I recently cared for a patient who raised my heart-rate a bit. Of course, any emergency physician will tell you, the potentially difficult and complicated cases often come at the end of the shift, as you’re trying to clean up all of the paperwork and ‘head for the house.’ Nurse Ginger came to me and said, ‘we need a doctor in room 11.’ I snarled, snatched the paper, grumped and gruffed and marched off to see the patient who had so selfishly interrupted my planned escape. (Disclaimer: I later apologized to the very correct Ginger, who had every reason to come and get me.)
Facing me was a woman in her 60’s with a tongue the size of my nurse’s head. Well, not quite, but it was sufficient to fill her entire mouth. This, of course, can sometimes be incompatible with the passage of air into the lungs, oxygen into the bloodstream and therefore, life itself.
She was breathing well, all things considered. Of course, she couldn’t speak. The swelling had been increasing over the previous six hours. For the non-medical, she exhibited signs of a syndrome called angioedema. In her case, hoof-beats usually being horses, the symptoms were probably caused by a drug called lisinopril, belonging to a class of anti-hypertensive drugs called angiotensin converting enzyme inhibitors.
This is a condition that really gets the attention of physicians who manage airways; and especially physicians like me who have struggled with airways a few times. So, I spoke to her as calmly as possible, our nurses administered oxygen, placed an IV and put her on the heart monitor. I ordered some Decadron (a steroid), some Benadryl and some Pepcid (both different versions of antihistamines). Then I started making phone calls.
Much of emergency medicine is just that. Recognize the gravity of the situation and then sending for help. Making phone calls. Rallying the troops. Calling for reinforcements. Popping a flare. You get the picture. The thing is, she didn’t need to be intubated (have a tube placed in her airway) just yet, but she was someone who might easily take that turn and desperately need an airway placed as quickly as possible.
I called anesthesia and I called ENT. Anesthesiologists are airway experts who have very cool airway tools, like fiber-optic laryngoscopes, with which to look down the airway without stimulating it or causing more swelling. They are the kings of definitive airway management. Those of us in emergency medicine are good, too. But when a smart physician senses trouble, he lets go of his pride and calls for back-up. Or, as someone put it to me in medical school, ‘focus the glory, diffuse the blame.’
Well, my anesthesiologist friend came to see the patient, and he called our ear, nose and throat surgeon friend. You see, if worst came to worst, our nice lady might need a tracheostomy placed, and he would be the guy with the skills to do it.
Then, we called her primary care doc, who knew her very well. In the end, we all decided to leave her be, admit her to the ICU with surgical airway equipment at the bedside, and wait to see if the medicines worked. Although controversy exists about whether the medicines I ordered actually help, she started to improve a little.
When I left for home at last, she was being seen by her family doc, tucked into the ICU and was breathing nicely.
But this isn’t a lesson in angioedema. It’s about teamwork. Medicine is multi-faceted. Primary care is important and specialties are important and emergency medicine is important and nurses are critical. Anytime we discuss improving medicine, we can’t ever focus on just one aspect. Primary care physicians have unique skills and the patience of Job himself. Specialists, like anesthesiologists and surgeons, have technical abilities the rest of us lack. They also have the experience to recognize when to act; and equally important, when to pause and wait.
And emergency physicians know when to make phone calls!
So I hope that whether health-care reform happens or not, we can remember that we have excellent medicine in America because we have nurses and docs with different skills and interests, different talents and knowledge.
Without that beautiful collage of professionalism, medicine just won’t function very well.
And I won’t have anyone to call when I really need help.
Edwin Leap is an emergency physician who blogs at edwinleap.com.
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