Friday, May 05, 2006

I'll Never Know

Emergency Physicians are sometimes derided as ''cookbook'' doctors unable to think much beyond the ''ABC''s (airway, breathing, and circulation). This is the order in which we address a critical patient... We secure the airway, then check and remedy any breathing problems, and then address circulatory inadequacies or problems.

There's truth to this "cookbook" criticism. We all tend to be big picture people with relatively short attention spans and near manic energy levels. We are confident people, some outwardly so, some not, sometimes with reason, sometimes not. A friend of mine put it this way, as an Emergency Physician one is "often wrong but never in doubt".

All I would say to my colleagues who do not do emergent care of patients is that when someone is dying then the Airway-Breathing-Circulation mantra will save your ass and your patient's life. I had a patient two days ago that I will always think about. This person had terrible underlying diseases and had a respiratory arrest in the field.

My paramedics intubated the patient in the field and thought they had a good tube. My respiratory tech didn't think so and I wasn't sure either so I pulled the tube and retubed him. Meanwhile he was in asystole, generally a non-survivable rhythm, and was purple from the chest up. I wondered though if it was because the paramedics had been blowing air into his stomach, and I went on with the code. The IV lines blew and I had to put a central line in his pulseless left groin. I got it in a minute or two and we slammed him with epinephrine, atropine, and fluids.

ABC. Ten minutes into the code and we were making no headway. When I tubed him I got a small bit of color change in the CO2 detector which was about right because of his down time, and I heard breath sounds over the apices of the lungs. Disturbingly, and ten minutes into the code, I thought I also heard bubbling over the stomach which would indicate a bad tube.

I pulled the tube again and put a third in. Futile care probably from the minute he went down in the field but damn it, three minutes later we had his heart back and an hour later he went to the unit with a good pressure. Total CPR/code time? About an hour. Chances of the brain being alive. Near zero. Pupils? Really big and not reacting to light.

ABC. ABC. Was the tube good? Was it dislodged during the code by the jostling or the NG tube? What could I have done differently? I could have used an esophageal detector device. We have no rescue airway equipment yet in our small ED. I could have done a cricothyrotomy to verify the tube. I could have etc... The point is that I thought "A" was taken care of and it may not have been. Ultimately in this case, shit rolls uphill. If it was a bad tube it was my fault even if I did "B" "C" and all the rest perfectly. If "A" is bad the patient dies, it's just that simple and that's where an Emergency Physician can not fail.

Assuming his first and second tubes were bad, did we cause his death. No. He had smoked himself to three heart attacks and had been ''sick'', according to the family for two days refusing to see his physician. The paramedics said that his last words before collapsing were ''no hospital''. Could he have had a meaningful survival with everything done correctly from the start. Perhaps, though I will never know. He had care withdrawn per the family's wishes as he was felt to have severe anoxic brain damage. That last tube was good and if a post mortem is done the pathologist will find it right where it should be. I will never know if the first two were. I will not crawl into a bottle of Jack Daniels over this but I will learn from it. ABC.

1 comment:

  1. I find it amazing how many ED's and paramedic still have to ask this question of tube placement. With true ETCO2 monitoring (not colormetirc, because we know that can be false as well) you can see by the numbers if the tube is good. Here in upstate NY we are required to use ETCO2 anytime we intubate a Pt but as soon as we get to the ED the ED doesn't have any way of monitoring the Pt like this and thus many of the ED docs (well really residents, cause the attendings to know) will say our tube is bad even with a capno of 40. As for the bubbling in the stomach, I've had a smoker code who've we intubated and had the tube pierce the trachea into the esophagus due to the deterioration. On a AP the tube looked great, on a lat you could see the tube curved back, kinda freaky.