Birthday and Breathing

Brooke came to the long-term skilled nursing facility at South Davis for vent weaning—that’s the immediate goal here, and this is a facility that specializes in vent weaning. He’s been here almost exactly a month now. But vent weaning has been a long, rocky road, the last weekend in particular. There had been some promising developments earlier on—at one point, he had managed 53 minutes off the vent, but that had seesawed down to 20 minutes, then up again but down to10, then down to 5. It was about then that the Tinker-Bell call for the Virtual Birthday Party went out—help keep that light brightly alive. Send cards, e-mails, scribbled notes, I’d urged, anything. The vent-weaning stuff had gotten pretty discouraging, despite all the positive messages the respiratory staff kept sending—but the numbers weren’t there. Brooke said he was confused by the various strategies—go for long times, go for deep breaths and high volumes, etc.—and finally after some consultation a uniform program was put together. Train the way you do for a marathon: don’t start out by trying to run all 26 miles as once, but work up to it in short pieces. But it was still hard, and still discouraging, to still be on the vent after four long months.

The new program has involved doing 15, then 20, then 25 minute sessions off the vent, twice a day, just with a mask over the trach opening to supply humidified, warmed air (this is what the nasal passages normally do, but it doesn’t happen if your air comes in through a hole in your throat), with a little extra oxygen. Even these relatively short sessions have been very, very arduous.

But this morning, he says, was qualitatively different from all the other mornings. From the beginning, he says (and now I’m taking dictation from him), he knew he was feeling a new strength, partly because he could visualize his diaphragm for the first time (thanks to a quick anatomy lesson from Mike during a brief visit here) and what inhalation and exhalation were actually doing, how they were affecting the diaphragm. At a certain point, about midway through the 30 minutes, he began to feel that his breathing was not only stronger, but that every breath had become a joy, and that he had suddenly realized that the pleasure of breathing was something that was an end in itself, and that he needed nothing else. For the first time in his life, he says, he experienced what he had always been looking for in Buddhist meditation, but had never actually found: the full life of breath. By the time the 30 minutes were over, he says, he had attained a serenity beyond anything he ever expected to experience in his life.

If you want confirmation of this, ask Pat Zwick—who saw it on Brooke’s face when Pat arrived, shortly after Brooke woke up from his nap following the morning session of trach trials. Pat told me about it on the phone: he said he’d never seen an expression like it.

By this evening, Brooke and I have been enjoying a lavish Chinese dinner, take-out, a present from an old student of his who now lives in Washington DC, and a bottle of beer (Brooke’s first, another symptom of return to the world). But breathing is another matter again: now it’s the work of the vent, and life returns to hospital-normal. We’re still reading the hundred cards that came in to celebrate the virtual birthday—wonderful, absolutely wonderful—and it tempting to think that the Tinker Bell phenomenon has actually played a role.

There are still many more steps in vent-weaning to go. Brooke has been initiating his own breaths for quite some time and has been meeting the first goal: CPAP (continuous positive airway pressure) all through the day, though back on pressure support at night. The trick now is to strengthen the diaphragm. But there will be many many more trach mask trials, until he can do trach mask all day long, with CPAP at night. Then comes trach mask 24/7 for 10 days, and they take the vent out of the room (though, of course, this is a hospital, and it’ll be just down the hall). Somewhere in there comes a speaking valve, and full-time cuff deflation (when incidentally he can talk all the time), then a cap on the trach, then still more steps involving secretion control, and then the whole thing is done. This will take weeks and weeks, maybe months. And there still aren’t any guarantees. But it is looking better now, and easier (thank god) for him—it has been a very difficult business.

Brooke has done a lot of meditation over the years, meditation that focuses on breathing, but the experience of this morning was something that he never expected to attain. And in a hospital, at that, mostly paralyzed, with a respiratory therapist watching numbers on a monitor and bells going off everywhere. Maybe that’s the point—experiences like this come when you least expect them and in settings that would seem as unconducive as one could imagine. They’re something at which you can’t aim and which you can’t plan, but astonishing, ecstatic, when they happen.