Monday, 13 April 2009

Blood on the dancefloor

The last patient on the emergency NCEPOD list is sitting in recovery after his operation. He’s drowsy, but comfortable and I’m chatting to Sara, one of the nurses when my pager goes off.

“Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please…”

I sigh and roll my eyes at Sara. “Just when you think all the work has been done, something else happens,” I say.

She smiles sympathetically as I turn and make my way out of Main Theatres towards A&E. To be honest, I’d been expecting this. I hadn’t had any trauma calls on my last couple of on-call shifts so, on the balance of averages, I was due one today.

Dealing with major trauma is one of the things that really worries me as a junior anaesthetist. Over the past few months, I’ve been making a big effort to improve my trauma management and get more experience of managing patients with major trauma. One of the things I wanted to achieve by the end of my ST2 year in anaesthetics was to be much more comfortable in situations just like this, and to some extent, I’ve succeeded. If I’d been in this situation a year ago, I’d be absolutely shitting it, but as I round the corner into the A&E resus room, I feel in control of my own emotions.

The first people I see are a couple of police officers looking intently at the scene that was unfolding in front of them. I give them a brief nod and headed into the resus bay.

The scene that greets me is bad. Very bad.

A young man lies on the casualty trolley screaming unintelligibly. He’s trying to trash around and two paramedics are trying their best to prevent him from hurling himself onto the ground. The bloody footprints of the hospital staff have created a perverse mosaic on the floor of the resus room as they desperately try and get control of the situation. A nurse has the man’s left arm locked in his vice-like grip in an attempt to keep it still as the surgeon is trying to shove a cannula into the man’s vein. I glance at the portable obs machine next to the trolley. It’s impassive display reads:

HR: -?-
BP: -?-
O2 Sats: 84%

Like I say, this is very bad.

Ken, the A&E charge nurse is trying to give this man some oxygen, but he screams again and thrashes his head from side to side.

“Are you the anaesthetist?” Ken, asks me.

“Yes, I am” I reply as I scan the bay for a pair of gloves to put on. The only box of gloves I can see contain small gloves, this has been a recurring annoyance throughout my medical career so far. I squeeze my goal-keeper hands into the gloves, quickly connect together an anaesthetic breathing circuit and turn on the oxygen. Ken stands aside as I plant my oxygen mask onto the patients face.

The patient looks horrific. His face is massively swollen to the extent that he cannot open his eyes and I cannot open them for him. The whole of his head is completely covered in blood, he is bleeding from his scalp, his cheek, his nose and appears to be bleeding from somewhere inside his mouth. My fingers keep slipping off his face as I try to hold the mask on to enable him to breath the vital oxygen.

Paradoxically, in the few moments that I’ve been there, I’ve been reassured by the situation. It’s probably not as bad as it looks. The mere fact that he is able to scream and fight means that he is not at the end of the road yet so, while things are undoubtedly very bad, they’re not yet critical. The surgeon has secured IV access and has moved on to examine the man’s torso.

“Can I have some suction?” I say and Ken passes me the Yankeur sucker which I put into this poor guys’ mouth. I suck blood, clots and saliva away from the back of his throat, which enables him to scream even louder.
"What's happened to this guy?" I ask. One of the paramedics starts to tell me the story, but to be honest I'm not taking it in at all. The patient is trying to sit up again and I lose my grip of my oxygen mask, which tumbles onto the floor.

“AAAAAAAARRRRRRGGGGGGGGGHHHHH!!!!!!!” he screams, but I notice that his scream gurgles towards the end as blood re-accumulates in his throat.

“This is fucked,” I state. “He’s got loads of blood in his mouth, he’s not spitting, he’s not swallowing, he’s probably going to aspirate if we leave him like this for much longer – I’m going to intubate this guy.” No one disagrees with me, and I quickly try to formulate a plan of how I’m going to intubate this man without killing him.

“Ken, are you OK to hold the oxygen mask while I draw up some drugs?” He nods to the affirmative and I hand him the mask, peel of my blood-soaked gloves and go to the drugs cupboard. It’s locked.

“Anyone got the drug keys?” I say, but I’m ignored as the patient continues to trash around. “WHO HAS GOT THE DRUG KEYS?” I shout. Sometimes, you have to make yourself heard.

“They’re over here,” comes the voice of Mary, one of the nurses.

“Thank-you” I say as she opens up the cupboard for me. I take out the thiopental and suxamethonium and start to draw the drugs into syringes. This takes a few moments and gives me time to pause for thought. I figure that this situation has the potential to go from serious to critical to fatal very quickly. Taking this into account, I conclude that it’s worth getting as much help as I can muster. I’m going to need to phone a friend.

“Mary, could you please call theatres and ask for one of the ODPs to come down to resus.”

“Certainly,” she says as she heads towards the phone.

“Oh, and Mary, could you also please bleep the ITU reg (my immediate senior) and ask him to come down too.”

I turn my attention back to the patient.

“Thanks Ken,” I say as I take the oxygen mask from him.

I put the Yankeur sucker back into the patients mouth and hoover out more blood. As I do so, he coughs and sends a spray of blood and saliva into my face. I feel the warm fluid trickle down the side of my face and my stomach turns. I make a face at Ken and he gives me a sympathetic look. “At least I had my mouth shut,” I say. Thank God for small mercies.

“Right, everyone; this man needs to go to sleep.” I say loudly. “Ken, can we take his hard collar off, now? And what I’d like is for you to do manual in-line stabilisation [of his neck], when the ODP arrives, she can do cricoid pressure and help me with the intubating equipment and we’ll get some one else to give the drugs.”

“Sure,” comes Ken’s response and he manoeuvres himself so he can comfortably keep the man’s neck as still as possible while Mary and I take off the hard collar.

I put the oxygen mask back on his face and right at that moment, like a cavalry unit, both the ODP and ITU reg arrive.

“I’m going to intubate him,” I tell them.

“What’s his GCS?” asks Ben, the ITU reg.

“Twelve” comes the voice of some bright spark in the bay. I’m pretty sure that his GCS is much less than twelve, but now is not the time to start a debate about it.

I shake my head, “He’s got a mouthful of blood and he’s not spitting or swallowing.”

“Can he maintain his own airway?” asks Ben

“No,” I reply
“OK then, I’ll draw some drugs up.”
“I’ve already got them,” I say. “They’re behind me.”
Ben picks up the drugs and goes round to where the surgeon had secured an intravenous cannula.
“Is everyone ready?” Ben asks. We all affirm we are. “OK, I’m giving the drugs now… Thio is in” the man on the trolley stops trying to fight us and becomes suddenly very limp. “Sux is in” The patient’s muscles ripple under his skin in an uncoordinated dance as the drug works its way round his body and paralyses every muscle as it goes.

I know it’s down to me now. Thanks to us, this man can no longer breathe and I have a small window of time to get a breathing tube into his lungs before he starts to die. The room has gone eerily quiet and I know that all eyes are on me as I pick up the laryngoscope and put it into his mouth. I’m hoping to see his vocal chords. What I’m aiming to do is push the tube between the chords into his lungs. They say that intubation should be a calm, smooth process, but I can immediately tell that this is going to be difficult.

All I can see is a lake of bright red blood. I pick up the Yankeur sucker and try to suck it away. The lake recedes annoyingly slowly, revealing the anatomical structures beneath it. But this doesn’t look like it does in the textbooks. It doesn’t look like any other intubation I’ve seen before. Everything is swollen, everything is red and everything looks sort of… twisted. I can’t see the vocal chords. I can’t see where I’m meant to put the tube. Worse, I can’t see any of the things around the vocal chords that are meant to give you a clue as to where to aim. I can’t see the epiglottis, I can’t see the arytenoids.

“Fucking hell,” I whisper to myself.

“Sats are 92%” comes Mary’s voice.

This man is starting to run out of oxygen and I’m going to have to do something. I pull harder on the laryngoscope handle, hoping to improve my view. The man’s throat is starting to fill with blood again, but I can’t see from where. Just at the limits of my view, I can see something pale and bumpy. I think it’s one of the arytenoids, but I’m not sure. I have a decision to make now. Do I step aside and let Ben see if he can intubate this man or do I try and do it myself, knowing that if I fail, it will be even harder for Ben to succeed? I trust my judgement and pick up the bougie [an intubating aid].
“What do you see?” says Ben
“Tricky,” I reply
“Sats are 88%” comes Mary’s voice again
Things are really serious now, I know that I only have a few seconds left to get the tube down before his body runs out of oxygen. There probably won’t be enough time for a second attempt before he is genuinely hypoxic. I hear the surgeon say something about a tracheostomy kit and have to act.

I push the bougie down where I think it should go and hope for the best.

To be continued…


Joel said...

Brilliant post!!

Lady In White said...

i hate cliffhangers

Lil' girl doc said...

hey great post! i successfully intubated a patient (my second one) a couple of weeks ago, with the aid of a bougie too! those things are awesome. i really admire your cool thought process throughout the whole ordeal; can't wait to see what happened next

brokenangel said...

i hate cliffhangers, we need to know what happened

Jo said...

Don't leave it there! What happened next?!

Medifix said...

Thank you for posting this blog and expressing your anxiety and telling us how you are trained to manage trauma. This clearly tells us what is happening in the NHS, how doctors are trained and why things have gone wrong from bad to worse.

I can visualize how hard this must have been as you mention you are a trainee ST2 anaesthetist. Where are the SPRS & Consultants? It is their responsibility and duty to be there, observe, teach and help you gain confidence and not leave you alone.

Injuries sustained after serious trauma (this patient had) is always very difficult to assess. This patient was obviously anoxic as he was irritable and fighting to survive. He must have been anxious looking “Angor animi refers to a patient’s actual and genuine belief that they are in the present act of dying

There is no doubt, the treatment for this is “Tracheostomy”, sticking a wide bore needle is life saving, unfortunately you had difficulty to intubate. It takes courage to handle the situation like this without support. I find it sad, because, the poor person’s life was left in your hands to manage by your seniors. Please think, how you would feel if you are loved ones or you life was in the hands of a trainee ST2 doctor.

I used to drag medical students and junior doctors and teach them because I believed my life will be in their hands one day, and so did not want someone to mess around my life when I need their help.

Our ministers, administrators and even the GMC make too many protocols and expect them to be meticulously followed. This is resulting in avoidable distress and pain to patients and ethically uncomfortable. Some doctors also told me that the nurses tell you what to do, when people like us can just stand and helplessly watch.

Harry said...

medifix, while im sure the general sentiment of your post is well-meant and highlights problems within the system, he said the ITU reg ("his immediate senior") *was* there - he got mary to bleep for him. RTFB (please read the blog more closely).

anyway, we're still waiting to see what happens, maybe a consultant does show up in the nick of time! :P or maybe dr A manages by himself ... update please! :D

Davey Jones said...

I cannot take the suspense

rosiero said...

I think I stopped breathing reading this. Any hope of an update sometime soon??!!!!

dylthedog said...

Great post please please please tell us what happens!!!!

Anonymous said...

Sigh! Are you studing for an exam or something Dr Anderson? Your postings are always informative and excellent reading but unfortunately are becoming more and more infrequent!

Dr Michael Anderson said...

fret not, all will be revealed very, very soon

Adam said...

Medifix, trauma tends to happen at night or outside of office hours. There has never been a requirement for consultant anaesthetists to be resident on call, this is not a case of "what is happening to the NHS".

It would never have been appropriate to perform a tracheostomy in this patient without anaesthetising and attempting to intubate him first.

Whilst Dr Anderson is "a trainee ST2 doctor" he has spent 5/6 years at medical school, had vast post-graduate training and passed postgraduate exams.

There is a massive difference between a doctor who has just qualified and a "junior" doctor who may have 5 - 20 years experience.

Whilst many of us have concerns about training few want to go back to 100+ hours per week. My 48 hours a week at the moment are more like 60 -70. I just wish I was getting paid for the extra 20.

Dr Anderson's management seems entirely appropriate so far (a second pair of hands no matter how senior you are is helpful). I hope I manage to avoid any doctors "taught" by medifix.

Hospital Lab Tech said...

Come on! Suspense is one thing but this is taking things too far :-)

Dr Michael Anderson said...

Medifix - what Adam said is right.

Everyone else - sorry about the delay, but I can now conclude this story

ChezziePoop said...

Great Post..