Category Archives: Inspire me

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

 

Story 17 STEMI.31 F. Naaah.Really!!

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READING TIME 4 MINUTES

Case has been storified to protect confidentiality 

At Storifield Royal 04:15

I was in the later half of my night shift and was looking forward for my break. Almost there. I could smell the coffee. Just then I got thrusted with an ECG and 2 words

CHEST PAIN 

         SIGN PLEASE

Here are the 2 ECGs that were done 15 minutes apart

0652

0552

and this was my reaction to it

 

ST elevation can be seen  in lead II,III,AVF,V2-v4.

As I walked towards the patient, I saw a young lady sitting on a chair clenching her chest with her left hand and holding a 5 week old baby with the other. She said I woke up with this crushing chest pain. I feel I have been kicked in the chest. Pain was heavy, not worsening with breathing. She had cold sweats and was feeling nauseated. There were no co-morbids.

Nurse shouted her pulse is 56,  BP 138/66, SpO2 97% on air. She is afebrile. We got her on the trolley, moved her to resus, cannulated and gave her analgesia.

Examination was unremarkable.

Cardiologist were called and a decision to activate the cath lab was taken. Reluctant to let go of her baby, we reassured mom that both of you will be reunited soon.

Angiography showed that patient had developed Spontaneous Coronary Artery Dissection(SCAD)

dissection

The culprit vessel was successfully stented and she made a full recovery.

Check out this 30 second animated demonstration on SCAD

learningpoints

Inspirations:

Spontaneous coronary artery dissection—A review

SCAD: current insights and therapy


 

 

 

 

 

Story 13 Crashing dissecting patient and ultrasound chick

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READING TIME: 5.5 MINUTES

On one fine Sunday afternoon at Storifield Royal, a pre alert was received from paramedics

” 77 year old male has had a sudden onset of severe back and bilateral leg pain an hour ago. Now he cant feel his legs. He is too agitated due to pain so we have not been able to record any observations. Patient looks pale and unwell. ETA is 5 minutes”

So we geared ourselves up to receive the patient with likely dissection. Here is the timeline of this case.

00:00 Patient arrives to ED

00:01 Monitoring ,O2 applied. 2 x large bore IV inserted.Blood sent

00:03 Analgesia prescribed. P 118/min BP 105/66 

00:05 ECG done. Ultrasound performed.

Longitudinal view of aorta showing dilated aorta with false lumen. Intimal flap of aorta can be seen moving with cardiac contraction. Slide2Figure 1: Longitudinal view showing the dissecting flap separating the true and the false lumen.

Slide1

Figure 2: Transverse view. Aortic Aneursym measuring 5.1 cm

00:07 Surgeons and ITU bleeped

00:08 Patient arrested. PEA followed by asystole

00:16 CPR discontinued

These epic 16 minutes tells the story  why dissecting aortic aneurysms are ticking time bomb.

Rapid.Ultrasound in.Shock(R.U.S.H) examination can promptly diagnose life threatening causes of shock in ED.

couplet

rush 2

Read in detail about the RUSH exam by following the links in foot notes.

RCEM recently has raised awareness regarding missed aortic dissections

rcem alert

 

Inspirations

The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll.

Rapid Ultrasound for Shock and Hypotension – the RUSH Exam

RCEM alert

 

 


 

Story 9 The curious case of Cyclical Vomiting

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READING TIME: 2.5 MINUTES

28 year old women known to suffer from “Cyclical Vomiting” presented to ED as she felt poorly. Vomiting a dozen times daily was a routine but today was something different. She had thrown up >20 times in a day.

Her initial observations were

Pulse 127/min BP 95/59 SpO2 93% on air

Abdomen was tender in epigastrium with no guarding. She appeared severely dehydrated.

Initial blood gas showed

pH 7.2

HCO3 16

Base excess -11

Glucose 7.8 mmol

Lactate 9

Urea 8.1 mmol/L

No obvious cause of shock was recognised. Pt was resuscitated with IV fluids and was given broad spectrum anti-biotics.

Significant lab results were

Urea 8.9 mmol/L Creatinine 136 umol/L GFR 39 INR 1.2

After 3.5 litres of fluids, repeat ABG showed

pH 7.14 HCO3 13  Base excess -10 Glucose 14 mmol Lactate 11.5

 

So glucose was rising, acidosis was worsening & lactate was creeping up. ketones were tested which were high (6.6).At this point, patient was started on DKA protocol as she met the criteria(hyperglycemia, ketonemia and acidosis).

But this wasn’t a simple DKA. Patient was in multi organ failure with high lactate and refractory acidosis. CT abdomen was arranged and ITU were involved.

tmp4446_thumb22

Fig 1 Large amount of free air can be seen in the pancreas

This was a case of necrotizing pancreatitis associated with DKA and multi organ failure as a complication.She was taken to ITU where she made a gradual but full recovery.

moral 1 of the story 9

Inspirations

Emedicine

Case report

Case series

Story 5 Can’t breath, Can’t talk

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Pictures_7540-680x1024

03:00 14th October 1937 A&E Storifield Hospital

It was a  quiet night when the Resus phone went off. “We have a 59 year old male who developed sudden onset of shortness of breath an hour ago. He was “tripoding” when we arrived and saturations were 81% on air.On 15L SpO2 are 89%. He had no history of chest pain , cough, fever or any other medical conditions. Wife says he smokes a pack of 20 a day. He can obey commands but is unable to verbalise due to severe SOB. Pulse 115,BP 162/75,RR 45/min. We will be with you in 12 minutes.”

So we started our preparation. Possibilities like pneumothorax, asthma attack, pulmonary embolism and a cardiac event were discussed. 2 minutes later, the paramedic called back and said he is now unresponsive on AVPU scale. Bad feeling started to creep in. The speed of his deterioration mimicked ALS exam scenario. The patient arrived. I did the primary survey.

A:Clear

B:Silent chest bilaterally. Minimal expansion, symmetrical, Trachea central. SPo2 83% on 15L NRB. No stigmata of tension pneumothorax

C:Cold peripheries. P 123/min BP 162/89 S1+S2 audible

D: E1M4V1 Pupils 5 mm Bilateral and equally reactive.

E:NAD Temp 36.1

ABG: pH 6.98, pCO2 16.02 kPa, pO2 21.7 kPa, HCO3 27.8 mmol/L, base excess −7.5, lactate 2.7

BVM ventilations were initiated.He was cannulated and IV fluids started. RSI performed. Grade I intubation.

12 lead ecg and CXR were done next.

ecgchest

 

In the presence of silent chest,type 2 respiratory failure and no obvious pneumothorax on the x-ray, he was given 500mcg IV salbutamol but with a question that this patient had no prior history of asthma.Xray and ECG couldn’t explain the patients condition.

A RUSH(Rapid Ultrasound in Shock) was performed looking at the heart IVC and AAA. Echo clip is shown here.

Echo

A suggestion to perform CT head was discussed. But with a clear history of shortness of breath ,globally hypokinetic left ventricle and a GCS that dropped later, a collective decision to activate the cath lab was taken without performing a CT head. Angiogram showed severe left main stenosis which was successfully stented

So summing it up, this man had an occlusion of left main causing acute coronary syndrome and global hypokinesia of left ventricle leading to flash pulmonary edema. This led to severe bronchospasm , the silent chest and respiratory.

He was discharged home a week later.

learning tales story 5

Inspired by

Acute coronary syndrome(BMJ case report): A rare presentation

 

Story 4 – Eyeechooo: I wanted to blow my nose not my eye

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F2.large

 A 32-year-old woman with a painful swelling around the right eye few hours after blowing her nose, presented to the accident and emergency department. There was no associated history of facial trauma. Examination revealed a grossly swollen right eye and palpable subcutaneous emphysema. The patient’s visual acuity and eye movements were normal. A CT scan of the orbit confirmed orbital emphysema secondary to a fracture of the floor of the orbit into the maxillary sinus, as a result of increased intranasal pressure during nose blowing. The patient was admitted and managed conservatively with antibiotics. She made a full recovery with complete resolution of all her symptoms.

Read Full article on BMJ
 

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