent-il-atory support.’” His recitation of these medical terms was impressively and surprisingly accurate. He continued, “and that you are unable to ‘wean the vent’? Are you telling us that there isn’t anything more you can do? It seems to me that it is a complicated way of saying that there’s not much more that you can do for Angelina.” His reddened eyes began to glisten faintly. “You do realize, don’t you, that Angelina was perfectly healthy before she arrived at this hospital?”

Dr. Connor paused, as if stifling a sigh, before replying. “Mr. Andriola, we haven’t run out of options for treatment, but your daughter is extremely sick and requires the very highest level of support for her hemodynamics – her heart rate and blood pressure – and from the ventilator. Her oxygen saturation…her blood oxygen level, is very tenuous. So far, we haven’t been unable to wean, that is reduce, that support. But we will keep trying. So far, your daughter has done much better on her stomach, in the prone position, than on her back.” He pivoted towards Lesley, “Doctor Gallagher, could you spend some time with Angelina’s parents this morning? Okay, who’s next?”

And with that, our small pack of physicians – Dr. Connor, myself, and three other residents moved out of the room. I looked back as we left and saw Mr. Andriola, mouth twisted open. In front of him lay his daughter, Angelina, no more vibrant than a lump of coal. I watched as the girl’s mother stepped forward and gently kissed her daughter on the head.