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 syndromewho 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.
