I stood at the counter finishing a chart for a girl with a toothache when the glass doors to the emergency department rattled. “We have an emergency,” shouted an older man with a hearing aid, “We need a wheelchair!” We wheeled in the older woman who was mumbling non-sensical words. “She’s stiffening up,” he shouted to us, although were standing right next to him. “Is there a doctor here?” he screamed frantically.
“I’m right here,” I said in a calm voice, “she’s going to be OK, but we need to have you step out of the room right now.” The scenario reminded me of the moulage scenes where frantic bystanders are planted in order to throw of the examinees in order to see how they deal with distractions.
She was in the middle of a siezure and stiff as a board, not breathing. Two of us picked her up, one at her shoudlers and one at her hips and she was as flat as a piece of plywood and turning bluer by the second.
By the time we got her onto the bed she had started to arouse. Her oxygen saturation quickly rose to normal as she began taking deeper and deeper breaths. The monitor showed some kind of SVT at a heart rate of more than 200, but occasionally going down to 130. The first question that instinctively came to mind, thanks to my critical care medicine instructor in medical school was ‘stable or unstable?’
This woman was clearly unstable so we performed a synchronized cardioversion, twice, and she finally settled into a sinus tachycardia. She was still breathing, but gurgling and not waking up from the mild sedation we provided. I decided to intubate her. When I looked into the back of her throat, the first thing I saw was a pooled collection of bloody mucus and a tiny, tiny airway. The intubation was successful and the medic crew was paged to help ventilate her while we continued stabilization.
Ultimately, she was flown to the Big Hospital Down the Hill, where they will look inside her lungs to find out where the blood is coming from.
What made this patient stand out for me? This was the first unstable patient I’ve cared for as an attending. I kept waiting for my boss to come up behind me and start shouting orders, but it never happened. I wished that someone else would start doing the things I was thinking because I couldn’t get the words out. I had never treated an unstable patient with this group of nurses before, I missed my ex-army medic nurses back ‘home’. Advice from various attendings kept going through my mind, and in the midst of the cardioversion, I wondered what my residency director would say if he were doing this case as a megacode…’doc shazam, what took you so long to decide to cardiovert? Did you think she was stable? Why didn’t you intubate right away when she was clearly having difficulty breathing?’
Of course, you never know what will come through the door, and this case was a combination of lots of things I’ve seen before, but never presenting just like this. It’s pretty simple when you break it down into the basic components…airway, breathing, circulation…which I pretty much did, just not as fast as I would have liked to.
I may have felt as frantic as the husband and son who brought her in, but I didn’t have the luxury of letting show as much as they did, as they emptied the contents of her purse on the floor in the middle of the department to get me her medication list. They were clearly distraught and I felt badly for them, but they were also making it very difficult for us to do what we needed to do to stablize her.
What made this case even more intense was that it occured in the middle of the busiest day I’ve had yet, with the department full, a patient on either side of the curtain, and no other docs in the hospital on a Sunday afternoon.
When I finally got back to the girl with the toothache and asked if she still wanted the injection she said, ‘just don’t do to me what you did to her!’ The lady on the opposite side of the curtain told me that she was all better now, after hearing what the first patient went through.
What a strange job I have.