Extubating the overzealously intubated patient

One of the curses of kalafong (hell) was that there was no neurosurgical service. This meant us mere general surgeons had to handle the many head injuries that came in.

So, for example, when some guy decided to cave in the head of his so-called best friend with a five iron on the golf course because they had started with the nineteenth hole instead of the first, we ended up either dumping them in ICU with a tube down the trachea to wait to see what happened or trying to turf them to a neurosurgeon that could actually operate them. It was far easier to dump them in ICU. Mind you, it was easier to turn lead into gold than to successfully transfer a patient to neurosurgery. So generally we hated it when we were called to casualties to handle someone with a head injury.

My colleague got the call. On old lady had apparently fallen and hit her head. The paramedic had intubated her on the scene and rushed her in. He proudly stood there admiring his handiwork as he presented the patient to my friend.

“Well, doctor, her GCS was three so I had to intubate her. She fought the tube so much that we had to inject her with 30mg dormicum.”

It was the usual story the paramedics spun explaining why they had intubated someone and at the same time illustrating that they thought we were idiots. You see, the GCS (Glascow Coma Score) is a scale that gives one an idea what depth of coma the patient is in. It is a measure of the patient’s normal responses as far as eye movements, verbal response and response to pain is concerned. A score of 15, the maximum, is essentially a normal person. A score of three is the lowest you can get and is equivalent to a corpse or maybe a brick. A person with a GCS of 3 does not fight a tube and doesn’t need dormicum. Then again 30mg of dormicum would pretty much drop a GCS of 15 to 3 or thereabouts.

My friend was understandably skeptical when he entered the room. “Oh, doctor, the other thing I forgot to tell you is the right pupil is blown.” This was lingo meaning the one pupil was severely dilated while the other was not. This was in fact a true sign which did indicate intracranial damage, usually bleeding with unilateral increased pressure. Maybe, despite the supposed need for 30mg dormicum, the patient really was in trouble.

The surgeon walked in. The patient lay dead still with only the rhythmic up and down movements of the chest as the ventilator pumped away. He took a quick glance at the eyes. Sure enough, the right pupil was massively dilated and absolutely unresponsive to light. This was not a good sign. He turned to his students.

“Look at the eyes. See the difference in the pupils? That is a very bad sign. This poor old lady has pretty much no chance of survival.” Immediately the patient lifted her head off the bed and shook it vigorously. The surgeon took a double take. that wasn’t supposed to be possible.

“Tannie, can you hear me?” The patient nodded. “Disconnect the ventilator immediately!” commanded my friend. The sister complied. The patient blinked a bit with her asymmetrical eyes, but breathed normally. My friend pulled the endotracheal tube out, to the absolute horror of the paramedic who had been so proud of his actions. With that the old lady sat up, lifting one hand to her throat.

“Daardie fokken buis het my rerig seergemaak! (that f#@king tube really hurt me)”

“Tannie, what is wrong with your right eye?” asked my friend.

“When I was only five years old I was injured when a stick poked me in the eye. Since then it has always been like that.” The paramedic went a bit pale and quietly left the room.

After listening to this story I too often extubated patients that the paramedics had overzealously intubated after flattening them with ridiculous amounts of dormicum.

“bongi” is a general surgeon in South Africa who blogs at other things amanzi.

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