Thursday, February 8, 2007

PostScript


Doctor, Please Don't Let me Die




I was at the end of an uneventful week of overnights; no sick patients, no traumas, a bit disappointing. What would be different about this night? I hoped nothing since I had to leave the hospital early to catch a flight to California. Do I have to say it...1 am and the trauma phone rings – the dispatcher notifies us that EMS is bringing in a man who was just shot in the chest. Supposedly he is a taxi driver who was robbed after 5 men got in his cab and put a gun to his chest demanding money. I heard that the driver tried to run, was shot, but still managed to scamper away until he collapsed to the ground. Sounds like this may be an interesting case, maybe a chest tube, even an intubation.

The trauma team assembles.

EMS finally arrives with a young appearing man. He is lying on a backboard with his eyes open. I think to myself that this will be another run-of-the-mill case, the trend of the week. He is transferred to the stretcher where I am at the head of the bed looking over him. His eyes are moving all over trying to see what’s going on. It must be very unpleasant what people feel when they are brought into the trauma room. The second they arrive, they are transferred to the stretcher and then all hell breaks loose. A team of physicians just start doing things while they are telling you to calm down, it will be alright, and asking you a slew of pointed questions like, “do you have any medical problems, any allergies, take any medications, when was your last meal?” As you answer these questions you feel your clothes being cut off. Ok, I can lose my $10 T-shirt, ok; I can loose my $50 pants, as long as my life is saved. Wait, those are my underwear! The patient lays naked on the stretcher, the exposure portion of trauma management. A missed injury may be disastrous; like a bullet wound in the groin that you didn't notice because you didn’t want to take off the patient’s underwear.

While the interns are disrobing the patient and trying for IVs, I am looking into the patient’s eyes, specifically his pupils to check for any evidence of brain injury. I don’t expect to find anything abnormal in this patient since he was shot in the chest. What I do notice, though, had nothing to do with medicine. The patient has a look of fear in his eyes. He became numb to what was going on around him and spoke in a sobering tone, “doctor, please don’t let me die; I have four children at home.” As he says this, the nurse calls out that his blood pressure is 80 mm Hg over palp – too low.

Something is wrong.

The team leader looks at me and says, “Tube him now!” With the laryngoscope in my left hand, I look into the back of his throat. I am trying to spot two little white cords that denote the entrance to the trachea. It’s funny how a cardiologist can take a stent or a small spring, make an incision into your groin through the femoral artery and place this stent into a tiny coronary artery, relatively far away from the entry site. It is rare that you hear a cardiologist say, “Damn it, I can’t find the coronary artery!” Or a gastroenterologist who takes a 5 foot tube and is able to visualize every aspect of your intestines. Why is placing a tube just centimeters further than the back of the patient’s throat sometimes seem like the most difficult thing to do?

As I look into this patient’s throat all I see is, well, throat! There is no trachea, no white “cords”. All I hear in my head is, “please don’t let me die, please don’t let me die”. And all I am thinking is, “please don’t let me be the one who kills this guy!” Seconds feel like minutes. I hear the nurse say his oxygen level is dropping; I maneuver around a little more, a bead of sweat drips off my forehead. I can’t see it. I pull the laryngoscope out and start to manually deliver oxygen into the patient’s lungs with a bag-valve-mask that is connected to oxygen. I hear air leaking from the sides of the face mask. It must be his goatee, I say to myself. Damn it, I can’t create a seal around his mouth, oxygen is not reaching his lungs.

I hear the constant ringing of the monitor-bing, bing, bing-reminding me that the patient’s oxygen level is too low – incompatible with life if not corrected rapidly. “Don’t let me die,” echoes in my head. The attending physician shouts, “Get the tube in!” I take another look, laryngoscope in hand I lift up the patient’s tongue. I can see his epiglottis – I feel somewhat relieved because under the epiglottis is the pathway to his trachea. I need to lift this small floppy piece of tissue out of the way. It feels like lifting a manhole cover. Finally, I spot two glistening white cords and like a dart hitting the bull’s-eye, insert the tube into his trachea. I connect the tube to oxygen and start pressing on the bag to inflate his lungs. “Oxygen level is rising,” says the nurse. “Thank the Lord!” I say to myself.

I secure his airway and watch as the trauma surgeon assists the intern place a chest tube. As they enter the chest cavity approximately 500 milliliters of blood splashes onto the floor. That’s equivalent to 1.5 cans of Coke. No wonder his blood pressure is so low. In order to keep up with his blood loss, we start a blood transfusion and give him intravenous fluids wide open. The bleeding seems to be slowing down and his blood pressure gradually rises to an acceptable level.

The surgeons take him away – still alive.

"PostScript" is a column designed to post moving, comedic, or interesting stories from anybody who works in or is a part of the health professions. All comments are welcomed.

Please feel free to share your story. To have your story posted, please send it by email to nyemergencymedicine@gmail.com

4 comments:

karen routledge said...

Hi Adam (and anyone else who was there)...so did he live??

Adam said...

He walked out of the hospital a few weeks later.

Anonymous said...

How is the patient?

Wyatt said...

Well told, you really captured the fear and sense of panic of the moment. It's weird how much it matters if the patient dies because you versus somebody else couldn't get the intubation.