Tuesday, 12 August 2008

This isn't how I imagined it would be

Throughout our medical training, doctors are taught what needs to be done in certain emergency scenarios. We have lectures on how to deal with heart attacks, perforated bowels, ectopic pregnancies etc… etc… and the point of all this is that we know how to recognise and deal with these emergency situations should they ever occur. The thing is, when things are going bad in front of you, it doesn’t happen like it says in the books and things don’t ever go how you’ve imagined they would.

Let me tell you about what happened yesterday.

I was rostered to spend the afternoon working on the High Dependency Unit (HDU), so after lunch I wandered down and introduced myself to the doctors and nurses on duty. One of the registrars was putting in a central line (subclavian) on a post-op patient, so I popped my head round the curtain to watch her do her thing. I’m still not as good as I’d like to be at inserting central and arterial lines and I find it quite useful to watch other people do them so I can pick up on one little tricks they may use. Harry, the patient concerned, had arrived from the surgical wards after having an operation a couple of days before. Apparently, Harry hadn’t been doing so well with his breathing and was on a non-invasive ventilator and on the morning ward-round, the consultant was debating whether or not to sedate him and put him on an invasive ventilator. Jane, the registrar was having a real struggle getting the central line into Harry’s subclavian vein, but she got there eventually and I wrote a request form for a routine chest X-ray at some point in the afternoon. The time is 14:25

After Jane has cleared up her stuff, I stay by Harry’s bed and look at his notes to see exactly what operation he’s had and what happened in the post-op period that ended up with him being admitted to HDU. Harry is drowsy and only just rousable, but he’s been like that since his arrival onto HDU earlier in the morning.

The alarms on the non-invasive ventilator start going off. Ventilator alarms and alarms in general are really common on HDU and ITU, so I’m not particularly interested at this stage and Emily, Harry’s nurse wanders round to the other side of the bed to investigate what’s wrong.

Emily says “Er, ‘Mick’ is it?”
“Michael.” I correct her
“Sorry, Michael. I’m not really happy with this ventilator – it’s saying that Harry’s tidal volumes are only 200ml” (this means that Harry is only taking tiny breaths, despite being on a ventilator – this shouldn’t happen – something is wrong)
I wander roung and have a look. “Is there a leak round the mask?” I ask. (Non-invasive ventilators require a tight fitting oxygen mask on the patient’s face so they can push oxygen into their lungs when the patient breathes. If the mask is not tight enough, the oxygen leaks out round the side and the ventilator doesn’t work properly).
“No,” comes Emily’s response, “these machines are really clever and they give you a number that tells you the amount of leak and Harry’s hardly got any at all.”
I really have no idea why Harry isn’t breathing properly but a quick glance up at the monitor tells me that all his observations are fine, so I’m not overly concerned. I give a mental shrug, tell Emily I don’t know what the problem is and go back to reading his notes.

The ventilator is still saying the same thing but on the monitor, Harry’s oxygen saturations start to change. Sats should be 97-100%, especially if someone is on oxygen and on a ventilator.
Emily and I watch as Harry’s sats go 97… 94… 91… 89… 85… This means that he is dying.

Emily and I look at each other, we’re going to have to do something. “We’re going to have to bag him,” Emily says.
I agree and while Emily takes Harry’s ventilator mask off, I reach for the “bag and mask” behind Harry’s head and turn on the oxygen as high as it will go.
The sats monitor read 77… 74… 70… 68… 65…
I hold the mask onto Harry’s face and do some airway manoeuvres while Emily squeezes the bag and pumps vital oxygen into Harry’s lungs. It works, the monitor reads 70… 82… 88… 93… and then we’re back to 100%
“I don’t know why that happened” I say as Emily and I connect Harry back up to his non-invasive ventilator. It’s now 14:39

Exactly the same thing happens, Harry’s sats go down again and once more Emily and I have to bag and mask ventilate him to get them back up again. This time, we call for help and Jane and Anil (another anaesthetic registrar come to see what’s going on).

Jane asks to take over ventilation to “see how he feels.”
Anil performs a quick respiratory examination. Bilateral breath sounds, chest clear at the front, trachea central. He asks Emily to call X-ray as we need an urgent portable chest X-ray on this man.

Anil asks me to draw up some intubation drugs, so I go and ask Debbie, the senior nurse in charge to show me where the thiopental, suxamethonium, atracurium and metaraminol are kept. Harry’s observations (“obs”) are still in the normal range but he’s more or less unconscious now.

I return with the drugs drawn into syringes. Jane is maintaining ventilation. Harry’s obs are still normal. The radiographers arrive and we all help position Harry for his chest X-ray.

The Xray is done, Jane says that it’s getting harder and harder to breathe for Harry. I do a repeat respiratory examination – there are very few breath sounds in either lung and the trachea remains central.

Harry’s blood pressure starts to fall from 163/95 to 100/40 over about 30 seconds. Anil tells me to give some metaraminol and I give 2mg. By this time, a couple of other nurses and the medical students have arrived. Anil asks the medical students to access PACS and see if Harry’s chest X-ray is on the computer system yet. It isn’t. Emily and one of the other nurses go off to get the resuscitation trolley.

The metaraminol hasn’t made much difference, Harry’s blood pressure is no 75/45 and falling. Sats are still 100% thanks to Jane’s ventilation, but she says that she can hardly breathe for him at all now. Ominously, Harry’s heart rate drops from 115 to 85 to 55 to 45 and keeps falling. Anil grabs some atropine from the resuscitation trolley and squirts it into Harry’s veins.

Harry’s heart rate starts to rise again until it levels out at about 130bpm. Emily and I get the laryngoscopes and endotracheal tube ready for Jane, should she need to intubate. Anil asks the medical students again if the X-rays are ready. “No,” comes the reply.

The atropine had brought the Harry’s blood pressure up to about 100/40 but now it is dropping down again. Jane continues ventilating but despite this, Harry’s sats start dropping again – 100… 97… 94… 92… 88… 86… I have a look at the bed so I know how to flatten it out should we need to start CPR

The X-ray is up!” comes a shout from the male medical student
“What does it show?” asks Anil
“Errr…. Maybe collapse? Maybe consolidation?” comes the tentative reply
Anil runs over to the computer screen

“There a huge pneumothorax there!” he exclaims. “Pass me that orange venflon.”
Anil picks up the venflon and plunges the needle into Harry’s chest (2nd intercostal space, mid-clavicular line)
There is a hiss of air as the pressure in Harry’s chest is released

Immediately Harry’s sats come up again to 100% and his blood pressure immediately returns to normal.

I’ve never seen someone have a tension pneumothorax before, but I know all about them from the textbooks. Whilst, Harry had all the signs of a life-threatening event, he didn’t actually have the signs that made us think “this is a tension-pneumothorax.” When I’ve studied the consition in books, I’d hoped that if I ever had to deal with a real-life tension-pneumothorax, the diagnosis would be quite obvious and I’d know what to do. Whilst, we all knew what to do, like is so often the case in medicine, the diagnosis was not at all obvious at all and we didn’t know what was going on until we saw his chest X-ray.

You’re not meant to do chest X-rays on suspected tension-pneumothoraces because patients die before the doctors see the results. Luckily for us, our radiology department managed to get the X-ray results back to us in less than ten minutes.

Jane put a chest drain into Harry’s chest and we’ve now sedated and intubated him in order to give his body chance to heal itself.

This was a definite “learning experience” for me.


Bright-eyed said...

Fascinating account - a case we had back in 1st year centred on a tension PTX (subsequent to a stabbing). Interesting to read how it's the first you've encountered, but also how the medical team go about making the diagnosis! Well played all round in the end.

madsadgirl said...

A fascinating and very powerful post. It does go to show that you can't learn everything from the books, and there is nothing like a real experience to complete your education.

Anonymous said...

Things are simplified for teaching; the real world is different. This is why we need experiential learning and not all these courses we have to send you on.

It is easier when you are spoon fed the story but on reading this I at first thought that I wouldn't have used the sublavian because of the risk of a pneumothorax and by the time I got to 'The alarms on the non-invasive ventilator start going off' I thought I would go to bottom line and see if my diagnosis was correct. But I am much older than you. And a chest physician. The important thing is to gain experience, learn and always try and put the pieces of the jigsaw together to get to the diagnosis. The advantage I had in reading this was that all the other things going on that distracted you and turned out to be irrelevant you left out of your story.

That's another thing you should remember - it is much easier for those who were not there at the time. There will always be people like me who will say it was easy when it wasn't really.

And I think your conclusions about the value of a CXR in this situation are correct - even though that is heresy.

Dr Michael Anderson said...

Bright Eyed - Thanks, Anil suspected the diagnosis before we had the Xray and we had big venflons and a chest drain ready, but the problem was that Harry had never had any definitive signs of a tension pneumo

Madsadgirl - you're right, i think I'll always remember what happened with Harry so next time, it should be easier to spot (hopefully)

Anon - Thanks for your comments, Jane went for the subclavian approach because of the lower risk of infection/accidental removal this was especially important because the surgeons were considering TPN. You are quite right though that it has a much higher risk of a pneumothorax, which in a ventilated patient can easily turn into a tension pneumo.

You are also quite right about other distracting things that I've left out. During the time period I wrote about I got bleeped by the secretary wanting my GMC number so she could put me on the theatre computer system, Anil asked me how much anaesthetics i've done previously, Debbie went to get another nurse off her break as more hands were needed, I explained to the med student that Harry's tachycardia was caused by atropine - not hypovolaemia etc... etc... there are dozens of details that I have left out

Oliver Smith said...

Life is not simple!

Good job!

steph said...


That would make a great scene in ER!

But it's left me still wondering... if the central line was to blame for the pneumothorax, why was Harry's breathing deteriorating before he came to HDU?

AdamF said...

Like Anon, my first recation was: tension pneumothorax.
Like him, though, I'm older and wiser for several stints in ITU/HDU.
Textbooks always present the classical descriptions of things, and are usually printed in black and white. In the real world, it's all shades of grey, though.
Good job to you all though...another life saved!

SSS said...

Blimey. I felt sick when you described the sats dropping. Great post.

Anonymous said...

C'est la vie.

A subclavian in a ventilated patient (even NIV)is asking for trouble...!

A useful learning experience for all concerned, especially the medical students.