Conflict and Integration: A Ventilator Story

Illustration created by the author.

The dispatch information reads: “69 y/o M, admitted to ICU for respiratory failure.” The patient is scheduled to be transported from the ICU to a specialty hospital. According to dispatch’s notes, the patient has a tracheostomy, or trach, an opening created surgically in the neck, with a tube inserted to provide an airway.¹ Dispatch continues: “Patient is on the ventilator, pressure control, with mandatory breaths.”

We’ll call the patient Atlas, in reference to the Greek Titan directed by Zeus to stand at the Western edge of the Earth and hold up the celestial spheres, or the “sky,” on his shoulders.²

I take a deep breath, and check the oxygen tanks on the ambulance, ensuring we have at least two full portable tanks, and a full main tank for the drive. The transport crew consists of a paramedic (me), and two EMT-Bs, including an orientee. After a thorough equipment check, we drive to the hospital, park and grab the stretcher; bleak and uneven pavement welcoming our boots on the ground.

We pass through the hospital’s white walls littered with modern art, and I feel an emptiness, longing to be affirmed by something like “Evening on Karl Johan Street” by Edvard Munch.³ It’s an alienating feeling, entering the ICU to a closely-knit tribe of overworked staff, but they greet me accordingly, relieved to hear that I’ll be taking a patient with me. I confirm the ventilator settings received from dispatch with respiratory therapy (RT) and scrutinize them, scrunching my eyes into a skeptical thin line. These are some of the settings given to me: PC: 24. RR: 18. PEEP: 10. FiO2: 50%.

The important thing to understand about these settings is that they are “high.” A considerable amount of pressure and oxygen are being used to keep the patient stable.⁴

I connect the circuit to the ventilator, connect the ventilator to the oxygen tank, and perform a circuit check to ensure that everything’s working. I take a deep, considered breath and scan the room, determining what furniture will need to be rearranged to fit our stretcher in. The circuit check passes, so I input the values provided to me. I walk in the room, where Atlas lies quiescent on the white sheet, eyes darting between the nurse and I.

He’s unable to speak, but fully alert and oriented, and able to express himself through writing and hand gestures. Tracheostomy is a traumatic surgery that changes a person’s life, effecting their self-esteem and ability to communicate, and can lead to depression and thoughts of suicide.^5,6 However, those with a trach, even those who are ventilator dependent, may learn to speak again through practice and technique, focusing on enunciation and the specific muscles being used, and synchronizing breathing with speech.^7,8

I introduce myself to Atlas. He gives me a small, half-hearted wave, likely not looking forward to leaving the bed for our stretcher, however, we move Atlas without issue. RT deep suctions before transport, as sometimes secretions can become dislodged when a patient is moved. Then, RT disconnects Atlas from the hospital ventilator, and I connect our ventilator circuit to his trach. Before leaving the room, I take some time to allow Atlas to adjust to our ventilator. Though our machine is smaller in size, it often feels “stronger” to patients, even when the pressure values are numerically the same.

Though nonverbal, Atlas is fully alert and oriented, so I ask him for confirmation that he’s receiving good breaths. He gives me a “thumbs up,” and appears to be comfortable. To continuously monitor vital signs, I place him on pulse oximetry, cardiac monitoring, and waveform capnography. A blood pressure check will run every fifteen minutes. I look at the monitor, and oxygen saturation (SpO2) remains at an adequate 96%.⁹ Though Atlas is currently tolerating the change in ventilators, I keep a bag valve mask with me. Atlas waves goodbye to several staff members, as we wheel the stretcher out of the ICU.

In high-stress situations, I have a mental exercise to navigate my thoughts and emotions that I call “Conflict and Integration.” It consists of five steps that I’ll include in the story. Keep in mind, pace-wise, all of the following events are happening within a few minutes. I’ll be “over-explaining,” in a sense, to articulate my decision-making process.

Step 1: Conflict.

Upon exiting, and entering the hallway leading to the elevators, the monitor reveals that Atlas’ oxygen saturation is dropping into the high 80s. I ask Atlas if he’s alright, and he responds, but this time giving me a slight shrug. There are minimal secretions at the opening of the trach, he’s not coughing, and there is no strong, “bubbly” sound, as RT had just deep suctioned, so I determine that secretions are not the main problem; the airway is clear.

Step 2: Inner Drama.

I feel tension in my shoulders, and there’s a pressure between my eyes, at the center of my forehead. I notice that I’m holding my breath. I consciously breathe in, and out, and in, and accept the situation. Although the acute stress is influencing my thoughts and emotions, I’m confident that I can rely on my training to find a solution.

Step 3: Acceptance.

With “ventilation” being the mechanical process of breathing, I accept that it’s our job today to keep the air moving, so that “respiration,” or the gas exchange of oxygen and carbon dioxide, can properly occur in the lungs.^10,11 I can see from chest rise and fall that Atlas is receiving breaths. A method of confirming adequate ventilation is to measure end-tidal carbon dioxide (EtCO2.)¹² In waveform capnography, I’m looking for rectangular waves with rounded edges to represent “normal” breathing and looking for a target EtCO2 value between 35 and 45 mmHg.¹³

Looking at the monitor, I can see the waveform is initially normal, but numerically, EtCO2 begins to climb into the high 50s, reaching as high as 61. Though Atlas has a strong radial pulse, and the cardiac monitor shows normal sinus rhythm, oxygen saturation begins to drop as low as 73%. This is concerning, but I accept the situation. Atlas is now working harder to breathe, sweating, with accessory muscle movement, and in visible discomfort.¹⁴

Step 4: Meaningful action.

We check the equipment, confirming that oxygen is being provided at 50% FiO2 and there are no leaks. The circuit is connected, and no alarms are revealing an issue, but Atlas is not tolerating being on our ventilator.

As we’re barely twenty feet from the door, we quickly wheel back to the ICU and call for help. I take Atlas off our ventilator and provide manual positive pressure ventilation with supplemental oxygen to the trach, via bag valve mask.¹⁵ Atlas’ presentation begins to improve following this change, appearing more comfortable, oxygen saturation increases, and EtCO2 begins to go back down. At the doctor’s order, we transfer Atlas back to the hospital bed, and bag valve mask ventilation is resumed by an RN. Respiratory therapy prepares the hospital ventilator. The transport is canceled, and Atlas will remain in the ICU for now.

We hear rumblings as we exit, with multiple ICU staff members commenting that they “had a feeling this would happen.” Upon returning to base, I speak with our company’s education coordinator, who trained me on the ventilator, to discuss what could have gone wrong. “It sounds like you made the right choices. Sometimes patients don’t tolerate the portable ventilator well, and from what the staff told you, it sounds like there’s been a history of that with this patient.” We trouble-shoot the ventilator and determine that everything’s working properly.

Following this, the crew and I go on another ventilator call that runs smoothly, with no issues. My first question for the staff is, “is there any reason you think the patient might not tolerate this well?”

Step 5: Integration.

I would describe the concept of integration in one of two ways: “the problem is solved,” or “the conflict neutralizes.” I make a distinction between the two, because they’re not the same thing.

In some ways, we did solve the problem. By taking Atlas off the ventilator and manually bagging, we were able to stabilize him. However, the transport had to be canceled, causing Atlas to remain in the ICU for the time at hand. In some ways, you could argue that we created the problem to begin with. I didn’t receive information beforehand that Atlas had issues on the portable ventilator in the past, forcing me to make a quick decision in the moment.

However, we called for help, kept him alive, stabilized him, and there was a deep learning experience for the entire crew. The conflict neutralized, and I can attest that the experience became “integrated” into my current mindset and practice.

As healthcare professionals, we frequently contend with critical situations, inviting a number of overwhelming external stimuli, and to sustain life, we trust our training. But how do we remain centered? How do we use this stress as a vehicle to become better?

When something challenging, or even terrible, happens in our lives, it can be hard to trust that we’ll feel safe again. A health issue or a traumatic surgery can alter a person’s life. A “call gone wrong” for paramedics can cause internal trauma that’s stored within. Honestly, it’s difficult to defend that this suffering can be in any way positive, as it has the potential to destroy our lives. At the same time, we need challenges in order to grow, to let go of who we thought we were, and to go deeper. I think it’s a balance.

Though painful, it’s vital for us to surrender old rituals, find the tenacity to adopt new ones, shed old skin, and metamorphosize. So often, we’re existing under forces more superficially powerful than us, and we must rely on our deeper values, internal strength, and resilience to pull us through.

Whether you’re the paramedic, or the patient on the ventilator, an array of challenges will test you, and the pressure may be significant. As human beings, our suffering can feel so overbearing, that we can’t fathom withstanding it. But eventually, the problem will be solved, or the conflict will neutralize, and intuitively, I feel that everything will be alright in the end.

References

1. Bhatti N. Tracheostomy. Johns Hopkins Medicine [Internet]. Baltimore, Maryland: Johns Hopkins University. 2024 [Cited 2024 Mar 20]. Available from: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/tracheostomy
2. Atlas (mythology). New World Encyclopedia [Internet]. 2020 Jul 23 [Cited 2024 Mar 20]. Available from: https://www.newworldencyclopedia.org/entry/Atlas_(mythology)
3. Evening on Karl Johan (1892) by Edvard Munch. Artchive [Internet]. 2024 [Cited 2024 Mar 20]. Available from https://www.artchive.com/artwork/evening-on-karl-johan-1892-by-edvard-munch
4. Owens, W. The Ventilator Book. 3rd edition. Columbia, SC: First Draught Press; 2021. Chapter 1: Initial Settings; p. 17-26.
5. Stan, D, Tatu M-D, Tatu AL. Psychosocial Implications of Patients with Tracheostomy – a Suggestive Example of Interdisciplinarity. BRAIN: Broad Research in Artificial Intelligence and Neuroscience [Internet]. 2021 Jul 19 [Cited 2024 Mar 20]; 12(2):308-321. DOI: https://doi.org/10.18662/brain/12.2. Available from: https://lumenpublishing.com/journals/index.php/brain/article/view/4468
6. Life with a Vent. From Med School to Life Support, When My World Shattered [Video]. Youtube [Internet]. 2021 Oct 10 [Cited 2024 Mar 20]. Available from: https://www.youtube.com/watch?v=NV_u874SynA
7. Bhatti N. Living with a Tracheostomy Tube and Stoma. Johns Hopkins [Internet]. Baltimore, Maryland: Johns Hopkins University. 2024 [Cited 2024 Mar 20]. Available from: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/living-with-a-tracheostomy-tube-and-stoma
8. Life with a Vent. How to Talk with a Tracheostomy Tube. Life with a Vent [Video]. Youtube [Internet]. 2021 Dec 12 [Cited 2024 Mar 20]. Available from:
   https://www.youtube.com/watch?v=FSL57g7iIN8
9. Blood Oxygen Level. Cleveland Clinic [Internet]. Last reviewed 2022 Feb 18 [Cited 2024 Mar 21]. Available from: https://my.clevelandclinic.org/health/diagnostics/22447-blood-oxygen-level
10. The Mechanics of Respiration. Medic Tests [Internet]. 2024 [Cited 2024 Mar 20]. Available from: https://medictests.com/units/the-mechanics-of-respiration
11. The Lungs. National Heart, Lung, and Blood Institute [Internet]. Last updated 2022 Mar 24 [Cited 2024 Mar 20]. Available from: https://www.nhlbi.nih.gov/health/lungs
12. Owens, W. The Ventilator Book. 3rd edition. Columbia, SC: First Draught Press; 2021. Chapter 7: Monitoring the Ventilated Patient; p. 77.
13. Duckworth RL. How to Read and Interpret End-Tidal Capnography Waveforms. JEMS: Journal of Emergency Medical Services [Internet]. 2017 Aug 8 [Cited 2024 Mar 20]. Available from: https://www.jems.com/patient-care/how-to-read-and-interpret-end-tidal-capnography-waveforms/
14. Accessory and Expiratory Muscles Activation During Spontaneous Breathing Trial: A Physiological Study by Surface Electromyography [Internet]. Front Med (Lausanna). 2022; 9: 814219. Published online 2022 Mar 10 [Cited 2024 Mar 20]. DOI: 10.3389/fmed.2022.814219. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8965594/
15. Stanton G. Bag-Valve Mask Technique in BLS: A Vital Resuscitation Tool. American Training Association for CPR [Internet]. 2024 Mar 15 [Cited 2024 Mar 20]. Available from: https://www.uscpronline.com/bls/bag-valve-mask

Steve Vernak, EMT-P

Steve Vernak, EMT-P, is a paramedic working in a private ambulance in Cleveland, Ohio. He expresses his experiences in life and EMS through paintings and music.

• Steve Vernak, EMT-P

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  Our Life Force, the Breath! A BiPAP Story.