Wednesday, November 18, 2009

Cometh The Hour

I have found this difficult to write about.

I suspect that we all, at one time or another have confronted our worst fears, either really, or in our minds. If you haven't you should.

It still might not be enough.

To me, an Emergency Physician is one who knowswhat needs doing, and how to get it done, in any given situation. Frankly, most of what we do, most of medicine, is not time critical... in as much as you can spend a few minutes mulling over your options.

The way I see it, my paycheck is the massive hoard it is because once in a while we don't have that luxury.

Imagine this.

Let us say a patient has been brought to you, having arrested out of hospital. They have survived, which is, in itself, a rareity. But they are now unmanageable, and need 'optimising'. In short they need their physiology dominated, by us, and controlled to maximise their eventual function. This will necessitate airway control; in this situation, there is a ittle time. The patient is maintaining an airway, and oxygenating and ventilating adequately, for now. It won't last. He will need intubation, and have to, effectively undergo a general anaesthetic.

You call for help from ITU, and go to talk to the family, update them and gain information. On hearing the phrase "general anaesthetic", the family immediately venture the fact that this patient has a difficult airway; you report this to your ITU colleague, and go back to the family. Having tidied things up at that end you return to your resus room, to find that the shit has hit the fan.

I had figured that we would wait until all the extra "difficult airway" kit was ready, and all hands were on deck, but somehow, matters had proceeded rapidly to a "can't intubate, can't ventilate" situation, in my absence.

For those of you not of a medical bent, this is my worst nightmare. Having paralysed a patient to pass a tube into their windpipe, you find you cannot pass the tube ("can't intubate") and moreover, you cannot force air into their lungs using a standard bag and mask combo ("can't ventilate".) In short, having stopped the patient breathing for themselves, you find you are unable to do it for them.

This is, I would argue, one of those time critical moments.

You should anticipate this sort of thing, prepare for it, be ready.

Walking in on it is not ideal.

Could you step up to the plate? Make the difference?

3 comments:

Anonymous said...

Betadine, blade, dilate, tube.

The time when those are in my hands rather than in my head terrifies me.

DrShroom said...

This is precisely what I should have done, on reflection, and it is to my eternal discredit that I didn't...

DHS said...

it's easy for me, as a disinterested bystander, to say those words. It's much harder to be there and make the decision, and it is not to your discredit that it didn't happen.