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#14 Hulk Hogan’s ear wave & Compassion

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READING TIME 5 MINUTES

BACKGROUND

If you have watched Hulk Hogan wrestling, you would know he has been a hero to many. Among his many sensational moves was a signature “ear wave”. Take a look

Before the Hogan decides to take on the the poor referee, he performs his ear waves where he walks to all 4 corners and “LISTENS” to the crowd. He makes them feel important. He is indicating it to them that “I am a world champion but I am “LISTENING” to you”.

THE STORY

A 29 year old female presents with abdominal pain and increased work of breathing. She suffers from type 1 diabetic. Her blood ketones are 6.1 and blood gas shows

pH 7.15 HCO3 15 Glucose 29 mmol Base excess -12 Lactate 1.6

The conversation between the “Doctor & Patient” was as follows

Hi..My name is  “dr fast & the furious”. How can I help?

Well Dr I have diabetes and

Do you take insulin?

Yes I am on insulin but yesterday I was feeling poorly. I had this terrible belly pain & felt like..

Did you had any vomiting…

No but I was…

any diarrhea…

No…

burning urine…

No..

Chest pain..

No…

Allergies…

No…but Doctor I was saying that I felt nauseous yesterday and didn’t wanted to…

Have you been taking your  insulin regularly..

Yes…

Okie I am just going to review your blood results and will come back to you..

Doctor reviews the results and makes the correct diagnosis of Diabetic Ketoacidosis, writes the correct management  and refers the patient to medics. He then carries on seeing other patients and doesn’t get time to get back to this patient. She goes to the ward, gets better gradually and is discharged 3 days later. After few  of weeks later, ED department receives a complaint letter that says…..

 

I would like to express my concerns regarding the contrast in  care I received between emergency department and the medical ward. As soon as I reached ward, doctor explained to me what was my condition, listened to me and treated me. I started feeling better after few hours. I felt the doctor in ED acted more like a traffic warden who just directed me to medical ward .I felt I was not listened to. How could the doctor have diagnosed me when we wasn’t even listening. I understand the busy and noisy nature of A&E but strongly feels that ED doctor should have spent minute or two to listen to what I had to say.

MORAL

ED compassion is as important for patients as giving good clinical care. Though there are many scientific papers and theories behind ED compassion, true delight of compassionate care comes from an introspection. Here is what I have found by listening…

5 lessons learnt

Be an ED hero

Have a listening ear

Let your patient know

You have time to hear

So next time when you are treating your patient,                         ask yourself have you listened?


 

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 11 Situational Awareness: From Bean to Spiderman in 2 minutes

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READING TIME:6 MINUTES

“Situational Awareness” or shall I say lack of…

So this is what happens when I lose “Situational Awareness”

& this is why “Situational Awareness” is essential.

This is a kind of junction I used to cross during my college days. All I had to do to keep my  “Situational Awareness” was to look 1-left, 2-right, 3-straight, 4-back mirror, 5-both side mirrors, 6-repeat all steps every 5 seconds. I wondered if this could be applied in Emergency Department to gain Situational Awareness!

So here is the story of one fine Resus shift

SLIDE 1

Situational Awareness has 3 components

SLIDE 3

A commonly used tool in US air force pilots to gain situational awareness at speeds of MACH 2  is OODA loop. Though we don’t break sound barrier, but sometimes the speed with which new patients arrives to Resus is not far behind.

SLIDE 4

So I applied this to my situation. Here is an example

SLIDE 5

and there I was…From BEAN to SPIDER-MAN in 2 minutes

 

SLIDE 6

Inspirations

Airmanship (Book)

Situational Awareness(Wikipedia)

Human Factors and Quality in Resuscitation(Resus Council)

 

Story 10 Paracetamol Clock

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READING TIME: 2.5 MINUTES

At your finger tips… ” WHAT actions to take WHEN at WHAT times” in paracetamol overdose(click to enlarge).

PARACETAMOL CLOCK FINAL4

INSPIRATIONS

Paracetamol overdose performa(Martin Wiese)

Toxbase.org