All 330 pounds of Joey were lying in the intensive care unit, transferred from an outlying facility after he was resuscitated.  The other hospital had him on a benzodiazepine infusion to calm him down in his delirium, but it made him stop breathing, and now poor Joey not only was withdrawing from alcohol, but his brain had been deprived of oxygen for a few minutes.  His brain did not need that. 

Joey's Mom has multiple sclerosis.  While she held his hand and sighed from her wheeelchair, his hapless Dad sat in the ICU, saying very little. I tried to toss a little hope their way by telling them that we plan to remove the breathing tube today or tomorrow, but he just replied, "That's what they say every day." 

Joey's Dad was right. We had tried day after day, but Joey flailed about dangerously in bed, getting close to  hurting himself or his nurse, when the massive doses of sedatives infusing into his veins were decreased.  The fanciest, newest of these drugs was dexmedetomidine, a drug that allows an undisturbed patient to"sleep" much of the time, yet be fully awake and alert when we touch him, speak to him, or move him. It works really well, but, its use is limited to 24 hours and its cost is 11 times that of the closest comparison drug. And "dex" is not the first-line drug for Joey's life-threatening problem: alcohol withdrawal-related delirium. 

Problem is, the first-line drug is the one that made him stop breathing before, in the other hospital.  That might have happened because it's lipophilic: it likes to hide in fat.  And it takes a while to saturate the fat stores in a person of Joey's size.  Once the fat is saturated, the drug starts working overtime and knocks out the drive to breathe. So it's a matter of careful monitoring and titration to keep patient and nurse safe from Joey's delirious flopping about while encouraging him to go on breathing. 

His Mom tells me that Joey is the sweetest son in the world.  He takes care of her, she says.

At age 34, Joey lives with his parents.  He drinks a lot. His cholesterol is too high, his blood pressure is too high, and he has diabetes. Despite eleven days in the hospital, his yellowed toenails need cutting, his skin is  flaking off in brownish scales, and his teeth need a dentist's attention. His legs have the characteristic brown tint of long-standing swelling caused by venous insufficiency, probably related to obesity and inactivity in his case. Some nurses misinterpret this as a sign of poor hygiene, which it is not.  

I turn down the lights, speak softly to Joey, and slowly decrease the sedation as we work to free him from the ventilator in small steps. I feel as if I'm guiding Joey across a tightrope stretched over a threatening chasm. If I fail, down goes Joey, and possibly his parents, too.

At the end of my shift, Joey is cruising along nicely with less help from the ventilator and lower doses of sedatives.  But now it's evening, and we do not remove breathing tubes from people like Joey in the evening; it's too dangerous when there are fewer people in the house in case of emergency.  The plan: let him rest overnight and take out the tube in the morning with a full team of health care providers to assist in case it goes badly.  Nobody likes "tubing" a 330-lb. person under good conditions, much less an emergency. 

The next morning, from my office at the school of nursing, I check the electronic health record and find that Joey is off the ventilator. 

Whew.  Made it across the chasm.