Assalammualaikum.
I am an Anaest MO. That means I work in both the operating theatre (OT) as well as the Intensive Care Unit (ICU).
Undeniably, the patients in ICU are very critically ill patients - they require intensive care and resuscitation and monitoring to keep them alive, of course dengan izinNya.
Some of these patients sadly, after surviving the most critical part of their illnesses, they don't recover to their previous state.
They might suffer a stroke along the way, or the prolonged acidosis in them have affected a good portion of their brain function permanently, or just in general, became very weak and thus will take a long time to recover. These are the state ICU doctors call "Poor/Slow GCS recovery".
It just mean that their mental state and muscle power takes very long to recover.
And most, if not all of these patients are intubated.
Intubation is a way of delivering oxygen and ventilation to someone through a tube down his/her throat and straight into the lungs. And we can't keep the tube in the throat for long. There are a lot of problems tagging along with a prolonged endotracheal intubation.
So we will usually counsel the family for tracheostomy. Tracheostomy is basically an operation in which the surgeon makes a hole in the front part of the throat/trachea, below the vocal cord and passes a tracheostomy tube through it. The tube is the same size as the endotracheal tube, but it is shorter.
It bypasses the whole chunk of throat muscles - the muscles which a patient needs to control in order to breathe properly, the muscles which a very weak patient might not be able to control.
Living with a tracheostomy is not exactly easy.
It affects not just the patient, but also the family members. More so if the reason the tracheostomy was performed was "Poor GCS recovery"
That means the patient will be almost vegetative, relying on the family members to care for him/her.
Normal people produce phlegm all the time - we then either spit them out or swallow them subconsciously.
But tracheostomi-ed patients can't do that. Coupled with the lack of ability to filter inspired air, patients will produce a lot of sputum especially in the earlier months. Thus family members MUST MUST MUST be able to perform suction of the airway - imagine putting in a smaller tube into the tracheostomy tube and suck all the mucus out. And it definitely is not for the faint-hearted. The patient will cough and gag and the secretions are not going to be clean and white. They are basically phlegm, spit, whatever you want to call it. They are not nice. They are gross.
So frequent suctions need to be done. And the suction is not just once early in the morning, and then once more in the evening when everyone's back from work. The patient's airway will be blocked by then. There need to be a dedicated carer to care for a trachy patient - to perform suction every few hours, more if the secretions are copious. See the commitment we need from family members? See why doctors don't perform a tracheostomy on just anyone?
I have had a few cases where the tracheostomy patient dies at home, some was even almost deliberately killed by their family members. One mother allegedly covers the vegetative son's face with a pillow to end his life. But hey, he wasn't breathing through his mouth nor nose! The son's lifeline was that tracheostomy tube, mom! Please don't ask me what happens to the son and the mother, I don't know. But I know things like these happen. Imagine what kind of frustration must the mother must have felt to try and end her son's life. Perhaps she thinks her son is not even living anymore, just laying there vegetative. Perhaps she thinks it might be better and easier for the son that way.
Tracheostomy is also not an easily reversible decision. There is no turning back.
In intubated patients, when the family and doctors agree, we can withdraw our treatments when we see there is no more that we can do. We can remove the tubes and let nature takes its course.
It is harder to do that once a tracheostomy tube is there. It is hard to withdraw treatment from tracheostomy, as we dont really remove the trachy tube from the body to withdraw treatment.
It always breaks my heart when I need to counsel family members for tracheostomy. Most of these patients are elderly, and the family I counsel are the children.
I need to really knock into them the reality of tracheostomy. Knock knock knock - these are what you signing yourselves for if u agree for tracheostomy. You mother or father will still be lying there, weak and very dependant on you. Tracheostomy is not going to fix it. Tracheostomy is ONLY to deliver the air into them so that they can breathe easier.
It doesn't fix their brains, it doesn't make their hearts stronger, nor will it cure the infection your mother / father might still be having.
And you now have to discuss with your family members - who CAN and who WILL take care of this parent?
Brutal question huh?
If they can't agree on a carer between them, then doctors can't perform the tracheostomy.
Then they might feel they are not trying the best for their parents - they will feel the guilt of not going all out for their parents.
But is tracheostomy really the best though in these patients?
If they DO agree for tracheostomy, but then later are unable to care for their parents, that will be an even greater sin.
The sin of menzalimi mak ayah sendiri. The sin when they let their mother father die drowning in their secretions, because there are no one to care for the parents. The sin of hoping and thinking "Baik lagi mak ayah mati".
But if they can't agree for tracheostomy - it might make them feel like they are giving up on their parents.
Tough, tough question.
Maybe this is the reason why many medical practitioners in the west are tyring to advocate an advanced directive - although it will be very hard to implement and has many loopholes in it.
A quesiotn for you:
Would you want tracheostomy done onto you in the future?
-Because life is a test-
[p/s: The terms in this post is simplified to suit the non-medical readers]
-AkMaR-
http://nur-akmar.blogspot.com
I am an Anaest MO. That means I work in both the operating theatre (OT) as well as the Intensive Care Unit (ICU).
Undeniably, the patients in ICU are very critically ill patients - they require intensive care and resuscitation and monitoring to keep them alive, of course dengan izinNya.
Some of these patients sadly, after surviving the most critical part of their illnesses, they don't recover to their previous state.
They might suffer a stroke along the way, or the prolonged acidosis in them have affected a good portion of their brain function permanently, or just in general, became very weak and thus will take a long time to recover. These are the state ICU doctors call "Poor/Slow GCS recovery".
It just mean that their mental state and muscle power takes very long to recover.
And most, if not all of these patients are intubated.
Intubation is a way of delivering oxygen and ventilation to someone through a tube down his/her throat and straight into the lungs. And we can't keep the tube in the throat for long. There are a lot of problems tagging along with a prolonged endotracheal intubation.
 |
| An intubated patient. [Source] |
So we will usually counsel the family for tracheostomy. Tracheostomy is basically an operation in which the surgeon makes a hole in the front part of the throat/trachea, below the vocal cord and passes a tracheostomy tube through it. The tube is the same size as the endotracheal tube, but it is shorter.
It bypasses the whole chunk of throat muscles - the muscles which a patient needs to control in order to breathe properly, the muscles which a very weak patient might not be able to control.
 |
| Tracheostomy Illustration . |
 |
| Tracheostomy. [Source] |
Living with a tracheostomy is not exactly easy.
It affects not just the patient, but also the family members. More so if the reason the tracheostomy was performed was "Poor GCS recovery"
That means the patient will be almost vegetative, relying on the family members to care for him/her.
Normal people produce phlegm all the time - we then either spit them out or swallow them subconsciously.
But tracheostomi-ed patients can't do that. Coupled with the lack of ability to filter inspired air, patients will produce a lot of sputum especially in the earlier months. Thus family members MUST MUST MUST be able to perform suction of the airway - imagine putting in a smaller tube into the tracheostomy tube and suck all the mucus out. And it definitely is not for the faint-hearted. The patient will cough and gag and the secretions are not going to be clean and white. They are basically phlegm, spit, whatever you want to call it. They are not nice. They are gross.
So frequent suctions need to be done. And the suction is not just once early in the morning, and then once more in the evening when everyone's back from work. The patient's airway will be blocked by then. There need to be a dedicated carer to care for a trachy patient - to perform suction every few hours, more if the secretions are copious. See the commitment we need from family members? See why doctors don't perform a tracheostomy on just anyone?
I have had a few cases where the tracheostomy patient dies at home, some was even almost deliberately killed by their family members. One mother allegedly covers the vegetative son's face with a pillow to end his life. But hey, he wasn't breathing through his mouth nor nose! The son's lifeline was that tracheostomy tube, mom! Please don't ask me what happens to the son and the mother, I don't know. But I know things like these happen. Imagine what kind of frustration must the mother must have felt to try and end her son's life. Perhaps she thinks her son is not even living anymore, just laying there vegetative. Perhaps she thinks it might be better and easier for the son that way.
Tracheostomy is also not an easily reversible decision. There is no turning back.
In intubated patients, when the family and doctors agree, we can withdraw our treatments when we see there is no more that we can do. We can remove the tubes and let nature takes its course.
It is harder to do that once a tracheostomy tube is there. It is hard to withdraw treatment from tracheostomy, as we dont really remove the trachy tube from the body to withdraw treatment.
It always breaks my heart when I need to counsel family members for tracheostomy. Most of these patients are elderly, and the family I counsel are the children.
I need to really knock into them the reality of tracheostomy. Knock knock knock - these are what you signing yourselves for if u agree for tracheostomy. You mother or father will still be lying there, weak and very dependant on you. Tracheostomy is not going to fix it. Tracheostomy is ONLY to deliver the air into them so that they can breathe easier.
It doesn't fix their brains, it doesn't make their hearts stronger, nor will it cure the infection your mother / father might still be having.
And you now have to discuss with your family members - who CAN and who WILL take care of this parent?
Brutal question huh?
If they can't agree on a carer between them, then doctors can't perform the tracheostomy.
Then they might feel they are not trying the best for their parents - they will feel the guilt of not going all out for their parents.
But is tracheostomy really the best though in these patients?
If they DO agree for tracheostomy, but then later are unable to care for their parents, that will be an even greater sin.
The sin of menzalimi mak ayah sendiri. The sin when they let their mother father die drowning in their secretions, because there are no one to care for the parents. The sin of hoping and thinking "Baik lagi mak ayah mati".
But if they can't agree for tracheostomy - it might make them feel like they are giving up on their parents.
Tough, tough question.
Maybe this is the reason why many medical practitioners in the west are tyring to advocate an advanced directive - although it will be very hard to implement and has many loopholes in it.
A quesiotn for you:
Would you want tracheostomy done onto you in the future?
-Because life is a test-
[p/s: The terms in this post is simplified to suit the non-medical readers]
-AkMaR-
http://nur-akmar.blogspot.com
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