As I walked into the ED for my shift, the nursing supervisor was fumbling with a syringe attempting to get medication out of a small vial.
“Ummmm. Looks like you need to adjust your bifocals,” I quipped. We have a running joke about who is older and bust on each other about our ages every chance we get.
When she turned around, the look she gave me signaled that it was no time to joke. Tears were running down her cheeks.
“What’s …?” She cut me off.
“Thank God you’re here. Get into Room 7 now.”
When patients are really sick, it has been said by people much smarter than me that your worth as a physician can be judged by how people invoke deities. There are the “Oh God” docs and there are the “Thank God” docs. Being classified in the latter category by a nurse whom I admire is a compliment, but it also meant that there was something very bad behind the curtain across the hall.
I set down my bag, unzipped it, and searched around for my stethoscope. The nursing supervisor grabbed my shirt and pulled me toward the room. “Use mine,” she said.
She threw open the curtains and it took me a second to size everything that was going on. Despite the commotion, it was eerily quiet. In one corner, a middle aged man and his wife were sitting holding each other’s hands. Both were crying. An ambulance stretcher was pushed to the side of the room. EMTs were trying to start an IV on one arm. Two nurses were working on getting an IV in the other arm. At the head of the bed was the respiratory therapist. He had a brow full of sweat and kept wiping his forehead with his arm as he worked the Ambu bag. He told the doc who had her stethoscope on the patient’s chest “I’m barely able to get any air into her lungs.”
Laying on the bed was the limp body of a 13 year old girl. Her color was between dusky and blue.
“What’s going on?” I asked.
“Bad asthma. She just stopped breathing on the way to the hospital,” said one of the EMTs.
“We can’t tube her because her jaw is clenched down and we are having trouble bagging her because she’s so tight,” the other doc explained further.
She was from an outlying area, so her transport to the hospital took 25 minutes. She was in respiratory distress when EMTs arrived, so there was at least 30 minutes of ineffective respirations.
“What has she gotten so far?” I asked.
“Nothing, we can’t get a line,” said one of the nurses.
I grabbed the nursing supervisor. “You need to go get epi NOW.”
She walked out of the room and said over her shoulder “I was doing that when you walked in.”
I watched the respiratory therapist try to ventilate the patient. The problem wasn’t that her lungs weren’t getting enough air, the problem was that her lungs were full of air and the airways were so constricted that the air couldn’t get back out.
I went to the side of the bed and started squeezing the patient’s chest between ventilations to force the air back out.
“IV in!” Announced one of the nurses.
Medications started pouring into the IV line – to improve the patient’s asthma, to sedate her, and to paralyze her muscles so that we could put her on a ventilator.
I looked up at the respiratory tech. Sweat was forming a triangular wet spot down the front of his shirt.
I prepared to insert a breathing tube and pressed down on the patient’s jaw to insert the laryngoscope blade. Her mouth filled with vomit.
We lowered the head of the bed so that the vomit would pool in her mouth and then suctioned her. Her oxygen saturation started to drop. We Ambu bagged her again. More vomit filled the mask.
We suctioned her again.
“Do you want me to call anesthesia?” asked the nursing supervisor.
“No. I can do this.”
“Are you sure?”
“Yes. She just needs to stop vomiting.” The tone of the beeps on the oxygen monitor became lower and lower – meaning that the patient’s oxygen level was getting lower and lower. Now I could feel the sweat building on my forehead.
With some additional suction, the airway was clear and I got the tube in place.
The beeps on the oxygen monitor began to rise in tone. Everyone in the room breathed a sigh of relief … including me.
As the respiratory tech taped the tube into place, a few drips of his sweat dripped onto the bed. I looked over at him. His whole shirt was soaked. He looked like he had just walked out of a sauna.
The secretary came into the room and handed me results from a blood gas. The pH was 6.7 and the pCO2 was greater than 100. Not encouraging.
The patient’s parents looked up at me. I tried to be upbeat. With a half smile I softly said “She’s doing better now.” On the inside, I wasn’t so encouraged. With her prolonged down time and that ABG, I wondered whether she would ever wake up.
We arranged transport to the regional Children’s Hospital pediatric ICU and within a half hour she was lifting off of our helipad. By the time she left, the sedation and paralytics we gave her would have worn off, but the patient still wasn’t moving.
All I kept thinking about was that this could very easily have been one of my daughter’s classmates – or even my daughter – who was only a year older than the patient. I had to stifle the urge to call home just to make sure that everyone was OK. It was 12:30 AM and giving myself peace of mind would only have created a whole lot of angst with my family.
About three hours later, we get a phone call from the Children’s Hospital. The physician wanted to give me an update about our patient. By that time it was almost 4:00 AM. The physician on the other end of the line sounded exhausted.
“The transfer that you sent over here …” During that small pause that followed I could already feel my face getting flushed. For some reason I suddenly had this overwhelming sense of grief.
“She’s already awake and trying to pull the tube out. Looks like you guys saved her life.”
All I could muster were the words …
“WhiteCoat” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.
Submit a guest post and be heard on social media’s leading physician voice.