Sara was 55 years olds and had severe COPD. The kind that would only allow her to be at home 2 months at a time before coming back to the hospital, but then only a month and then only 2 weeks. From past notes in her chart, she always seemed to come in very sick at the last minute. Each time she was placed on IV steroids, antibiotics, nebulizers, aminophyline, and oxygen, which is the extent of the treatment available. Each time she pulled through and go home for at least a week of rest before the next exacerbation.
Sara was gray when she arrived. This is a shade that I have never seen in a Nepali patient. I imagine if she had light skin, the color would have been blue. She was gasping for air and placed on oxygen. Her pulse oximeter read 87% (normal is above 90%). Everyone relaxed except me, this number just didn’t coinside with the ‘gray’ patient in front of me. The gasping lasted for another minute and then she fell back unresponsive. We all just stared in shock and my resident accurately stated “I think she is crashing.”
My own pulse oximeter gave a seemingly more accurate read, 50% and so we started to “bag” her (a mask is put over the patient’s face, and a rubber bladder is squeezed, forcing air into the lungs). The best we could get her oxygen saturation to was 60%. Sara still had a carotid pulse, but no pulses could be felt in the extremities, and no blood pressure could be obtained.
This is the fork in the road where Western medicine and Nepali medicine diverge. In Rochester where I trained, we would only bag a patient until they were able to be intubated and placed on a ventilator. While there is a ventilator in Tansen, ironically it is saved only for the healthiest of patients, where the only problem is respiratory failure, from something like a snake bite. This lady had a few more things going on than respiratory failure and a vent wouldn’t be used. So how long should we to bag her? There were only 3 reasonable end points. She could get better, and start breathing well on her own; she could die while we were bagging her; or the third and most disturbing possibility, she would be somewhere in between, where she required us to continue bagging her in order to continue to live. In this case, should we bag for 10 minutes, an hour, or until one of the first 2 possibilities came around? How do you choose? I decided on the arbitray number of 30 minutes, and we bagged away.
I have seen many families lose loved ones here in Nepal. Often their response is blank faces. They continue along and go about the duties necessary to manage funeral rites. This isn’t because they are indifferent, but Nepali people simply manage loss in a different way than western culture. Sara’s family was an exception. They were emotional and crying and as we continued treatment, more and more family members showed up. After 15 minutes of bagging, this became a little uncomfortable for us, since we all were fairly certain she was dying. I needed to do something to make the atmosphere a bit more comfortable, so I decided to go through all of the “verge of death” scenarios I could think of, asking my resident and intern what the appropriate management would be of those patients. That may not sound a bit morbid to non-medical people, but it is helpful to be prepared and was good for our team.
To our surprise, after 25 minutes Sara started to grab at the mask, and try to sit up. I was amazed! She was getting better! We stopped the bagging, and sat her up. I checked a blood pressure, and it had gone from undetectable to 170/90! I checked her pulse oximeter and saw it drift down from 65%, to 60%, to 55%, and then back to 50% where we had started. We had to start bagging again.
I wasn’t quite sure if her 30 minutes should start over again since she woke up, or if she only got 5 more minutes. I made a compromise and decided that 15 more minutes would be the limit. Otherwise, we could do this all night long. We had given her IV steroids, antibiotics, and diuretics. If those didn’t work within 45 minutes, this very sick woman, unfortunately, would not survive.
After 10 minutes, Sara again started to rouse. She was calling for her son and daughter. I decided that this would be our ending point. If she were going to die, it should be with her family, and not with a doctor pumping air into her lungs. If she were going to live, this was her chance to prove it to us. I told my resident we would not bag her again.
This was not a comfortable decision for me. In the West, choosing not to escalate care, or “do everything” is a choice that is only made by the patient or family who understand the patient’s wishes. As doctors, the default is to give every intervention that could possibly benefit, even if that chance is infinitesimally small, until the patient or family tell us otherwise. We don’t get to rely on ‘we did all we could do’ practicing medicine in Nepal. It is the doctor who has to make the decision and choose when a patient will get antibiotics, bagged, and CPR if their heart should stop. Most patients who die in the hospital do not get CPR, since they are already so sick from what had caused their heart to stop in the first place, and CPR won’t fix that.
In the West, one of the most painful things for a doctor is to continue to treat a patient when they feel as if they are only delaying death, rather than prolonging life. During my intern year I treated one such patient. The family was admirable in the fact that they refused to give up hope for their loved one who was on a ventilator, and on 4 different medications to support her blood pressure. However, it was hard for us on the medical team to watch her dying. Her body had gained some 50kg in fluid, and had skin tears over much of her stretched skin. We on the medical team wanted to argue with the family that they were making their loved one needlessly suffer. It was clear to us that she was dying, and every further intervention only led to more adverse side-effects. The truth was, however, that the patient was likely very comfortable. The sedative medications that were continuously coursing through her veins put her into a very deep sleep. It was us doctors who were suffering.
In Nepal it has been somewhat relieving to not have to “code”, or do CPR on every patient whose heart stops. When it is clear to us that a patient is dying, and CPR is not going to reverse the overall process, it is refreshing to allow them to “die in peace,” without us stripping their bodies naked, breaking their ribs with chest compressions, and putting tubes in their throats only for them to eventually succumb to their illness anyway.
While I knew this in theory, I was torn as I walked away from the bedside of the woman with COPD and an oxygen saturation of now 65%. She wasn’t clearly dying, but she certainly was not doing well. She was teetering right on the edge. Perhaps with a few more hours of bagging, to help her blow off some more CO2, she may do okay. But we had no machines to do this for us, and we could not spare an resident or intern for the rest of the night. The only option was not satisfying on so many levels. We had to walk away. At that point I did my final, and most important intervention that night, I prayed for Sara.
2 hours later when I came back to check on things, I was not surprised to find Sara’s bed in the emergency room empty. I asked if they had moved the body to the morgue, and was suprised to find they had moved her to the medical ward. I walked down to see what was happening, and found family gathered around Sara’s bed, and Sara sitting up and talking back! Instead of gray, she was now a glowing pink. I checked her oxygen saturation, and was shocked to find it was now 98%.
This was a humbling moment for me. Sara’s entire course changed the moment I gave up and just prayed, up to that point she was slipping away. It was pretty evident that it hadn’t been medicine, or me, but that I treated, Jesus healed.
It would be a super happy end to the story to write that Sara was home and breathing easy right now. She is still in the hospital and may eventually recover enough to go home, but she will probably be back in the next couple of weeks with another COPD exacerbation. Maybe I lack faith, but this is usually how things go. But I do see things a little differently now. When I walked away from Sara’s bedside, I felt that I was abandoning her. It was as if she were now completely on her own now to fight her illness. I no longer had any medications to offer her, and pushing air into her lungs with a bag was not reasonable, but she was not on her own. It is God who cares for the “hopeless” cases in Nepal or in the United States and He does it with or without medicine and with or without a ventilator. When I walked away from Sara, I was not only admitting my own personal defeat, but I was getting out of the way to let God do His work.