Seconds

May 14, 2010

What would a lawyer say about the five minutes that just passed? “What do you mean you didn’t know what the diagnosis was? What do mean you didn’t wait for her companion to return before paralyzing this patient? Aren’t you trained to stabilize patients? Didn’t you consider that the companion might have important information?..."

The other night I was moonlighting at my local community hospital when a woman rolled in gasping like a fish out of water. Ironically, there was plenty of water - in her lungs. 

The patient looked to be about 70 years old and she had the rough, leathery skin with big dirty pores that you see in people that smoke and spend a lot of time in the sun. She was focused on her pursed-lip breathing, having difficulty keeping her eyes open (is she retaining carbon dioxide or tiring out or did she take too much oxycodone?), not answering my or the nurses questions (was she deaf?).

“Who is she? Where is she from?” I asked, as I quickly squeezed behind the gurney to listen to her lungs.

“Never been here before - the guy that brought her here is parking the car,” someone said.

“Parking the car?!!” I touched her skin, which was cold and clammy and beginning to mottle around the legs and wrists. Her lungs sounded congested but there was so much noise in the room that I couldn’t be sure I wasn’t hearing subtle wheezing (does she have emphysema and is this COPD exacerbation or is she actually in cardiogenic failure?).

“Her BP is 240/160!”
“We can’t get a pulse-ox reading!”
“Is that V-tach?”
“I think I’ve got a line here!”

The patient had been in the room for about 90 seconds but the course to me was clear. “I need to intubate her now - get me the crash cart,” I said as calmly and definitively as I could (who was I trying to convince?).

Suddenly a million calculations and decisions are made in the blink of an eye. Will I need to put some blankets behind her head to establish a chin-to-sternal-notch position? Should I use a Miller or a Macintosh blade? Should I have the Glide-scope set up just in case I can’t see the vocal cords on direct visualization? Number 3 or 4 Macintosh blade? I hope to God someone checked the batteries on the laryngoscope. Why doesn’t the suction suck? Should I start with a 7-0 endotracheal tube or go straight for a 7-5 to facilitate the ventilator management in the ICU?

How long does it take to park a damn car?

“Gerry what meds do you want?”

“Let’s go with 10 mg etomidate and 120 mg of succinylcholine….wait…hold on…her BP is off the charts and maybe this is congestive heart failure from hypertension induced renal insufficiency…if her beans don’t work, her potassium might be high and the succinylcholine might cause dysrhythmias… Let’s use vecuronium and we will bag her for the extra 30 or 60 seconds it’ll take.”

As I placed the bag-valve mask over her face I instinctively reached into her mouth and pulled out her dentures. I bent over and whispered to her that everything was going to be OK.

“We don’t have vecuronium.”

“Holy God."…think, think, think… "How about roc? Do we have rocuronium?”

“Yeah”.

“Good - she looks like she is about 50 kilograms. Get me 30 mg of rocuronium and let’s finish this.”

I leaned over and performed the single most important skill that any emergency physician can do: pass a plastic tube into the mouth, past the tonsils, under the epiglottis and through the vocal cords into the trachea. I’ve done it hundreds of times and every time I do it I am terrified because I know what can go wrong. Doing it wrong means death. Horrible, suffocating, messy, bloody death.

Not this time. I watched the tube slide effortlessly through the dusky-white cords. Perfect.

After checking for correct placement and securing the tube, I stepped back and watched the nurses clean up the mess that we had made saving this woman’s life.

What would a lawyer say about the five minutes that just passed?

“What do you mean you didn’t know what the diagnosis was? What do mean you didn’t wait for her companion to return before paralyzing this patient? Aren’t you trained to stabilize patients? Didn’t you consider that the companion might have important information? What?! You didn’t get a chest X-ray before intubating her? Isn’t that the standard of care - get a chest X-ray before intubation? Maybe an X-ray would have helped you figure out what the diagnosis was! You mean you didn’t even get a blood gas test and you didn’t even know what the pulse-ox percentage was? Shouldn’t you have waited to get a full set of vital signs before paralyzing and intubating her? That’s why they are vital signs, because they are vital to your understanding of the patient. Wasn’t your decision to intubate this patient without a full set of vital signs or an X-ray or a pulse-oximetry reading reckless on your part, Doctor, and wasn’t it a violation of the standard of care?”

I called the hospital today – the patient is scheduled to be discharged home tomorrow.