This morning we watched a man almost drown on dry land. He came in to the hospital, breathing fast, looking bad. He had the tell-tale signs of uncontrolled chronic heart failure. His legs were swollen. His hands were swollen. His belly was likely full of fluid. But most dangerous at that moment, what was causing his acute distress, was that his lungs were full of fluid. Since the left side of his heart, normally tasked with moving freshly oxygenated blood from the lungs to the rest of his body, was failing, his lungs were backed up with fluid. Having to deal with the extra work for too long, the normally relatively weaker right side of his heart had also failed, as evidenced by his water-logged extremities.
We hooked up our minimally functional, minimally clean oxygen machine and tried to convince him to keep the uncomfortable mask on his face. We administered IV furosemide, a diuretic that helps open up the veins in his lungs as well as gets the kidneys to dump fluid out of the body. One, two, three, and then four doses of increasing strength (up to a cumulative dose of 240 mg) and we weren't seeing a response. We gave him a pill of a different diuretic, spirinolactone, with the hope that it would potentate the action of the first diuretic, a risky move without knowing how well his kidneys were working. He was so short of breath he wasn't able to swallow it. The intern brought sublingual nitroglycerine from the pharmacy, hoping that he could place a tablet below his tongue that would then dilate the veins in his lungs and allow him to breathe easier. He spit out most of the dose along with some frothy sputum.
I could see that he was getting tired. That is a very bad sign in the world of heart and lung disease. In my hospital in California, respiratory therapists would have been paged to the ER a long time before this point and would have placed him on BiPAP. This non-invasive ventilator machine works by pushing fast-flowing oxygen into the lungs of a patient via a tight fitting mask, forcing the fluid out of his alveoli so he can breathe again. Failing this, he would have been intubated, placed on a ventilator, perhaps put on a nitroglycerine drip, maybe even dialyzed if his kidneys couldn't take off the fluid.
But instead he sat there, in severe respiratory distress, leaning onto his thighs, hands and arms cold and clammy due the reduced circulation and stress of the moment. And I thought he was going to slowly suffocate due to the fluid in his lungs, or perhaps have a build-up of carbon dioxide that would cause him to get confused and then take away his drive to breathe, or maybe have a heart attack or cardiac arrhythmia.
Amazingly, his breathing slowed a bit, his pulse began to improve, and he began to look interested in his surroundings. The medications had taken effect, and he was turning the corner. I have no guarantee that he will make it through the night. There are a dozen things that could go wrong between now and AM rounds. But the junior docs saw that such a sick patient could be stabilized. And we will hope and pray that he survives until morning.