Day 302 Drowning

It's 630am in the morning. I just finished another 24 hr call. (This is the 3rd Saturday in the last 4 weeks) I'm a bit exhausted, but I wanted to write down the events of last night. It was a very busy night and very stressful at some points. I was called by a nurse at around 11pm because a patient was desaturating on the floor. She was an elderly lady with chf and pneumonia. I was told over the phone by the nurse that she really didn't look good. I was a bit surprised to hear about it because I was the only resident on the telemetry floor. The admission was done by the other intern and he didn't let me know she was going tho the AMU. What followed next I will never forget.

I went to the telemetry unit to see here. She was extremely anxious, and was saying that she coudn't breath. I check the pulse oximetry and she was at around 80% !! She was about 85yrs old and her code status was AND without intubation. They had her on a non-re breather mask with 100% oxygen. I called respiratory and ordered the usually ABG, EKG, Xray,CMx2. The respiratory tech came and was getting the ABG, and in the meanwhile I called the attending to let her know what was going on. It turns out she was aware that she was really sick and that the family wanted to make possibly comfort measures. I returned to the room, and then all hell broke lose. The patient was now really anxious, she was crying softly and saying "I can't breath !!! HELP ME !! HELP!" I tried to stay calm. I looked at the respiratory tech who had been trying to get the ABG for about 10 minutes (possibly even more). I told him forget the ABG lets put her on high flow oxygen and if we have to we can use bipap. He left the room and went to get the high flow system. I then look over to the lady and she was on the non-re breather mask and she talked slowly and weakly lifts her hands up and try to pull of the facial mask. I try to calm her down. I examined her and even without my stethoscope I could hear the rales. (I had also seen the previous xray of the chest. She has pretty bad CHF , effusion and infiltrate. The xray looked pretty awful!) I loaded her with another does of lasix 40mg IVx1. While we are waiting for the respiratory tech to get the supplies, I try to calm the lady, but then she is starting to cry a bit and keeps looking at me and the nurse "HELP me please... I can't breath." I grabbed her hand and tried to reassure her "WE are going to give you something to breath better. WE are going to give you another mask so you can breath better...ok.." I don't think it help much. She was kicking her legs out and kept on saying "help me..help me." It was so horrible. I got the sense that she probably felt like she was drowning, since she was in CHF and had very bad infiltrates. (She didn't have any severe plueral effusions, in which case she probably would have needed a thoracic tap. I doubt the attending would have agreed to it.) For a minute I wasn't sure what to do. (I didn't want to give her ativan and sedate her.) By this point the other first year had arrived in the room (he had done the admission) He seemed a bit worried. I ordered some respiratory treatments in the meanwhile. I then thought about giving her morphine -for the anxiety properties and for its dilatory properties. I told the nurse to give her 2mg IV morphine, which I placed in the system. By this time about 15minutes passed and we still couldn't find the respiratory tech. The nurse manager walked in, and was upset. "Where is the respiratory tech? He never gets the ABG. He always passes it on to somebody." She went back to the station and started paging the tech. I went back to the room and was trying to comfort the patient. She kept anxiously saying "I can't breath with this mask." We checked the mask to make sure it was working properly. I got the sense that she didn't like how the mask made her feel. I think she felt as if it was suffocating her. And she was acting as if she was "drowning". I tried to stay calm. It wasn't the first time I have seen someone de-saturating and having troubles breathing. And they tend to be a bit lethargic and non responsive. But this is the first time I had someone yelling "PLEASE HELP ME! PLEASE!" While she was on the non-rebreather mask her saturation still was low about 80 percent and fluctuating. Since she kept fighting the mask, we tried to give her Oxygen by nasal canula, but her saturation dropped to about 70%. I wish I could describe to you situation better so that you can get a sense of how this lady was softly screaming and in distress.

A few minutes passed, and finally the respiratory tech appeared with the 100% high flow oxygen system. I told him "lets try the high flow, and if she doesn't improve we can always put her on bipap" He agreed and put her on the high flow system. Its high flow oxygen, but its with a longer nasal tube and has 100 percent high flow oxygen. I didn't want to do bipap yet. I think if she would have seen the bipap mask she would have been extremely agitated. We placed her on the system, and her saturation started to go up around 90%. I check back her meds,and she was on morpine 1mg IV q2h prn. I told the nurse to give her the morphine every two hours so that she can calm down. In about 20 minutes my prayers were answered. ( I had been praying in my head) She was sating around 95 %. And was not acting up. She was calm. It seemed the morphine was having its affect and the high flow really helped. When I saw the situation had calmed, I took a step back and went to the lounge to take a short break and get a cup of water. I felt so relieved. It felt as if I had run a short marathon. I checked back on her in about 30 minutes and she was sleeping comfortably in the room and saturation was 100%. I spoke to the tech to try to titrate down the oxygen, since she was on 100%. He brought it down around 95% and was going down slowly. I also put her on respiratory treatments to help her breath better. (We tried to previous also give her respiratory treatments, but her saturation dropped 80%. )

I hope I tried to explain the situation as best as I could. I'm really glad we were able to help her. Even if its just to help her breath a bit more and so that she won't feel like she is drowning.

Hard to believe how going through scenarios like this you learn to stay calm and try to do certain things to help the patient. If you read my first experience with a similar situation I had in the
Intensive Care unit my first week of residency!! (Day 5 http://thankyougodforresidency.blogspot.com/2008/06/day-5-good-bad-and-ugly.html) They say the long term memory is instilled in you when you have vivid experiences of them. The more unpredictable and different the situation is, the more you remember it. Some of the most stressful moments I have had, have also been the most educational.

For those that are starting residency soon. Work hard and be a good active participant in your residency. Stay close to a senior you can talk medicine with. You will have seniors that you don't feel comfortable asking certain things because you don't want to seem stupid. But find the seniors that are patient and are able to help you out in any situation. You will see that the more situations you encounter, the more you will feel comfortable.

It's 8:30 in am now, I'm gonna try to get some rest.

God Bless

Dr.Mike