05 February 2007

What I learned from BK

In the four years since I have graduated from medical school, I have had some memorable patients. Even before I attended medical school(I was a pediatric-perinatal respiratory therapist), I had patients who touched my life so profoundly that they spurred me on to keep going when I thought that I could not stuff another fact into my head. They are with me everytime I walk into a room or interact with any patient in any manner.

When I was a pediatric respiratory therapist, my specialty was the respiratory care of the patients in the Pediatric Intensive Care Unit. I preferred pediatric respiratory patients because they were unlikely to continue smoking after spending days in the intensive care unit or hospital. I also liked the challenge of delivering medications by inhalation to children. I had to gain their trust and deliver their medications at the same time. Often this would take the form of having a pediatric post op patient blow feathers across a table or perform incentive spirometry and light up a clown's nose. I also enjoyed the artistry needed to mechanically ventilate children of various sizes and needs. Pediatric Critical care was a wondeful method of practicing respiratory therapy and seeing respiratory physiology in action on a daily basis.

One of my most memoriable patients was a child who had been born prematurely to a set of much older parents. BK was born at 24 weeks gestation (normal is 38-40 weeks) and had spent the first five months of their life in the neonatal intensive care unit. At the time (late 1980s) inhaled pulmonary surfactanct had not been available for administration into children born this early. As a result, BK, who had been on mechanical ventilation because of extreme lung immaturity, developed bronchopulmonary dysplasia.

Children with bronchopulmonary dysplasia (BPD), a result of ventilation with relatively high levels of positive pressure, developed changes in their lungs that closely resembled the changes seen in adult patients with emphysema as a result of smoking many years. These children were chronically susceptible to pneumonias and were often oxygen-dependent, and bronchospastic when they were weaned from positive pressure ventilation. With the advent of artificial pulmonary surfactanct, BPD, is far less common today than in the late 1980s.

BK had been weaned from mechanical ventilation but remained oxygen dependent. This child also had problems with growth and nutrition but had a spirit that was a thousand times larger than its tiny body. BK also had parents who loved every second of their child's existance, even the touch-and-go, up-and-down character of getting a small premature infant into the catch-up phase of life. They had spent countless hours of the first five month's of their child's life at the bedside in a neonatal intensive care as they saw the sheer determination of this child's will to live.

BK was discharged from the hospital at age 5 months. Going home meant going home with an oxygen tank, respiratory medications and an infant apnea monitor. It also meant careful attention to feedings and nutrition but BK's parents were joyful and happy to have their child home. BK also had two nurses that assisted Mom with daily care and feedings.

BK was home for three weeks before a viral upper respiratory infection called Respiratory Syncitial Virus or RSV caused increased work of breathing and a trip to the pediatrician's office. Later BK was admitted to my Pediatric Intensive Care Unit. Because of the highly infectious nature of RSV, BK was placed in an isolation room and placed back on mechanical ventilation with administration of a medication to treat the RSV infection.

When I first saw BK, I saw a tiny child with huge blue eyes that saw straight into my heart. This child never smiled but took in my every move from a vantage point in an isolette. At first, my care of BK consisted of delivery of the medication to treat the viral infection. Later, my care consisted of delivery of inhaled medications and extra oxygen within the isolette. At times, BK needed to have nebulation therapy every hour.

During our 15 minute treatment sessions, I would gently support BK's head and chat with the child through the isolette. Most six-month-olds will mirror your smile and heartily respond to your touch but not BK. Those huge blue eyes would blink and watch but no smile. For two weeks, I spent most of my shift taking care of BK in terms of the delivery of respiratory care. In those two weeks, I developed a great relationship with BKs mother and father who doted on their child at every turn.

After three weeks, BK was able to come out of the isolette for "love and hug" therapy by Mom. It was a wonder to see the great relationship between Mom, Dad and little BK. Still those huge blue eyes followed everything and everyone. If BK had any respiratory difficulties, I was close by and ready to administer what was needed. BK also gained some weight and seemed to be thriving.

One afternoon, we had difficulty keeping BK's oxygen saturation levels up. At this point, the "holding and hugging" sessions had to be sharpy curtailed. Finally, BK needed to go back on the pediatric ventilator for some positive pressure therapy. Still those huge blue eyes never betrayed the struggle that this tiny child was going though. BK's Mom brought in nursery rhymes that she had taped and music for the isolette to drown out the sound of the positive pressure.

After three days, little BKs continued to deteriorate and finally late one afternoon, BKs parents made the heartbreaking decision that their child would not be subjected to mechanical ventilaton again. At this point, we delivered almost continuous nebulization therapy which provided some decreased in BK's struggle to breath. Finally, we placed BK in Mom's and Dad's arms. At this point, those huge saucer blue eyes were peacefully closed and little BK breathed the last breath surrounded by family and extended family of the PICU who had grown to love this little warrior.

Five years later, when I dropped in to visit the pediatric critical care pulmonologist that I had worked with so closely when I was covering the pediatric intensive care unit, we took a tour of the new pediatric hosptial and the new units. By this time, I had left respiratory therapy had had just received my first acceptance to medical school. I had wanted to surprise my pediatric pulmonologist and he was just so proud of me. As we walked by the doors of the old pediatric intensive care unit, now housing offices, we both looked at the last room at the end of the hall and said, "BK's room" at the same time.

I learned so much in the six weeks that I knew BK and family. I don't know if BKs parents every realized how much their child had touched all of us and how we never forget the struggles of such a young child. BK did not see a first birthday but brought so much joy even though we never saw a smile.

To this day, my patients and their struggle keep me going in that 30th hour. My patients never "give up" and I never "give up" on my patients. This job is difficult but to have a chance to meet and experience patients like BK, every difficult task is work the effort.

1 comment:

Jacqueline said...

That's a powerful story, thank you for sharing.