1. Cappell, Mitchell S. MD, PhD

Article Content

Nurses often have in-depth, personal interactions with patients and their families. But are personal interactions, or even acts of kindness, relevant in the current era of quantitative, scientific, and technology-driven medicine (Huh & Rex, 2008; Pierce, Bozic, Hall, & Breivis, 2007a, 2007b)? Can they improve the medical outcome? I herein report my own case, in which one nurse's singular personal interactions played a major role in preventing reintubation and reinstitution of mechanical ventilation. This report illustrates the enduring value of nurse-patient interactions and acts of kindness in medicine. Publication of this report was approved by the Human Investigation Committee of William Beaumont Hospital.


As a 55-year-old academic gastroenterologist with a history of mild hyperlipidemia, moderate hypertension, and one myocardial infarction in 1999 and status post two coronary artery stents placed in 1999 and 2000, I underwent quintuple coronary artery bypass surgery at the hospital, where I was Chief of Gastroenterology in November 2008, after cardiac catheterization revealed five coronary artery stenoses. Very soon after surgery, I was extubated based on a 98% oxygen saturation, a negative history for pulmonary disease, and no history of smoking.


Soon thereafter, my oxygen saturation declined to 89%, despite supplemental oxygenation. During the next 4 days, my nurses advised, pleaded, cajoled, admonished, and ordered me to inhale more deeply, cough more strenuously, and sit longer on a chair. Their interventions were unsuccessful, however; my oxygen saturation remained borderline. Deep inspiration and strenuous coughing were too painful. Sitting on a chair for long periods did not resolve the problem. I was nearly reintubated several times, but each time I forced myself to breathe harder and faster until my oxygen saturation level rose above the danger zone.


On postoperative day 5, one nurse devoted considerable time on coaching me to improve my oxygenation and avoid reintubation. She explained, "We will work as a team to improve your breathing and coughing to increase your oxygen saturation. I know and appreciate that you have severe pain, and that breathing deeply or coughing forcefully exacerbates this pain, but you have to breathe deeply to open up more of your pulmonary alveoli to prevent pulmonary shunting and you have to cough more forcefully to clear your airway of mucus to improve your oxygen saturation." I tried to inhale deeply, but my inhalation was arrested because of pain. I tried to cough my way to a higher oxygen saturation, but my coughing was likewise limited by pain. This nurse arranged for my physicians to prescribe higher doses of analgesia to help me breathe more deeply and cough more forcefully without pain. This, however, was also unsuccessful, as was having me sit on a chair for prolonged periods. She spent considerable time with me using an incentive spirometer, but this did not help either.


Finally, after 9 hr without success, she waved a pulmonary catheter at me and diplomatically stated, "Your cardiac surgeon ordered that I insert a pulmonary catheter because you are not coughing forcefully enough to remove the mucus blocking your airway. I would not have to do this if you could cough more forcefully." I responded, "I will try." I coughed but my coughs were no deeper or more forceful than before. I did not cough up anything. When she then inserted the catheter through a nostril just beyond the nasopharynx, I felt sharp, visceral pain. I held up my hands like a soldier surrendering in battle, or perhaps more like a traffic cop trying to stop a speeding motorist. She grinned victoriously as she withdrew the catheter and said, "You understand you have to cough forcefully, otherwise I must reinsert this catheter?"


Fearing the evil catheter, I coughed-despite pain-longer, deeper, and more forcefully than ever before until a large, thick, purulent, and ugly mucus plug shot out of my mouth and flung across the room onto the wall!! I coughed as forcefully as the demon vomited in the movie The Exorcist (Roizman, 1974). The nurse laughed as she dodged the flying missile, frowned as she removed the adherent mucus from the wall, and smiled when my oxygen saturation abruptly rose from 90% to 98%. It was a home run, the shot heard round the world (Emerson, 1899; Prager, 2006)!! Although my oxygen saturation drifted somewhat lower after this incident, I never again came close to reintubation, was transferred out of the ICU the next morning, and was discharged home 3 days thereafter.


At discharge, my oxygen saturation was borderline without supplemental oxygen, so I was discharged with home oxygen therapy. I determinedly never used supplemental oxygen at home as I rapidly brought myself to walking 3 miles per day within 1 week after discharge. I attribute my avoidance of reintubation and of home oxygen therapy to my persistent nurse as well as my own zealous cardiac rehabilitation.


The nurse's successful strategy included (1) extreme sympathy for my illness, and acknowledging my difficulty in breathing deeply and coughing forcefully due to pain, (2) offering a team approach in which she would coach me to breathe deeply and cough forcefully, (3) increasing the analgesia to help me breathe deeply and cough forcefully, (4) progressively increasing the strength of persuasion to achieve my compliance, and (5) finally, when nothing else worked, offering me a choice between inserting a painful, endotracheal catheter versus forceful coughing. This nurse, with her strategy, achieved what numerous nurses, physicians, and technicians had unsuccessfully attempted. As long as patients are people, with emotions and feelings, personal interactions and acts of kindness will play an important role in nursing. This case report demonstrates the enduring value and importance of a caring, interactive, and persistent nurse and of acts of kindness despite the ever-increasing quantitative, scientific, and technology-based nature of medicine. While illustrated for cardiothoracic surgery, this value and importance should pertain to the endoscopy nurse.




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Pierce, R. G., Bozic, K. J., Hall, B. L., & Breivis, J. (2007b). Health care technology assessment: Implications for modern medical practice: Part II. Decision making on technology adoption. American Journal of Orthopedics, 36(2), 71-76. [Context Link]


Prager, J. (2006). The echoing green: The untold story of Bobby Thomson, Ralph Branca, and the shot heard round the world. New York: Vintage Press (Random House). [Context Link]


Roizman, O. (1974). Filming "The Exorcist". American Cinematographer, 55(2), 154-157. [Context Link]