Breathless: The Role of Compassion in Critical Care

Introduction

My world is a hospital, but not just any hospital. It is Pennsylvania Hospital, the nation’s first, founded in 1751 by Benjamin Franklin. The hospital is based upon principles of compassion and tolerance as a refuge for the sick and injured, including the poor and what were then labeled as the insane.

Every day, I witness the compassion and tolerance, envisioned by Ben Franklin, as nurses, doctors, physical therapists, and other healthcare professionals work tirelessly to help those who are ill or dying. I witness the pain of families as they experience the roller coaster ride of critical illness in modern-day intensive care units. I observe the skills of physicians who provide care, decrease suffering, and help families come to terms with end-of-life issues such as withdrawal of life-sustaining medical devices, advances in medicine unthinkable a century ago.

As a medical student, I began to appreciate the complexities of human life from an intellectual perspective. Courses in physiology and biochemistry opened my eyes to the incredible events occurring at a cellular level. I learned how a complex human could grow and thrive in an environment rich in sunlight, water, and oxygen. In college, I learned that over a period of billions of years an environment initially rich in carbon dioxide produced vegetation that survived by converting energy from sunlight and carbon dioxide into an environment rich in oxygen. With the release of massive amounts of oxygen into the earth’s atmosphere, human life could then evolve as we know it today.

The oxygen we often take for granted enters deep into the body with each breath we take. This, in conjunction with glucose, a simple sugar in our diet, allows us to produce energy at a cellular level to maintain body heat at a perfect 98.6 degrees Fahrenheit and fuels cellular functions of highly specialized organs. Although billions of cells in an individual share the same genetic information, only certain segments of chromosomes are activated in specific cells. A cell in the liver, for example, has certain segments of chromosomes activated to become liver cells, capable of producing proteins necessary for daily liver function.

Cells in the heart containing the same genetic information have specific chromosomal segments activated so that proteins can be produced to manifest as heart cells that, when working with other heart cells, are capable of rhythmically pumping blood containing oxygen to all the cells of the body. Through a complex network of blood vessels, the human heart provides life-sustaining oxygen along with a constant supply of glucose so that individual cells produce energy in the form of adenosine triphosphate (ATP), the high-energy substance that is needed to fuel all bodily functions.

As a physician with years of education related to cellular function and the cooperative nature of complex human organs, I have watched as diseases have unraveled these intricate processes. I will always marvel at modern medicine, including infection-fighting antibiotics that fight virulent microorganisms. I am amazed also by clot-busting drugs that restore blood flow to vital organs. I observe highly advanced procedures as surgeons remove damaged segments of diseased organs that would otherwise doom a patient. I have observed the suffering of patients and families as they struggle to overcome the adversity of disease. I have witnessed the remarkable capacity of the human body with its tremendous ability to heal and regenerate.

I hope this book will engage patients, practitioners, and the general reader in a way that will lead to better understanding, communication, and decision making, and, ultimately, better outcomes. I have tried to include both technical terms for practitioners as well as common-sense explanations that will be more familiar to patients and families.

I hope that, in a small way, this book will advance the cause of empathy and greater appreciation of the marvels of the human body. I hope, too, that we all realize that life itself is a miracle and how precious and fragile it is.

In this book, I will share stories of patients who have entrusted me with their care during critical moments of their lives over a span of almost forty years. For privacy reasons, I have gone to great lengths to de-identify patients by changing names, merging characters and adjusting biographies. Although each chapter was inspired by one or more patients I had the great privilege of caring for, specific dialogues were modified to further protect the confidentiality of patients and their loved ones. Where these efforts were less than certain to ensure privacy, relevant portions of the manuscript were reviewed with the patient and loved ones and permission to publish was obtained.

Finally, I also focus on ethical issues and the process by which I and other practitioners make decisions on critical issues. Such issues are an important aspect of modern medicine.

1

Thump

The year was 1982, and I was a lowly medical intern working the night shift in the emergency room. In those days, we did not have seasoned, board-certified, emergency room physicians by our sides. It was a rite of passage—just me and Rose, an experienced emergency room nurse, and whoever came in through the doors after midnight. It was scary. I knew that my medical resident, with one additional year of training, was just a phone call away. I also knew that she was sleeping and to be awakened only if absolutely necessary.

Just then, a middle-aged man walked through the electronic doors to the emergency room complaining that he had passed out an hour earlier. It was my responsibility to figure out what had happened, how to treat him, and decide whether to admit him to the hospital or discharge him to go home. Rose seemed to know everything. She was the one who guided all new interns through the graveyard shift. She understood the delicate balance of suggesting a course of action without disrupting the traditional doctor-nurse relationship. With her diplomatic style supported by years of experience, she gently recommended appropriate tests or treatments to novices like me.

I did not have to say a word. Rose immediately placed our patient on a cardiac monitor. Passing out, also known as syncope, could be due to a temporary malfunction of the heart’s intrinsic pacemaker that sends electrical signals to the heart muscle so that it contracts regularly. Without a rhythmically pumping heart muscle, blood supply to the brain is quickly cut off. This results in loss of consciousness or passing out. If the heart does not resume its contractions, you die within minutes.

Suddenly, the patient stopped talking and his eyes rolled back. The look of imminent death was upon him. Instinctively, I glanced at the heart monitor and saw a flat line. Seconds earlier, the monitor had shown the perfectly regular rhythm of a beating heart. There I was with four years of medical school education, but minimal clinical experience, terrified that this patient would die if I failed to respond quickly and correctly.

Then I remembered one of my mentors, a cardiologist who taught me as a medical student. He once told me of a patient whom he had encountered with a similar story. He shared with me how he resuscitated the man with a simple thump to his chest. Without hesitation, without turning to the nurse, without awakening my medical resident from deep slumber, I slammed my fist down on the patient’s chest. Quickly, I turned my attention to the cardiac monitor. The flat line was replaced immediately by electrical activity in the form of what we call QRS complexes—the signals of a beating heart, the same wave forms you see on a heart monitor during medical TV shows.

His heart rate was a bit slower than normal, but fast enough to trigger a functioning heart muscle once again. As blood flow was quickly restored to his brain, the patient began to talk. He spoke as though nothing had happened, but something big had happened. His life was restored with a thump on his chest. I used a mildly violent act, which would ordinarily be interpreted as aggression, to restore a beating heart, a thinking brain, a feeling soul.

I instructed the nurse to page the cardiologist on call. My job was to keep the patient alive until the cardiologist arrived. I knew that the patient needed an emergency pacemaker. Because his own internal pacemaker was failing, we would have to insert a device into his heart to replace the electrical activity that had lasted long enough from birth through his journey to our emergency room that night. I did not budge from his bedside until the cardiologist arrived. I had a clear sense of the urgent nature of what was transpiring.

Prior to the cardiologist’s arrival, my patient’s heart stopped several more times. Each time, one quick thump to the chest restored electrical activity and a beating heart.

Later that evening, the cardiologist placed a pacemaker and the patient was transported to the third floor of our hospital for further care and monitoring in our coronary care unit.

My night shift continued as I examined and treated other patients. No patient that night or, for that matter, any subsequent night of my career, could compare to this man whose heart stopped repeatedly only to be restored with a simple, quick thump to the chest. An old school intervention that, decades later with advances in technology, is rarely even discussed as an option, but one that some of my older cardiologist colleagues knew well.

More than thirty years later, I still find myself wondering about that magnificent night. To this day, recounting the event gives me an exhilarated feeling. It also leaves me with many unanswered questions. Was it just a coincidence that I happened to hear a lecture on this arcane subject? That this patient with faulty electrical wiring came to our emergency room during my night shift? Would advances in science make results less dependent on coincidences like these? To this day, I wonder. Although the answers remain elusive, one thing remained certain: that doctor-patient interaction was a formative experience for me as a young doctor and beyond any other human experience I could have imagined.

2

Compassionate Detachment

At the core of the successful doctor-patient relationship, dating back centuries, is the physician’s deeply held belief that all human life has equivalent intrinsic value and all are worthy of dignity. The physician’s expression of curiosity helps form a lasting connection with patients and their loved ones. This respectful attachment lays the foundation for a trusting relationship, one characterized by empathy and compassion. Medical decision making in the context of this relationship is based upon the patient’s personal values, goals, and priorities. However, in the moment of a life-threatening emergency, transient detachment allows the physician to maintain extreme focus without distraction.

When treating a patient in a medical crisis, there is no internal discussion or extensive reflection on what is at stake. There is only a derangement of physiology that must be addressed quickly. For a doctor, this type of compartmentalization is essential. For now, the part of the brain that is able to focus on the physiology and acute derangement must supersede and suppress any emotion that would interfere with the timely intervention that can mean the difference between life and death. Now is the time to turn on that switch and act quickly.

At this moment in time, the patient’s interests become parallel with those of the physician. The patient’s wish to live becomes the physician’s wish for him. His desire to watch his grandchildren grow becomes the physician’s desire for him. His goal to reach old age becomes the physician’s goal for him. Whether the urgent situation involves a long-standing patient or one who has just entered the hospital, this precious individual, often clinging to life, becomes the physician’s sole responsibility as critical decisions are made. In the moment, there is no time for lengthy deliberation.

Seemingly an oxymoron, compassionate detachment is a vital attribute of the highly effective healthcare provider. When fears and anxieties about making a catastrophic mistake begin to surface, it is essential to maintain calm competence without arrogance; not just a façade but a steadiness that penetrates to the core and allows for optimal decision making during moments of clinical crisis. Certainly, the acquisition of wisdom, knowledge, and experience with aging helps to guide the clinician down the winding path of decision making during time-sensitive, life-threatening emergencies. But whatever the level of wisdom and experience, it is essential that it is brought to bear with a steady and singular focus.

How do medical professionals do this? At the core of the brain is a structure known as the thalamus. You could compare this part of the brain to an air traffic controller who determines which sensory inputs reach the frontal lobe for the decision-making process. Imagine yourself in a busy restaurant where multiple loud conversations are taking place. It is humanly impossible to focus on multiple conversations at once. However, through control by your thalamus, you can consciously decide which conversation to focus on while ignoring the others. As you choose, you may switch your attention from one conversation to the next.

To function effectively as a physician, one must be able to multitask and be able to change focus quickly when clinical situations arise and only return to a prior problem when the newly discovered concern has been adequately addressed. Each new issue might be addressed in seconds, minutes, or much longer depending on its complexity. It is not uncommon for a physician to leave one problem and return later to that same problem as new information surfaces or additional thoughts reach the frontal lobe, perhaps from new processing, or prior relevant experiences, or knowledge acquisition. Each new problem requires intense focus and often quick decision making.

For example, a patient who is experiencing labored breathing, chest pain, or low blood pressure may be at risk for cardiopulmonary arrest within minutes if not quickly and properly managed. If an emergency issue such as this arises, it must be addressed immediately, with complete and detached focus. Once the critical moment has passed, an opportunity to review the events that have transpired, with genuine concern and compassion, will follow.

3

Breathe

Another fundamental in the world of a critical care pulmonologist that applies across emergencies is understanding the miraculous process of breathing. Most of us will spend our entire lives without a conscious awareness and understanding of breathing. Yet, it is this very process that allows us to survive on planet Earth. As plant life evolved over billions of years, our atmosphere became enriched with the diatomic molecule known as oxygen, the vital gas discovered by Joseph Priestley in 1774. As the human species evolved, it developed a symbiotic relationship with plant life.

Humans and plants have lived in harmony for over one million years. Plants produce the oxygen that we breathe into our lungs to make energy. Humans produce carbon dioxide that plants utilize to make their energy through photosynthesis. This harmonious balance is the essence of life as humans and plants coexist.

As a fetus grows in utero, the developing lungs are filled with fluid and not involved in this gas-exchange process. Instead, oxygen is delivered to the fetus through the placenta firmly attached to the mother’s uterus. As oxygenated blood enters the placenta, it passes through the blood vessel known as the inferior vena cava of the fetus as hemoglobin-containing red blood cells make their way to the right side of the heart. Rather than journeying to the tiny alveoli in the lungs, the blood is shunted to the left side of the heart through openings known as the foramen ovale and the ductus arteriosus. By shunting blood away from the fluid-filled lungs of the fetus directly to the left side of the heart, oxygen that has already been attached to hemoglobin in the red blood cells may be delivered to all fetal cells for energy production.

When the infant is delivered, either vaginally or by C-section, the umbilical cord is clamped, and the baby generates negative intrathoracic pressures by sucking in air. Subsequently, fluid that had filled the tiny air sacs of the fetus is quickly cleared and the foramen ovale and ductus arteriosus close to allow blood to flow to the capillaries surrounding the infant’s tiny air sacs for oxygen and carbon dioxide exchange as seen in the mature adult. These first of many breaths have set the stage for life in an oxygen-enriched environment.

We humans have evolved so our brains ensure we exhale enough carbon dioxide and inhale enough oxygen to survive. Carbon dioxide, a by-product of cellular metabolism, is essentially a waste product that must be excreted. If exhalation through the lungs is inadequate, volatile acids build up in the bloodstream and cause dysfunction of major organs. Extreme retention of carbon dioxide inevitably causes death.

How does the body ensure adequate excretion of carbon dioxide? At the core of our brain, an area called the brain stem contains the medulla oblongata. Within this core structure of the brain is a cluster of cells known as the Pre-Bötzinger Complex, which serves as the pacemaker of breathing. If these cells function normally, as carbon dioxide rises in the bloodstream, an increase in nerve impulses is sent through the spinal cord via the phrenic nerves to the two hemidiaphragms, one at the bottom of each lung. This increase in nerve impulse transmission leads to faster and deeper breathing so that increased CO2 exhalation may follow to return this potentially deadly molecule to its normal range. This process is the ultimate example of homeostasis in the human body. The same well-tuned mechanism is seen in all mammals.

The other major function of the lungs is to inhale oxygen. Oxygen makes up 20.9 percent of our atmosphere and we must breathe in a constant supply to live. At the cellular level, energy sources such as glucose require oxygen as we create a molecule known as ATP. This chemical fuels all cellular functions and maintains body heat. Without it, we die. The brain in particular will cease to function within minutes of oxygen deprivation. The body has fine-tuned sensors that have evolved to make sure we breathe in enough oxygen.

During exercise, oxygen demands increase dramatically as our muscles contract and require increased supplies of ATP. Our physiological response is to breathe deeper and faster. In a deconditioned person who rarely exercises, running will quickly lead to an uncomfortable feeling of breathlessness. In a highly conditioned athlete who runs marathons, cardiovascular changes in the heart’s