Winning the battle, losing the war

Okay.

So I just returned from patient Z's room after I got paged that he yanked out his own breathing tube. Normally, this is a good sign -- the person wants to breathe on their own. In this instance, however, the guy doesn't have the ability to protect his airway since he had a stroke, seizure, aspirated his own food and gave himself a chemical pneumonia (damn that spicy stroganoff the hospital serves). So back in goes the tube. The only thing is, you gotta sedate and paralyze someone to intubate them. Not a problem: push drug x, push drug y, the guy is out cold and generally flaccid as a 12-beer penis at 4 a.m. I'm at the head of his bed, bend his neck backwards and outwards a bit, intubation blade in hand, it slides in easily and moves the tongue out of the way and --

oops -- there's a problem: the dude's moustache was so fucking thick, I couldn't see shit.

"Do you see the vocal cords?" -- the first and only question my nervous attending is belting with levity that will soon morphe into impatience.

"Kind of." (What the fuck kind of response is that? I wonder.)

"What the fuck kind of response is that?" he blurts back.

"Dr. B, all I see is hair."

"Hair??!! Is he a cat? Did he lick a furball into his throat?"

The oxygen monitor is making that ominous beep that becomes deeper in pitch and slower in frequency as the oxygen saturation of the blood lessens.

"Dr. B, it's his moustache. It's in the way." (What the fuck? The nurses keep him clean-shaven but they leave this big bushy-ass 70s disco gay leather club handlebar obfuscating mess of hair on his upper lip??)

"What?"

"Um....."

"DO YOU SEE THE CORDS OR NOT? IF YOU DO NOT SEE THE CORDS STEP AWAY FROM THE HEAD OF THE BED OR I WILL BOX YOU OUT."

(Box me out? The attending is 5'4" on a good day, I'm sure he wasn't star center of Podunk High Basketball team.)

Yeah, that's helpful. Yell in one ear, have me listen to dropping oxygen monitors in the other ear, all the while trying to establish an airway.

ER residents can do a lot of things, and similarly, there a lot of things we cannot do. But we're quite well trained at tuning out extraneous bullshit and listening with a third ear to what's important. So while I hear "blah blah blah," I'm listening to "beep, beeeep......beeeeeeeeep," and suddenly through the thicket I see the patient's vocal cords and POP goes in the tube.

"Did you see the tube pass through the cords??" says the attending.

Goddamit I saw the fucking cords and I passed the fucking tube and the guy is breathing and he's fine, it didn't help with you shouting in one ear and it certainly doesn't the fuck help right now to keep yelling.

"Yessir," I meekly said, "I saw it go right through the cords. His O2 sat is up to 100% and I hear breath sounds bilaterally and equally. I'll order a chest xray now to check tube placement, and I'll send off a blood gas."

No response from the attending.

I grabbed a suture removal kit, took out the scissors, and cut that moustache off until it looked pre-pubescent.

--------------------------

I paused for a minute.

What exactly were we doing for this man?

I've been seeing him everyday for over two weeks now, and he has had zero mental status improvement. His organs are slowly but surely shutting down one by one. Each day when I check his laboratory work, the proximate markers of his individual organ function continue to belie what we attempt to do on a semi-shortsighted basis. Get his oxygen better. Make him breathe more. Bring that fever down. Give him another antibiotic. His kidneys shut down? Put a dialysis catheter in him and give him mechanical kidneys.

At what point do we stop?

His wife already had signed a DNR order. What exactly constitutes rescuscitation on this man? He is septic from an unknown source, he's on every "big gun" antibiotic known to modern medicine, his blood pressure continues to drop, and then we start pressors on him to bring the pressure up.

I think there's an indefinable moment when everyone knows that further work is futile; the only question is, what is that point? As docs, we sit back and say such self-soothing things as, "his BP was dropping, I started levophed on him, now look! His pressure is back to normal." Or, "his creatinine shows he's in acute renal failure, we dialyzed him, now look -- his electrolytes are back to normal."

So it's these little battles we win, but it becomes an ethical gray zone to say when to give up the war. Not to drudge up political battles, but I will: Terry Schiavo. Her post-mortem showed her brain had the consistency of oatmeal. That war was over long ago.

I'm just wondering when we will decide for Mr. Z that his war is over. I actually pray that he is not conscious for any of these painful interventions we do.