Who breathes?

Folded in, contracted, like an umbrella, rusted together, welded stiff. Curled in agony, curled like a fetus. Malnourished--the rehab in Virginia hadn't been doing their job. Tried to put pillows between her knees, couldn't pry them apart. Veins flat and flaccid, bones piercing the skin from the inside out. Jaw clenched like a pit bull, the teeth loose and dirty from lack of oral care, bed sores, break down, perfed stomach, septic. Cold. Warmed her up. The only thing that moves are her eyes--her left eye seems to see and perceive. I didn't get this at first.
I've become hard. I watch students and new nurses come into our unit and they're so soft, so compassionate and caring. Slow. Gentle. But if you're going to become good at this, you have to make a compromise between fast and gentle. And sometimes gentleness and kindness aren't what you think they are--but that's a different meditation. I have lately very few patients that really get to me, but I wanted to throw myself over this child and weep.
First time on a motorcycle. 17. Went for a ride on her best friend's (a boy) new motorcycle. Climbed on the back. Here she is in our unit.
Old head injury--over 7 months. I don't usually see them after they leave here and go to rehab.
She looks like a concentration camp victim.
"Is this normal? Is this what happens? Was she neglected at the rehab?"
Cindy Chang, our impeccably dressed, workaholic, incomprehensible chinese unit dietition answers me, "is what happens, head injury, no muscle, cachexis. See it all time."
But I'm still horrified. "But couldn't we fatten her up somehow?"
She smiles. "Obesity big problem in America."
"Shut up."
When the girl doesn't like what we're doing, she bites down and holds her breath. She's intubated, because she's been septic. But it resolved miraculously quickly. God, young bodies are miracles. So are old ones. But young ones, even compromised. Boom boom boom. Life force surging through. She hates the tube.
I try all weekend to get her extubated. Over the weekend, we have, unfortunately, our laziest nastiest respiratory therapist working. She just wants to keep her intubated. The residents, new to the floor are scared and intimidated. The RT keeps finding excuses.
"She'll get pneumonia."
"Her lungs are clear," I argue
"She doesn't have the ability to clear her secretions."
"So she should stay intubated all the time? She wasn't intubated in rehab."
"We might have to go to the OR again."
"Anesthesia could intubate her again...I believe that's part of their skill set..."
I don't want to get to nasty with her, because, in the long run, I need the good will of this fucking RT more than winning my point of extubating this girl 2 days early. It's like a chess game around here, some times. Know your pieces, know how they move. How far you can push them, when you can get them into position for someone else to take them off the board. If it was life threatening, I'd get nasty, but we aren't yet to the critical point of risking VAP (ventilator acquired pneumonia). I could push it faster, but in the next room, someone is busy dying--on pressors, desatting, and this RT isn't good with stress--to be effective with the other, more critical patient--but at 1500 on Monday, after battling it for 4 days and being put off--I finally get hot. I drag Baggins, our diminutive fellow into the room. The girl's lips are swelling and blistering around the tube, the tape cuts into her cheeks.
"RT didn't extubate?" he says, surprised.
"RSVI's too high--but that's her baseline. It's just an excuse. All day."
We get the RT in--
"We're extubating now." He says.
"Her RSVI's too high. And she holds her breath when she's mad"
"Let's just give it a shot."
"Okay--I've got to go check the ventilators on the other side, and go to CT scan, but then I'll do it." Hedging.
"Okay," Baggins says, "I'll go ahead and do it. You have your pager, right?"
Sometimes, I hate Baggins, and sometimes I love him.
So we extubate. The girl sighs a long sigh. Then starts breathing and falls asleep. Sats high. Jesus.
Would you do that to your kid?
In between our usual inane conversations about things like excess body hair, we talk about this.
Quality of life.
But how can you ascertain that? And you know, you're not here just for yourself. You're here more for other people. We fear suffering so much, we say we fear causing it, but we cause it all the time. I don't think this is true, when people say that. I think they fear something else. If it were my kid, and he was still looking out at me through his good eye, and holding his breath when he got mad and biting nurses, I could not let him go. We think a life is worth something only if meets certain standards, and this error in thought is what leads us to both passively and aggressively commit acts of violence on others--others of other races, of other creeds and faiths. It's why we're able to go to war in Iraq, it's why we're able to ignore the Sudan, it's why we're able to ignore the poor of our own country. Same error--we think we're God and can decide when a life is worthwhile and when it's not.
Who breathes you?
Who is breathing?
The girl, the creature, skin and bones, lies in our tower, our twilight ship. Breathing just as surely as you and I.
Breath of the world. Breath of all. We can only serve.
That's my 1/2 hour