Thursday, June 26, 2008

Humble Pie

It has been a rough week for me procedure-wise. The other day I saw a septic patient. He had a fever, diarrhea, a heart-rate twice normal, and a soft blood pressure. So, we did all of the usual things, and then I got called to his room because there was a problem getting IV access. No problem-- time to put in a central line (an IV placed into one of the larger veins in the body- internal jugular, subclavian, or femoral veins). I didn't want to access his neck because he'd been shot there recently and there was a lot of scar tissue, a retained bullet and bone fragments. I didn't want to access his groin because of the diarrhea issue and with him being paraplegic it seemed like it would be easily contaminated. So, I settled on the chest. The needle connected with the vein and I had no problems floating the catheter in over the wire. However, when I went to check the ports, I drew back air instead of blood. Uh-oh.


At this point, the patient's father came in the room and said that central lines wouldn't work on his son (which doesn't make sense) and that he would have to have a PICC line (large catheter placed into one of the arm veins). So, we abandoned the procedure, and called for the PICC team.


And that's when the patient decompensated. He went from a heart rate of 120 to 160 to 200. The monitors get very angry when one's heart rate is 200... that's a whole lot of beeping! I had already had a sinking feeling about my failed procedure, but this just confirmed it. A quick portable x-ray showed it all: the patient now had a
pneumothorax.


There was no time to wait for a PICC line. This guy needed fluids, antibiotics and was heading towards needing a pressor. Quickly, I put in a femoral line while the ICU was called. The ICU resident automatically called the cardiothoracic surgeon and that's how I ended up creating business for my least-favorite surgeon. The treatment for a pneumothorax is to put in a chest tube to decompress the air and reinflate the dropped lung. I'm capable of doing a chest tube on my own, but by that point surgery was involved and it was too late to uninvolve them.


I talked to the patient and his father and let them know what had happened. Apparently, the exact same situation had happened when a subclavian was attempted when the patient was shot several months ago. My attending was pretty cool about the whole thing, shrugging it off with "Well, they say you haven't done enough subclavians if you haven't dropped a lung." However, I think I am going to be more than a little gun shy about doing them in the future. As for the patient, he did well and went home a few days later.


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And then there was the patient that walked out of an ICU against medical advice a few days ago. The nurse called me immediately into her room and there I found a heavy older woman only able to speak 2-words at a time. She said the other hospital called her at home and told her to come in immediately or else they would send the police to her home to escort her to the hospital. (This story doesn't quite make sense because the patient appeared to be completely capable of decision-making to me, but that was her story.)


Anyway, the woman was in respiratory failure and had asthma and COPD. Not a good combo. She refused any IVs, and said she had a DNR (Do Not Resuscitate order) "somewhere" and did not want to be intubated. So now I have a patient in respiratory failure that's tying my hands behind my back as far as letting me help her.


We started breathing treatments. She had already taken oral steroids at home.


She got worse.


She agreed to let me give her one shot of something, so we drew up some terbutaline.


She got worse.


She agreed to an IV finally, and medication-wise I threw everything I could think of at her.


She got worse.


We tried non-invasive ventilation.


She got worse.


Finally, she said she wanted to be put to sleep. I confirmed that she meant she wanted a breathing tube, and to be put on the ventilator. I then called her neighbor and made sure there was someone to take care of her dog. Apparently, that was why she left the other hospital in the first place and didn't want to come in today.


We set up for intubation. She was difficult, but the tube passed easily, good color change, breath sounds. Fine. Before we could confirm it with a chest x-ray she desats and turns purple. I pulled the tube, but now I can't get it back again. I can see just a hint of where I need to put the tube but it's not going in. I try to use a different tool, but it doesn't work either. Finally, a colleague steps in and is able to get it. The patient went off to the ICU. She got extubated two days later, and is still in-house, but at least she's been moved out of the unit.

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So it hasn't been the greatest of weeks. Two big blows to my confidence. Everyone has bad days, but it is kind of poor timing as I am about to start working part-time at another hospital without an attending to be my safety net.

3 comments:

Chris said...

Damn....my throat and lungs hurt after reading all of that :)

Honestly, I can understand your concern. When most of us "have a bad day", we just forget the new coversheet for our TPS reports. You have a much more serious consequence behind your "bad days".

If it's any help, I have confidence in you to intubate me. What? NO you can't practice.....I'm healthy dammit. :)

ru said...

LOL at Chris' comment. I am sorry about your crappy week. One of those things would have been stressful enough, but dealing with both events within days of each other must be really frustrating. I am glad that you care so much about doing a good job. I would let you intubate me even though I am healthy. You make it sound so interesting!

Shazam! said...

Hey, those things DO happen you know. When I was an intern, I shared call in the ICU with a fellow ER resident. He had done several chest tubes already and I had none. I had done several central lines and he had few.

So the next central line we had, he did the insertion...then I did the patient's subsequent Chest Tube.

It happens and its a known complication. DOn't let it deter you...learning to access anywhere possible is best for your future patients.