A Sign of Weakness

While I waited for the lab to process the gas. I skimmed over fifteen pages about scleroderma, a mysterious, untreatable condition in which the skin and organs stiffen. The most feared complications are cardiac and pulmonary. Some victims develop fibrosis of the heart early in the course of the disease, and quickly die, as the accumulation of gristle disrupts the heart’s conduction system. In the lungs, collagen invades the membranes where the blood exchanges oxygen and carbon dioxide with air: the lungs stiffen, thicken and fail.

It is possible to get an idea of how this would feel. Putting your head in a paper bag is a dim shadow of it; thick quilts piled high come closer. The difference, of course, is that you can’t throw scleroderma off. The bag stays dark; the quilts simply thicken, over years.

The blood gas was not encouraging. The numbers on the screen told me several things. Her blood was acidic. CO2 trapped in her lungs was mixing with water in her blood to make carbonic acid. The acid was chewing up her stores of bicarbonate, which meant that her lungs were getting worse faster than her kidneys could compensate. The really bad news was the amount of oxygen dissolved in her blood, which at a partial pressure of fifty-four millimetres was unusually low, especially for someone getting supplementary O2. Taken together, these numbers spoke of lungs that were rapidly losing access to the outside air.

I remembered a patient I had taken care of during an ER rotation a year earlier, an old lady with pneumonia. I had gotten a gas on her, too, and it had come back essentially normal. The attending had asked me to interpret it. ‘It’s normal,’ I said. ‘And?’ the attending replied, directing my attention to the patient gasping on the gurney. I looked at her for a moment. She was breathing about forty times a minute. ‘You’re about to tube her,’ I said. ‘Right,’ the attending said, and did just that. A normal gas on somebody working hard is a bad sign. A below-normal gas on somebody working hard to breathe on supplementary O2 is a very bad sign, especially if her chart carries the notation ‘DNI’. The letters stand for ‘Do Not Intubate’. It’s the patient’s order to her doctors and it draws an inviolable line. No breathing tubes, no ventilators, no call to the ICU for help.

I hurried back down the hall to the room. The sun had set, leaving the sky a dim purple. The room was dimmer still, the patient’s face a sheen on the white pillow, her chest visibly stroking from the door. I stood in the doorway for a minute, watching her, trying not to match her breathing with my own. Her face was turned to me. The eyes glittered.

‘How are you feeling?’

‘Not. So. Hot.’

‘I know,’ I said. ‘I’m going to get you some more oxygen.’ I reached for the regulator in the wall and cranked it up to six litres, the maximum you can deliver by nasal cannula.
The nurse appeared at the door. ‘Do you want me to call respiratory?’

‘Yeah,’ I said. ‘That’s good. Call respiratory.’ Respiratory therapists know all sorts of tricks: complicated masks that somehow squeeze more oxygen into room-pressure air.
I went back to the workroom and paged Keith. It occurred to me that I was displaying weakness. I told myself I didn’t care.

He called back in a minute, cheery, calm. ‘What’s up?’

I told him.

‘She’s DNR? You checked the chart?’

I set the phone down and found her chart. There in the ‘Consents’ section was the legal form, witnessed and signed.

‘Yeah. DNR/DNI.’

‘Well, that’s it,’ he said. ‘If it’s her time, it’s her time. Just crank up her Os and give her some morphine. That’s all you can do.’

There was silence for a minute.

‘Do you need me to come up there?’

‘No. I’m on it. It’s okay. I’ll call you if I need anything.’

‘Okay. Have a good night.’