Last Gasp Effort

It was a fairly standard Monday morning in the Emergency Department at the Royal Infirmary of Edinburgh.  I was on duty for "resus & results" - trying to make some headway through all the results from investigations ordered from the preceding few days and signing them off or following them up, plus also providing clinical leadership for our resuscitation room cases.

We had just started thrombolysis (clot-busting treatment) for a patient in one of our resuscitation bays in collaboration with our colleagues in Stroke medicine, when another call came in:

"Crash call, arriving Resus in 4 minutes!"

Checking results would have to wait for now.

"What's coming in?" I asked our senior nurse who co-ordinates the resus room activity.

"55yr old short of breath."  She tells me and hands me the slip of paper with the Ambulance pre-alert information.

There is nothing else to learn from that, so we set about preparing for our next patient.

Those 3 or 4 minutes waiting for patients can sometimes be helpful moments to talk through roles and immediate tasks that are likely to be required, bearing in mind we have no idea what may be the cause of this patients breathlessness.

Our patient arrives, and immediately we realise all is not well.

"He just started this sort of seizure activity on the way in the door..." The paramedic explains.

Our patient is in a rigid position, with an ominous blue tinge to his lips, staring eyes and a sweaty brow.  He is not responding to us or the paramedics, and we rapidly haul him over to our trolley and listen to the story of our patient.

"See if you can get some access." I ask our doctor in training as the paramedic starts telling us some information.  An IV drip will be really important to give treatment through in this situation.

I am trying to gauge the patient's effort of breathing whilst listening to the story.  We will need to settle him quickly and try and improve his ability to ventilate if he is not to deteriorate.

" This is Archie, a 55yr old man, lives independently with a friend, has an inhaler for asthma, and has been struggling for breath all weekend.  He has been bringing up some spit, but he hasn't been able to talk since we got to him.  He was just sitting on his bed with his hands on his knees, nodding."

This position - tripoding - as well as the inability to say anything, are very concerning signs.

And then, to confirm all our fears, Archie stops breathing altogether.

His body goes slack.

I support his airway whilst the paramedic checks for a pulse in his neck.

"There's no output." He tells the team.

Some curses fly through my mind, followed by a rapid calculation of what we need to prioritise over the next few seconds then minutes.

"Shall I start compressions?" The paramedic asks.

"Yes, thanks." I say, and I start ventilating the patient with a bag and mask.  We are now in a completely different scenario to the one we were expecting, but one which we are all trained and prepared for.  We will just need some more pairs of hands.

"Could we have a couple more trained nurses in the room - we'll need a whole list of drugs very quickly?"

We will also have to plan for rotating the team members doing chest compressions.

"Have we got an IV line in?" I ask, and our excellent junior doctor replies in the affirmative.

"Let's give 1mg adrenaline IV, please."

We ensure the stopwatch is started and connect some monitoring, whilst preparing for putting a tube in Archie's windpipe at the 2 minute mark.  Once we have secured the ability to get oxygen into his lungs, we will then have the perhaps harder task of trying to break the critical obstruction that exists there to allow him to ventilate.

The first 2 minutes are up, I put a breathing tube down into the windpipe, and check it is in the correct position.  The chest is moving as I squeeze the bag attached to the tube, but not by much - it feels "tight". 

The paramedic has done an incredible job with chest compressions, as Archie is still trying to make some effort to breathe.  We check the electrical signals from the heart on the monitor - these look encouraging.  We feel for a pulse - he has an output again.

Now we have to ensure he is anaesthetised and paralysed to maximise the ability for us to ventilate Archie, and also to make sure he is oblivious to this ordeal.  Following this, we connect Archie to a ventilator, but not before we have squeezed all the trapped air out of his chest.  This is a common problem in severe asthma, when, because it is so difficult to breathe out (not in), air stacks up in the lungs, making the chest fuller and fuller of air that just gets in the way.  We often have to disconnect all the breathing tubes and literally squeeze the air out of patients, like playing an accordion.

This done, we then throw the asthma "kitchen sink" at Archie, with various drugs that will all hopefully help open up his airways and break his wheeze.

Within an hour, he was looking pink again, and the pressure in his chest had decreased markedly.  He has good levels of oxygen, and spends a day or two in the Intensive Care Unit, but is able to go home after his (and our) scare a week or so later.