Story#20 Dirty Dozen, Titanic and Mr Bean

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Reading time 5 minutes   

Background

Human factors are commonly found to be the underlying reasons behind most aviation accidents and are famous as dirty dozen. As an ED and pre-hospital physician, we interact and work in flash teams all the time in extremely high risk circumstances. But can we train our selves to minimise these risks? Lets watch how Bean copes with stressful situations.

Bean = You(just assume)

Going Downstairs = Procedure

Lady = Check list

 

Elderly Man = Complication

Story

Its 0645 and only 15 minute to handover. What has been a very challenging shift for resus staff, they just have to sort one last patient out.

It is a 71 year old bradycardiac man with a heart rate of 30/min. Except feeling light headed on standing up, he is otherwise asymptomatic. His BP is 144/77, SpO2 98% on air & RR 18/min. His PMhx includes hypertension and ischaemic heart disease for which he had CABG 2 years back.

The ECG shows Mobitz type 1 heart block. While awaiting cardiology review, doctor decides to give 0.5 mg of atropine to record the response. While the nurse is getting atropine out, she notices patient goes pale and unresponsive. ECG shows asystole.

Call for help is given and the team starts CPR. The doctor leading the arrest says to  the nurse  ” What took you forever to give atropine”. He then tells her to give adrenaline 1 mg. A bit shaken, she carries on giving the drug.

ALS is carried for 2 minutes. On next rhythm check, patient is still in asystole. CPR is resumed. Doctor asks the nurse again to prepare adrenaline for the next cycle.

On the next rhythm check, patient has an organised rhythm and a pulse of 28. Blood pressure is 110/60. The doctor says to the nurse in rather impudent tone ” now give it(atropine) before he arrests again”. She gives 10 ml of 1:10000 adrenaline instead. The patient arrests and CPR is unsuccessful.

The nurse later tells that she knew doctor meant atropine but in a rush gave the mini jet of adrenaline that was in her hand.

The doctor said he had issues with this nurse as she was not prompt and he had to carry out most of the treatment himself for the patient. He couldn’t remember if he wasn’t clear enough in asking for atropine post ROSC/

Other team members felt there was no coordination in team. They also felt that busy shift meant they couldn’t get their breaks properly and everyone was tired. They also had few sicknesses which led to current staffing level being dangerously low.

Do you smell dirty dozen? 

 

Moral

Here is a 2 min clip from Titanic about all 12 factors in dirty dozen.

 

And now watch the true story of Elaine Bromiley who died as a result of attempted routine sinus operation that when horribly wrong..

If you feel others will benefit from this post, kindly share.


 

 

Story 19 Small pneumothorax, severe SOB and our thinking processes

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Reading time 6 minutes

Storified

At Storifield Royal, Wednesday 21:35

The pre-alert phone rings..

” Hi Resus. We are bringing a 69 year old female who developed severe shortness of breath this evening . She had an operation done on her left lung 2 weeks ago but we are unable to get much history due to her respiratory distress . She was discharged on Monday( 2 days ago). I have her discharge letter which says a lung nodule was removed from her left lung along with partial lobectomy. Her Hospital no. is DIB-123-SOB & obs are

P= 119/min      RR 40/min       BP 106/66 

Temp 36.2       SpO2 85% on 15 L NRB mask

ETA is 4 min. “

4 minutes of pre-alert were used to do the following:

Review of discharge letter – patient had a solitary lesion on left lower lobe . A lobectomy was performed to remove this lesion. Pt had developed pneumothorax on left side post procedure which was drained . Her chest tube was removed 1 day prior to her discharge.No other significant Past medical history.

Preparation for ABCs

Team briefing – SHO tasked  to perform ABG . Nurse to cannulate and take blood samples. ITU on stand by.

The patient arrives. At a glance,

A:Patent and clear. Trying to speak but unable to say anything due to severe shortness of breath

B: Normal sounds on rt side. Unable to auscultate on left side due to sub cutaneous emphysema.

SpO2 89% on 21 L( 15L/min NRB + 6L/min nasal cannulae)

RR 44/min

Chest expansion bilaterally symmetrical. Trachea central.

C: Pulse 122/min BP 110/71 Abdomen soft

ECG showed sinus tachycardia and incomplete RBBB

D: GCS 15/15. Neurologically intact

ABG( on 21L/min)

pH 7.29 pCo2 3.9 pO2 9.9 HCO3 21 Lactate 3 BE -4

Furthermore, a bed side echo was attempted but due to the presence of sub-cut emphysema and respiratory distress, optimal cardiac window couldn’t be obtained.

By this stage, I have formed the diagnosis using my type 1 thinking (types of thinking explained below)

It has to be a Pneumothorax.  Subcutaneous emphysema, history of operation on that side, post op insertion of chest drain for pneumothorax , what else could it be?

Even though patient was severely hypoxic, a blood pressure was stable. A quick portable chest x-ray was performed.


 

CXR showing small left apical pneumothorax

CH08b

I was not amused!!!angry-funny-face-of-baby-boy

As per my type 1 thinking, x-ray would have revealed a big pneumothorax. Findings were not adding up. Small pneumothorax couldn’t explain patient’s condition. A look back at her x-ray on discharge showed apical pneumothorax on left side was old and was persistent post chest drain.  It was a time to put a different thinking cap on (type 2)

Before we move on, let us just watch a short clip to help us understand types of thinking processes. No animals were hurt in the making of this video!!

This is what is going through goat’s mind

 I ve been put down. I have seen it in the past what happens next. Oh there comes the  knife over my throat. Oh dear….

Goat’s fast, intuitive reaction and instantaneous decisions with TYPE 1 THINKING tells her that she must be dead.She stays still.

After few seconds, she realises something is different. She doesn’t feel dead. When made to stand up, using her focussed decision making & reasoning with TYPE 2 THINKING PROCESS, goat decides to walk away. Sheeww!! What a relief.

In our patient, old persistent pneumothorax is not the reason for the new SOB that she developed 2 hours earlier. With relatively normal looking chest x-ray , a decision to perform CTPA was taken. Patient was given sub-cut low molecular weight heparin while awaiting CT. A scan was performed with the support of ITU colleagues.

Arrows showing bilateral emboli almost completely obstructing the pulmonary blood flow.

On return from scanner, pt’s blood pressure had dropped to 89/60. Patient was thrombolysed using IV alteplase resulting in immediate improvement of her symptoms. Oxygen requirement reduced drastically to mere 6 litres/min over next 45 minutes while alteplase was being infused . Patient was admitted under thoracic medicine for further care. She made a complete recovery and was discharged home 2 days lateron long term anti-coagulants.

 

learningpoints

Inspired by

2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

LITFL Thrombolysis for sub massive PE

LITFL ECG in pulmonary embolism