Friday, July 21, 2006

Pumps

He was a beautiful elderly man and his family members were gracious and courteous. An army surgeon who had married one of his combat nurses back in the days of real television news on just four over-the-airwaves channels, crappy Doors singles dominating A.M. radio, and the Vietnam War.

He was lucid and his stories about how he met and fell in love with her and his improvisatory surgical techniques had me staying in his room to listen. My other patients were not so needful of me anyways. Lucky that.

The drab-green canvas gurney burst through the doors with the proverbial sucking chest wound. No tubing to be found in the shaky little field operating room, so somebody fetched some from the garage and they "sterilized" it in a jar of rubbing alcohol while the surgeon used a Kelly clamp to punch a hole in the soldier's flank.

"It was a gusher," he said, like I couldn't have guessed. Morphine for the soldier.

They inserted the tube and used a rubber band to tie a condom to the end of it, which they slit to create a makeshift Heimlich flutter valve.

I had worked with other surgeons who had similar experiences from that era. One could insert a chest tube at the hospital bedside in two minutes flat and it was stitched into place before the patient realized he'd even started.

The elderly surgeon had metastasized lung cancer spread to the bone and liver, and he was generally in enormous pain. Our hospital has a nurse practitioner who specializes in pain management so she got on board and we phoned the primary doctor and begged him for a morphine pump.

He was a little reluctant, but the patient and family said they "wanted to try it."

The patient was laboring to breathe even with a 100% non-rebreather mask, and anything we could do to make him less uncomfortable would be welcome to him.

The primary doctor gave us an order to initiate a morphine pump at 0.5 mgs. an hour and titrate it up to 2 mgs. per hour as needed. I told the pain nurse about the order and we looked at each other and said, overlapping one another's words, "let's start it at two."

I had an hour or two before my shift was over. Soon after we set up the automatic pump he was visibly relieved. His respirations stayed steady but less labored. Morphine's a great dilator. He was able to talk without distress.

His wife and daughter thanked and praised us repeatedly for this simple intervention.

I went home and walked the dog. When I came back the next day the news was that he had died later in the night shortly after his family had said good-bye to return to their hotel.

This is totally different from the recent stories regarding possible euthenasia
in a Katrina-flooded New Orleans hospital.
I had a pump. I had electricity. I had help.

New Orleans had no electricity, no supply lines, no help on the way in and no way to get out. The hospital was flooded.

So you can plainly see that my actions were entirely within the bounds of human propriety and clearly criminal charges do not apply.


More here and here.

5 comments:

DisappearingJohn said...

I don't know if I'm tired, and missing the sarcasm, or what, but I see no similarities in these two events...

I see a wide ranging difference in controlling a patient's terminal pain, which may hasten an already descending death, and outright injecting a lethal dose of a medication because you don't think a patient will "survive the evacuation"

In the second case, if the events played out as reported, I would have no problem with charges being filed against the person who injected the medication. If the evacuation caused tremendous pain, and you injected the drugs to lessen the pain, and a death resulted, that's an entirely different issue...

Charles said...

The only criminals in NOLA are the ones prosecuting the doctors and nurses they abandoned to make do in Hell.

When you are in Hell, with no idea when you might get new supplies or even whether you can hold together long enough to give a patient in intractable pain his next dose, you do what in your best judgment seems right.

Melissa said...

I'm reasonably sure that I have hastened some deaths, although it was not my intent to do so. If a person is writhing in agony, hours away from death and the family is pleading with you to give them more pain medication, you do and sometimes they stop breathing. Maybe they were going to die that instant anyway. It's hard to know.

I'm not going to judge the New Orleans doctor and nurses. I wasn't there and don't have all of the facts. I hope that I never find myself in a similar situation.

Chuck said...

Good post. I just wanted to stop over and tell you that I appreciated your pointing out some things I hadn't considered over at Eli's blog.

The Platypus said...

I find it impossible to believe that two or more care providers would conspire to hasten a death no matter how bad it got.