Excellence in Failure

It was a fairly typical Winter Saturday lunchtime in the Emergency Department.  Busy enough with the season's faire: chest infections, falls on slippy pavements, road traffic accident victims, but we had kept up with demand through the morning, and the place was under control.  As I was just considering this apparent control, our tannoy system bellowed out:


This means that ambulance control have requested the assistance of staff from the ED to attend an incident to help manage a patient or patients.  These incidents can be extremely variable, from trapped victims in cars, patients who are violent and aggressive,  patients in cardiac arrest, to major incident situations.  We train all our Emergency Medicine doctors in these situations, and try and provide an Emergency Medicine consultant to all incidents, depending on how busy the department is, as the whole Medic 1 team, nursing and medical, is spared from the departmental core staffing quotient.

On this day, with things under relative control, I decided to go with one of our senior trainee doctors and the nurse to the incident - a patient who was found unconscious near the bicycle he had been riding

Having confirmed we had all the equipment and medication we might need, we dashed out to the waiting ambulance to take us under blue lights to the country road where this unfortunate man had been found.

After a nauseating 20minutes spent being hurled around the back of the ambulance, and having gone over our procedures for when we arrive on scene, we get to the incident spot.  First job: establish some lines of communication.  Information is very scanty, with no witnesses, and we get a clinical handover from the paramedics. 

"Approximately 40yr old male, found by his bicycle, no sign of injury, helmet undamaged, GCS 6, airway difficult to manage..."

We move to the patient, where the other paramedic is supporting his airway so the man can still breathe.  He is partially conscious - GCS is the Glasgow Coma Score, a score of 6 is not good - and his eyes are closed, he is groaning and grunting, and occasionally he is making abnormal contracting movements with his arms and legs. 

One thing is certain, his brain is not happy.

This may be because he has fallen and injured his head, or he may have suffered a sudden bleed in his brain that caused him to fall.  At that moment in time, it is largely irrelevant to us.  The priority is to prevent any further damage to his brain, and to do that, we need to place him in a medical coma and take over his breathing, whilst trying to support his other body systems and thus his brain.

We quickly establish roles to perform the next stage of this, an "RSI" - Rapid Sequence Induction (of anaesthesia) - followed by intubation of the windpipe to take over the breathing of our patient.  This is the most risky part of the treatment, as we are paralysing the patient so he will stop breathing, and if we cannot secure a tube in the windpipe rapidly before his oxygen levels drop, we may cause more damage to his brain.

Our senior trainee is "at the head end" and he will be doing this procedure.  We go through our checklists, prepare all our drugs and equipment, and verbally rehearse what we will do if the worst happens and we cannot get the tube in the correct place.  The monitoring is attached, and checked. 

We apply high concentrations of oxygen to buy our patient (and ourselves) more time to achieve our goal, and the monitor is beeping a healthy high-pitched beep telling us the oxygen levels are as high as they can be. 

"Thio 300mg in; Sux 100mg in; Flushing well."  I say as the anaesthetic and paralysing drug are injected.

We wait the aching 20-30seconds until we get the tell-tale twitching of the neck and chest muscles, demonstrating the action of the paralysing drug.

A few more seconds, the patient is now not breathing, and all his muscles are now slack.

Our trainee then starts to align the mouth with the opening of the windpipe using a laryngoscope, so he can insert the breathing tube into the windpipe.  This is always more difficult in patients where we are worried about a possible neck injury, and in many other situations where we can predict a "difficult airway".  On this occasion, he struggles to get a view of the opening. 

"I can see epiglottis but not the cords - I'll go with the bougie."  This is a flexible gum elastic pipe that can be used to guide a breathing tube over, and can be used "blind" to find the windpipe.

The beeps are getting less high-pitched.

There is a critical point in this procedure when a decision may have to be made to accept defeat, to pull back, ensure safe oxygen levels despite a less-than-ideal protection of a patient's airway.  It requires a certain amount of humility and situational awareness, which are not universal characteristics of all doctors.

However, in this instance, our trainee rises to this particular challenge.

"I've failed, lets pull out and re-oxygenate."

We remove the tube and laryngoscope, and together use a 2-person technique to quickly re-fill our patient's body with oxygen, and, as planned, we move to "Plan B" which involves a more experienced technician at the head end.  We get the tube into the windpipe, and we are able to safely transport our patient to the ED for further investigations and treatment.  It turns out he had collapsed due to bleeding in his brain, and not fallen, and was rapidly transferred to our neurosurgical colleagues at the Western General Hospital.

Our trainee has had an invaluable, though nerve-wracking, learning experience that he has handled with calmness, professionalism, and with the patient's best interests in mind. 

As a trainer of doctors, and possibly a future patient, I can't ask for more than that.