Notes: SBT = Spontaneous Breathing Trial
Lisbon's internal dialogue is mentioned in brackets ( )
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Chapter 18: Let the trials begin
Tuesday Evening
Jane's condition was improving. The drainage from his chest tube had dropped to almost nil and the chest x-ray showed that his lung had expanded to a sufficient degree, so Dr. Evans felt that this would be the right time to initiate a spontaneous breathing trial to determine if his patient could make an effort to breathe on his own with minimal ventilator support. The first trial would be set for 30 minutes wherein the effort of breathing would be initiated by the patient and the ventilator would only kick in if the patient was unable to do so. Dr. Evans kept Lisbon in the loop.
"Agent Lisbon, do you have any questions regarding the SBT?"
"Yes, I do Dr. Evans. If Jane passes this trial, can he be extubated?"
"Not so soon. He will need to sustain 2 more trials of longer durations for us to be able to extubate him safely. The next trial will be an hour long if he passes this one."
"Can I sit near him while this trial is going on?" Lisbon asked warily.
"Yes, why not? You can talk to him and provide encouragement through this. It might actually help him sustain the trial."
"I see, but if there are any distress signs should I keep encouraging him or would that be dangerous for him?"
Dr. Evans smiled. "There's absolutely no need to worry Agent Lisbon. First of all, Mr. Jane will be continuously monitored through this trial. If there are any signs that he isn't tolerating the trial well, a nurse will immediately stop it and revert to the original settings on the ventilator. If he's in distress it will only be for a minute or two, so there's absolutely no need to worry, okay? You may hold his hand and continue talking to him, but it's advisable to not push him to complete the trial in case he's unable to. His sedation is now at a minimal level, so he will be able to follow instructions, you might see him grimace if he's uncomfortable, so please be mindful while you speak to him during the duration of the trial."
Hearing the doctor's instructions Lisbon tensed up a bit. She didn't want to do anything that would hamper the trial. She simply wanted to ensure Jane's safety during it and she hoped that he would pass it.
She pulled the chair in the room near his bed and held his hand firmly, but not too tightly. She closed her eyes and said a little prayer mentally while the nurse began changing the settings on the ventilator.
"Agent Lisbon, the trial has begun." The nurse announced cheerfully.
Lisbon smiled back but she was so worried! For the first time she felt afraid to talk to Jane. She was afraid that she might say something and it might have a negative impact on the trial, so she just sat there holding his hand and letting him know that she was there for him.
5 minutes passed and things were looking alright. Lisbon had set a countdown on her phone, so she was relieved when the first 5 minutes went by without a hitch. 25 more minutes to go, she prayed that those too would go by without any issues.
At the 6th minute there was a musical beep that played on the monitor. Lisbon looked at it and so did the attending nurse. Jane's heart rate had climbed to 100 and his blood pressure increased by a little bit. His respiratory rate had increased too. It had climbed to 30. The nurse noted the change, but remained calm. Lisbon shot a worried look at her.
"I'll be observing his vitals for a minute more, and if the values continue to rise, he will be back on full ventilator support Agent Lisbon."
Lisbon relaxed on hearing that, but her full focus was on Jane. Jane fortunately held his own for another two minutes but after that he struggled to breathe on his own. It took a lot of effort on his part in that state to continue breathing on his own. He was fighting the ventilator which was forcing a breath down his lungs due to the settings it was on. Lisbon wished she hadn't seen that struggle. It brought tears to her eyes even though the whole episode lasted less than 2 minutes. She had continued to hold his hand tightly throughout the whole trial, but now she freed her hand from his and rushed out of his room unable to contain her tears. She made a dash for the washroom and just sobbed her heart out for a few minutes. It was too much for her to see him struggling to breathe after what she had witnessed when he was dying in her arms just a few days ago.
Ten minutes later she made her way back to his room. The nurse was still there writing notes in her chart. Lisbon looked like she had cried, but the nurse did not bring it up, instead she waited for Lisbon to take a seat and calm down a bit.
"Agent Lisbon, Mr. Jane is not under any distress any more. He is back on the regular ventilator settings and his sedation has been upped again. He's comfortable right now." The nurse gave Lisbon a small smile and a little pat on her shoulder.
"So, what happens next?"
"Dr. Evans will discuss that with you in some time. Till then, you may wait here in Mr. Jane's room."
Lisbon nodded and heaved a sigh of relief. She looked at Jane with sadness in her eyes and heart, but continued holding his hand offering all the support she could give him non-verbally.
Ten minutes later Dr. Evans came in with the nurse who had administered the trial. Lisbon rose from her chair to meet him, but he motioned for her to remain seated. He looked at the readings mentioned on the medical chart and advised the nurse to keep the charts in his office for further evaluation.
"Agent Lisbon, the trial did not go as expected and I understand you are worried, but please know that more than half the patients don't pass their first breathing trial, so this is absolutely normal. This also means he will need to be tested again, but we will do that tomorrow as we don't want to stress his body anymore. His parameters are back within the normal ranges, so there's no need to worry. Get some rest if possible."
"Thank you, Dr. Evans. Would you be able to advise why this trial didn't work out as expected?
"I'll have to go through the data to see if there was any particular cause, but more often than not, patients are simply too weak the first time the trial takes place. Now the plan for tomorrow is to conduct breathing trials every 3 hours. We are hopeful that he will pass at least 2 of them so that he can be moved to the longer trials."
"Won't that be exhausting for him?"
"Yes, these trials do cause patients to get exhausted, which is why we keep intervals between them. If he passes one trial but his parameters show that his body is tired, we will skip the next trial 3 hours later and instead try another trial at the 4-hour mark. Our main aim is to extubate him as soon as possible so as to avoid any complications that can arise from being on a ventilator for a long duration."
Lisbon felt a little relieved on hearing that. Sleep came a little easily that night but with a whole lot of anticipation too.
Wednesday morning
It was still only 7:30 am and the doctor wouldn't be in to see Jane for at least another hour, so Lisbon took this opportunity to visit Jane. Standing at his bedside she noticed some beads of perspiration on his forehead. The room was sufficiently cold, so she wondered why he was sweating. She brushed her worries aside and gently wiped off the perspiration using a wet wipe that she had carried with her. She touched his face and it didn't feel like he had a fever, so she sat down on the chair hoping it was nothing. A few minutes later the monitor near his bedside beeped showing an increase in his heart rate and breath rate which was followed by a high-pitched harsh sound from Jane whenever it seemed like he was he was breathing in rather than breathing out. Lisbon panicked and she hit the call button. The nurse came in quickly but Jane's condition was deteriorating rapidly.
The nurse yelled out, "Code Blue". Within a few seconds a whole team of medical personnel barged into the room with a crash cart. Lisbon was in shock as she was ushered out of the room.
Meanwhile, the team in the room got to work quickly. The head of the bed was rapidly lowered and someone disconnected the vent while another nurse started manually ventilating Jane by using an Ambu bag. There was a glass window on the door of the room and Lisbon was witnessing the life-saving attempts taking place inside the room whilst tears were rolling down her face.
This went on for about 5 minutes till a doctor from the medical team entered the room. Lisbon saw him overlooking the procedures being performed on Jane. He came out a few minutes later and saw Lisbon standing outside the room in tears.
"Agent Lisbon, please take a seat." The doctor guided her gently to a sofa and asked someone to get a bottle of water for her. A nurse came back with one, and gently handed it to Lisbon. After a few sips Lisbon calmed down a bit and asked the doctor what was happening with Jane.
"Agent Lisbon, Mr. Jane was experiencing an obstruction in his upper airway due to which he was having difficulty breathing. There was an excess buildup of secretions in his airway which led to reduced oxygen levels and thus a difficulty in breathing. We have suctioned it out and have increased the rate of oxygen flow to compensate for the stress he experienced. He's not in danger anymore, but due the physical stress, his heart and breath rate will be high for some time and we will continue monitoring it closely."
"He's not in danger anymore in spite of the high heart and breath rate?"
"No, he's not. As I said, we will be monitoring him very closely for the next few hours. Dr. Evans will be here soon and he will be able to advise what the next course of action will be."
"Oh okay." Lisbon wiped her eyes as she acknowledged what the doctor had told her.
"Can I be with him till Dr. Evans arrives?"
"Yes, you can. Try not to worry." The doctor gave a small comforting pat to Lisbon and took her leave.
Once again, she entered his room with trepidation and looked at him but almost pulled away from looking at him, she looked at the bedside monitor instead.
135 – Heart rate 140/100 – BP 95 – O2 Saturation 30 – Respiration
Those weren't great readings, she could tell by the way his chest rose and fell and the way in which his accessory muscles worked to compensate the stress in breathing, but then the doctor had mentioned that this would go on for a while, so she tried to push aside her worries and once again pulled up the chair that sat there faithfully in his room.
She was too overwhelmed to say anything, so she gave him a little kiss and held his hand for a while in silence. Ten minutes had passed and there was still no change in the readings on the monitor, so Lisbon thought of doing something to help get his readings down if she could.
"Jane, it's Lisbon. I'm only trying to help."
She sat as close as she could to his bed and placed one hand very lightly over his chest while she held her cross with the other hand. Closing her eyes she breathed in calmly and exhaled calmly. In her mind she spoke to Jane. (Jane, you're safe, there's no need to be scared anymore. Just breathe as calmly as you can. In 1..2, out 1..2. In 1..2, out 1..2) She continued this breathing pattern with him for 10 minutes and could slowly feel his breathing pattern change and slow down. His chest rose and fell more slowly and his accessory muscles were only showing a slight strain by now. She felt a bit tired so she finally opened her eyes. Both of them were sweating a little, but Jane's parameters had improved by a bit and that made Lisbon happy.
125 – Heart rate 135/95 – BP 97 – O2 Saturation 25 – Respiration
She relaxed into her chair and wiped her face. Just then, Dr, Evans and his team entered the room.
"Good morning, Agent Lisbon."
"Good morning, Dr. Evans."
Dr. Evans too a look at the readings noted by the nurse in the medical file. He then proceeded to check Jane's lungs using a stethoscope.
"Lungs are clear. Post noon, take him for a CT scan and let me know" Dr. Evans advised the junior doctors who had accompanied him. He then turned to speak to Lisbon.
"Agent Lisbon, I understand you might a few questions."
"Yes, what happened today?
"So, during today's trial we found that he was unable to sustain the effort of breathing on his own as the secretions in his lung were a little higher than normal which in turn partially obstructed his airway, so this caused a mild drop in his oxygen levels and thus the respiratory distress. Even though the secretions have been suctioned out, his body was subjected to an undue stress and that's the reason why his parameters are currently a little elevated."
"For how long will his parameters remain elevated? An hour has already passed since that incident."
"It takes about 3 to 4 hours for the parameters to return to normal, Agent Lisbon."
"I see, so now what happens to the breathing trials?"
"We will be able to decide once we have the results of his CT scan that he will undergo this afternoon."
"Okay, thank you Dr. Evans."
"I'll meet you in the evening again Agent Lisbon, till then you may continue visiting him every hour."
"Thank you, Dr. Evans, will do."
