Imagine this: a very thin elderly woman in a hospital bed. A list of her medical problems would be longer than your forearm in 12 point type. She’s been very ill for months. She can’t eat and is fed through a tube. At one point she couldn’t even breathe on her own and was on life support. Her kidneys are failing and she is on almost-daily dialysis, which she sometimes cannot tolerate without the use of vasopressors. Her circulation is bad. She has a massive bedsore on her tailbone and her foot is starting to turn colors. Bad colors.
Over the last few days, she has grown increasingly unresponsive. Sure, she’ll open her eyes when you say her name, and she’ll barely move her head in response to questions. But for the most part, this woman who would clearly call “Nurse!!! I know I want something, but I don’t know what it is!” last week is no longer even verbal now.
As I go about my day, preparing her medications and changing various dressings, I wonder what the point is. She’s clearly dying. She has tremors, so the pulse ox on her finger sometimes doesn’t read correctly; I have already gone in the room 20 times to adjust it. Usually it shows that her oxygen saturation goes from 98% to 60% in the space of 10 seconds, which is just not altogether possible… hold your breath for 10 seconds. I can guarantee you’d still be in the 90% range.
Except for this time. This time, I’m sitting in front of the monitors charting, and I hear the familiar dong-dong-dong and look up. My patient’s pulse ox is reading 80%. I figure that her tremors are acting up again for the billionth time (and resolve to put the damn thing on her ear next time I go into her room) and continue charting.
Perhaps 30 seconds have gone by. The monitor now senses that her pulse ox has gone to 60%. (DING! DING!! DING!!!) We’ve been here before, several times. I sigh and look up from my charting just in time to see her heartrate go from 110 to 54.
I run into the room where I see that her pulse ox has a nice, even waveform. Definitely accurate. Although her heartrate has come back up to the 80′s while I was rushing into the room, her pulse ox is definitely in the 60′s, and although her chest is moving, there is no condensation on the inside of her oxygen mask. She isn’t breathing effectively.
I have some choices at this point. It would be entirely appropriate to find an ambu-bag and put the form-fitting mask over her mouth to force air into her lungs while I call for help. But for some reason, my instinct tells me to grab the Yankauer suction and stick it into the back of her throat.
Her eyes are open, but they are staring past me. I watch as the Yankauer fills with copious amounts of pale yellow/tan mucus. Part of me is relieved – this will surely fix her right up. But it just keeps coming and coming – where was all of this crap stored for heaven’s sake??
Then it stops. I’ve lost suction. I look at the suction head on the wall. It’s still set to high. I look up at her sats. They’re firmly in the 80% range. I look at her mask. There’s condensation on the inside. Good. She’s moving air.
I pull out the Yankauer. What was on the end of it may very well haunt me for the rest of my days. It was long and the matter at the end was the size of a large marble. It was black and somewhat solid, not like sputum or mucus. I wiped it off with a paper towel, regained suction and stuck it back in her throat. More mucus, more sputum. Sats up to 92%, definite air movement. Whew.
I didn’t figure sending the product of my suctioning session for culture would quite help us figure out exactly what it was. After showing the doctor, he suggested that we send it to pathology.
After the excitement died down, I wondered just what I did for my patient. Sure, I kept her from suffocating, but if that had happened in a nursing home, where she wasn’t on a monitor… I can’t really say I felt great about “saving” her. Does that sound a bit callous? I’m just not sure what I saved her for. More bedrest? An amputation of her foot? More infection? More dialysis?
Interestingly enough, she became a different person after our little incident. She began speaking again within the hour. She began calling out for the nurse again. Her children came to see her and marvelled at how she was so much more alert and responsive than in days past. She insisted she wasn’t in any pain.
I had a few days off after that. I came back to work to find that she had coded and was reintubated the day after I had taken care of her. She remains that way now.
I also found out that what I pulled out of the back of her throat was described by the pathologist as “meat fibers.”
Meat fibers. In a woman who hadn’t eaten anything in weeks. No wonder it was unrecognizable.