Bad Day at the Office
Thanks to Dr Bill Griggs from Adelaide South Australia for sharing this case!
I am going to share a case that was not a lot of fun.
I travelled to a small rural area in Australia by helicopter to
pick a 60 y.o. woman with CREST syndrome who had
been unwell in a small local hospital with
"gastroenteristis" for 2-3 days. We went to get her
because she was anuric and had no recordable blood
pressure or saturations despite being GCS 14.
On our arrival she had acidotic respirations (deep and rapid) and
still no recordable blood pressure. She was cyanosed and
sat probes would not read. She was GCS 13 (E3V45M6) My
provisional diagnosis was ischaemic/infarcted
bowel which eventually proved correct.
There was no pathology or radiology available at the very small
remote hospital. Path results took hours to come back as they had
to go elsewhere. There were no results for the last 24 hours.
I inserted a subclavian CVC and got a pressure of 35-44
with wide swinging - not a good number for either venous
or arterial! Although I had a brief moment of doubt about
placement, it was in the vein.
After loading her with fluid and beginning inotrope support
(peripherally as I was not 100% sure the central line was not
arterial) we got an NIBP of around 80/-. Her respiratory function
was getting worse and she seemed less responsive so I elected to
ventilate her.
In our kit we had two older model Heine laryngoscope handles and
one each size 3 and size 4 disposable blades. When the paramedic
connected the blade to the handle, the blade broke at the
attachment point. In retrospect our daily testing regime
of putting on the blade and opening it to test the light and
battery had resulted in some weakening of the attachment area. We
have since changed this practice. I was keen for a size 4 blade and
backup so I asked the hospital to either provide a laryngoscope or
some size 4 disposable blades. They produced two size four blades
of a different brand but which seemed to fit.
Due to her syndrome the patient had a small "parrot
beak" mouth with very limited opening. She had also
vomited recently so I elected to do a RSI. The only monitor that
was providing readings was the ECG. Her HR was 120 down from 140.
The most recent NIBP was 80/-. She was still blue on 100% via
BVM.
We began the RSI.
The view on laryngoscopy was poor. The mouth was small but I
managed to achieve a view of the arytenoids when the second
disposable laryngoscope blade broke. It was at the same
point as the previous one. I was pulling very hard on the handle to
get a view but have previously lifted patients heads from the bed
and never seen this before.
I said a bad word under my breath and grabbed the third (and last)
blade. I got to the same view and then it too
broke. I was not very happy.
I asked for another and a nurse left the room to look for one. I
began to attempt BVM ventilation. At this stage the cricoid
pressure incorrectly came off briefly and the patients
mouth immediately filled to the lips with gastric content.
Despite suction and renewed BVM attempts I could not ventilate her.
Her mouth opening seemed too small for a LM and the regurgitation
was also not going to helpful trying an LM. So I moved to a
surgical airway.
I did a midline incision over the cricothyroid membrane but hit a
distended anterior jugular vein - remember the CVP of 35-45? It
produced a fountain of blood which in turn induced a number of
gasps from the people in the room. I had no vision but
inserted a tube into the hole. The tissues were very
wooden due to her CREST so it was not the usual tactile environment
with soft tissues. I connected the end tidal CO2 and began
squeezing the bag. After 4 breaths there was no CO2
reading. I had thought I was in the correct spot but did
not want to be ventilating the mediastinum. I left 100% O2 attached
in case it was in the right spot but stopped squeezing.
Still not happy.
At this stage I was low on options so got the paramedic to pass me
the size 3 blade from our kit and went back to the top end. This
time with suction, pulling and luck I got a view of the rear part
of the cords. I passed a tube but hit resistance. At this stage I
asked for the neck tube to be removed and was then able to advance
the oral tube. This time I got a CO2 reading.
I checked the HR which was (to my amazement) still 60 and not zero.
However despite ventilation, over the next two minutes the
rate decreased and we had to begin CPR.
10 minutes of CPR and ALS resulted in return of spontaneous
circulation. At this stage she had a BP of 100, a HR of 120 and an
intermittent saturation reading in the low 90s.
As there were no peripheral pulses I attempted a femoral arterial
line but the line ended in the vein.
At this stage we left.
Just prior to leaving the CO2 reading went flat again but this was
an issue with a loose connection. In retrospect the cricothyrotomy
tube may well have been in the correct spot but the CO2 connector
may have been loose then as well. This fits with my apparently
hitting the tube when I succeeded in oral intubation.
On arrival in the city she went to the OT / OR where a large length
of perforated dead bowel was removed.
To my amazement after further surgery and ICU by day 10 she
had been extubated and was awake, sitting out of bed and
talking with her family. Patients are resilient.
Unfortunately on day 12 she had a sudden collapse (? pulmonary
embolism) and died.
Learning points ?
1. I should have chosen a different career!
2. I am sure there are a number of points along the way where
different decisions could have been made. People may enjoy
pointing them out :-)
3. The testing of handles using disposable single use blades was
not clever.
4. It appears the issue with the brand/model of handle and blades
was not new. We have changed all our handles now. The problem is
that the cross bar on the handle was narrow and the blade
attachment was a bit smaller than the gap it had to fit into. These
two things allow the blade to move within the handle attachment
area with a single point of excess pressure which led to the
breakages.
5. Don't give up. Patients surprise you from time to time when
they do well when you think it is hopeless.
6. Don’t allow a current affairs media film crew to come along for
the day to film what you do unless you'd like to work under a
bit of extra pressure....
Reliving it all means I'm going to go and have a lie down
now.
Comments on this case are welcomed. Submit here.
Comment #1
From Pierre
Thank you for sharing your case with us.
Retrieval work always has the potential to give you something interesting and challenging, especially given the limited space you have in most helicopters (unless it was BK117 or bigger) to carry your kit bag and patient. And there's nothing like knowing that this really can be called remote anaesthesia and be a potential strange environment.
From the history you've given I'll assume she has scleroderma (? +/- Pul hypertension?), which given her age group always means she was going to be a difficult airway before she got ill and compromised. She must have been awfully close to scoring an ASA 5E.
There seems to be a few holes lining up ala swiss cheese model, sick patient, foreign place, limited kit, limited resources, difficult airway, limited time, equipment issues including monitoring. Probably the biggest clue it was all going to get very challenging fast was the media crew.... in my experience they are attracted to very sick "about to arrest" people. Was there any additional skilled help there to further assist you? In this situation it does become very daunting. And it is very easy for someone to say why did you do this and that, when they are not in the depths of it all. And more importantly, you have already reflected on the situation and how you would change things if there was a next time. The ultimate outcome would almost certainly still be the same. And I suspect your kit bag will be getting a make over with some new gear.
Andrew Heard has written an article on CICV which may be worth a read
The Formulation and introduction of a "can't intubate, can't ventilate" algorithm into clinical practice. A.M.B. Heard. Anaesthesia, 2009, 64, pages 601-608
Thanks Pierre - Editor