Agraphia Medical Tragicomedy


You Probably Should Quit Smoking

"Medic 5 calling ER.  We've got a patient who was... uh... smoking with his oxygen tank on.  It blew up in his face and now he's not breathing.  We'll be there in... uh... about 2 minutes.  He looks pretty bad."

Few things mobilize the ER staff quite as quickly as a bad accident.  So much of we see is routine chest pain, mild abdominal pain, and chronic migraines that a "real" emergency inevitably causes extra hands to materialize.  I immediately started getting set up for an advanced airway.  Burned face usually implies burned tongue, throat, and larynx - and although your face can accomodate a certain amount of swelling, swelling INSIDE the throat will close off an airway fast.  It's critically important to not only act fast, but before things get bad.

I was pleasantly surprised to find my training paid off.  This guy was the sickest person I've seen in about a week, but I knew exactly what to do.  Heart rate through the roof, blood pressure quickly circling the toilet, oxygen saturations less than 50%.  Calmly and quickly I intubated him - fast enough that the respiratory therapist, surprised, asked "already?" when I asked her to hook the patient up to the ventilator.  While intubating, I could see the ash trail down the bronchus, a telltale sign he was a smoker (alright, let's face it.  The guy needed to leave his oxygen cannula on at full blast to muster up enough breath to inhale his cigarettes.  That's olympic caliber dedication to tobacco right there).

That's when things went downhill.

The minute the paralytic wore off, he started squirming.  His blood pressure started rising.  110.  150.  210.  275.  The nurses started having trouble holding his arms down as he went to pull the breathing tube out.  Heart rate jumped into the 140's.

Knowing full well that too much sedative at one time could be a huge problem, I started carefully adding medications.  No response.  He kept trying to pull out my precious tube, the only thing keeping him alive at this point.  I gave him some more sedative, waited 5 minutes, and gave him more.  Still thrashing around, unconsciously reaching at the tube firmly lodged in his airway.  If I lost that, he was dead.

Suddenly, he crashed.   His blood pressure went from 275 to 75 in the blink of an eye.  Surely a mistake, I thought to myself.  I rechecked it, checked, and checked again.  It was real.  He was on the cusp of dying, and I could barely feel the pulse in his neck.

It's incredible how 4 years of medical school and 3 years of residency flash through your mind.  Over the next 15 minutes I started systematically checking for reasons why his blood pressure had dropped so rapidly.  Had the breathing tube been pushed in too far?  Pulled out?  Had his emphysema caused a rip in his lung, leading to a buildup of air?  Was our ventilator set wrong?  Did he have a sudden heart attack from the stress?  Had the sedatives all finally added up together?  Had his lungs filled with fluid from to the flames, suffering burns like his face?  The possibilities flew through my mind.

The nurses stood in silence while I pondered, carefully checking every tube, line, setting, and lab value.  A few threw out ideas.  I stood, thinking.

Finally having ruled everything out but over-sedation, I gave him a dose of medication to raise his blood pressure.  It worked like a charm, and I let myself relax a bit.  As he started to squirm again, one of the nurses asked if she should sedate him some more.  I gave her an icy glare.

It was only after he safely got on the chopper to the burn center that I realized how scary that situation really was.  I initially had no idea why his blood pressure dropped so rapidly, and I've never seen anything quite that dramatic before.  What's worse is that aside from burns to his face and his mouth, nothing else was wrong with him.  If he died?  I would have assumed it was something I did wrong.

Sure, if you really want to split hairs, he was a horrifically bad COPD patient with about 80 years of smoke and tar caked in his lungs, with countless other medical problems.  It's incredibly difficult to properly ventilate these people, and especially in the setting a huge fireball inhaled into his lungs, I suppose he was a setup for disaster.  Still and all, if he had died, I wouldn't have forgiven myself.  I sincerely hope all goes well for him at the burn center.  I've done what I can.

Can't prevent people from hurting themselves, though.  This field is exhausting sometimes.

Comments (15) Trackbacks (0)
  1. Is ketamine available in your ED?

  2. Thanks for sharing a harrowing and complex experience so simply and eloquently. Your writing reminds me of Atul Gawande’s work. I can hardly wait to read your book.

  3. What are the dangers of over-sedation in an intubated patient with a BP over 200? Why not touch him with a little bit of neo or nor if he dips hypertensive?

  4. I know what you mean. Just some few weeks ago, I was stationed at the ER and we were experiencing the aftermath of a week’s worth of heavy rains and flooding. Patients who have been stranded were only able to come in then and a lot of them had multiple fractures and/or lacerations from slipping/falling. Now this was hard because the trauma area of the ER only had 1 resident, 1 intern, and me (a lowly clerk). We were swamped.

    About early evening, a GSW patient came in to our ER. He shot himself in the chest some minutes prior for pure dramatic effect after fighting with his wife, in public no less! I couldn’t help but feel a bit resentful because I thought my time would have been better spent tending to those who took life more seriously. The joke, “hook to clerk” will never be funny to me ever again.

  5. Very good work reacting quickly and appropriately. As an ex-smoker myself, the affects are truly scarring. However, smoking while on oxygen is just dumb and educating the patients can be much harder than fixing the problems they cause.

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