Thursday, January 10, 2008

9th jan 2008

9th jan2008

The character of the unconscious
There’s an assumption that an unconscious person – or someone in intensive care – is a body. An unresponsive shell. That people around exhibit their own personality while the body on the bed does nothing – is devoid of personality.

This is not the case.

The human character comes through regardless of consciousness, drugs and injury. George’s stubbornness in the face of his sedatives, the excitement he shows in his heart rate when the doctors suround him. The reduction in blood pressure when he hears our voices chatting to the nurse. The growing discomforts and sudden calms he exhibits in reaction to events inside his body and outside –these all combine to bring his personality into sharp focus.

Perhaps we just imagine these things – perhaps they’re just the result of the incredibly close monitoring of the intensive care unit.

On the other hand, perhaps when you take away all the window dressing of day to day life – all the distractions and the diversions – you finally get to what defines and creates a person. From today, I see George as strong, resilient and quick to bounce back, interested in people, and curious about everything, not accepting of his fate, but knowing his own mind. Even under morphine and sedatives, able to know the difference between Lisa and I and the Doctors and nurses.

Can I really read all this from a few random movements and a screen full of pulsing graphs? If not, then I have to wonder why the nurse comes out with the same observations before I do.

The idiot’s guide to intensive care
When you first see an intensive care ward, it’s a bewildering array of machines, pipes and monitors and the nurses are moving around all over the place in a slow but deliberate dance, constantly pushing buttons and changing settings while alarms of varying kinds go off at intervals.

However, once you work it out, it’s a little clearer. In fact it would make a great videogame. Here’s how it works:

Either side of the bed are two rows of modular machines about 10cm by 30cm. Each can have a syringe of drugs clipped into it. The machines move imperceptibly slowly, feeding the drug into the patient and the nurse controls their speed – changing the rate of administration by minute increments. If the pipes get blocked – either because there’s something wrong, or because George moves, a dull alarm goes off and they have to be re-adjusted.

George is on four right now – a water one, SMP (which keeps him sleepy), Morphine (to control the pain) and another drug to lower his blood pressure.

Below the bed and to one side is the ventilator – George’s artificial breathing machine. It is contoled by a complex looking panel of knobs and digital displays controlling the rate, strength and consistency of the air he’s given and each time it gives him a breath, the pipes leading to his nose jump like something alive. There are two significant numbers on the device – one (in green) shows the number of breaths he’s being given per minute (23 is about right) and the other (in red) is the number detected. Thus, if both numbers are 23, then he’s taking as many breaths as the machine gives him. If the red number rises, then he’s starting to breathe on his own – and the difference is the number of breaths he’s taking of his own free will. The idea of the game is to reduce the green figure slowly until George is doing all the work himself. If the ventilator isn’t working (usually because the nurse has replaced it with a hand operated balloon type ventilator while his lungs are drained of fluid or some other procedure is undertaken) then a loud, urgent sounding alarm goes off.

Above the panel is a display showing his heart rate, his blood pressure and its saturation. From this you can work out if he’s awake, asleep or having problems. Touching this screen gives more information about each graph.

As you probably know, blood pressure is actually two figures expressed as a fraction. If you notice that a heart beat is in two parts (ba-boom – ba-boom – ba-boom) then the top figure is the time between the end of the boom and the next ba – and the bottom figure is the time between the ba and the boom (which is the time the valves take to open and close. The top figure for George should be around 90 – but it started off at about 125-130 – possibly because his heart has had to work very hard all his life, and hasn’t got used to the idea that it now doesn’t need to).

If the figures go a little off normal, a warning beep sounds – which is really just there to make the nurse take notice of it – and the figures flash. The nurse then usually makes an adjustment to add more sedative, or morphine, and turns the alarm off. If things go too far off normal, the alarm is higher pitched and more urgent. Turning the alarm off just resets it, so it will go off again quite quickly. The alarms can be turned off completely if they’re too annoying, but then a red light on the top of the monitor flashes to remind you not to leave the alarms switched off.

The idea of the intensive care game is to adjust the medications so that the alarms don’t keep going off. This stabilises your patient and gets everything under control, but really it’s all about giving the patient’s own body time to take back control so you can slowly reduce and eventually remove the medications and interventions one by one until he’s doing everything himself.

The doctors occasionally pop in to give advice to the nurses and tell us what they plan to do, but they’re responding to their reading of the text books – when the doctors leave, the nurses who are with George 24 hours a day watching his responses tell us what’s really going to happen.

Don’t use the lifts
We’ve learnt not to use the lifts to the Intensive care unit. We’ve also learnt to avoid the family room. Both are places where visitors go when things go wrong. In the family room, you hear conversations you’d rather not hear, and in the lifts today, we passed a crying woman holding a tiny pink blanket.

The stairs are better by far – and have the additional advantage that if you’re eating the hospital food, the excercise of using the stairs may help you avoid your own cardiac surgery.

Taking out The tubes
Gradually, over the course of the day, the intensive care game was won by stages - a few of George’s tubes were removed and some of the medication syringes were turned off or scaled down. First to go was the breathing tube – when it was removed, he was able to make sounds for the first time since the operation (the tube went through his vocal chords – I did ask if they could leave it there, but no such luck). He Started with a horse whimper and moved over the course of the day towards full throated crying.

He wasn’t fully awake for most of the time – with the sedative still keeping him quite drowsy, but he did still make his presence felt. However, removing the breathing tube meant removing the morphine (which affects his breathing apparently).

Eventually, his tubes were reduced and we were able to pick him up and cuddle him which quietened him a little. Lisa’s mum came in at lunch time – on a flying visit on the way back from working at Peter’s and we had lunch with Sam .

Later, we were even able to give him a little food. He’s on just a syringe full every 2 hours which just wets his apetite for more and upsets him, but it’s a start.

Later still, we go out and meet Sam again at a Japanese restaurant directly above the London Aquarium (it’s a great restaurant and the fish is so fresh I wonder if they have drilled a hole in the floor). I’m tense – the last couple of days are catching up with me, and it’s good to have some time away from the hospital.

George doesn’t notice us leave. He’s not asleep, but has suddenly become fixated on the waveforms tracing across the screen.. we leave him staring – hypnotised by his own heartbeat.

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