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Wednesday, February 20, 2008

An RTs worst nightmare

I certainly picked a good night to come back to work -- a full moon. Hopefully a full eclipse of the moon brings me some good luck as opposed to the usual bad luck normally associated with full moons.

I'm sure I'm not alone in dreading the first day back after a long vacation. But was especially dreading coming to work tonight considering the last six days I worked were pure hell, and the last hour of the last day before my vacation were the worst ever.

When I say the worst ever, I mean it. Think about this a minute: As an RT, what is your worst nightmare?

Mine is that I'll stare at a piece of equipment when a critical patient is depending on me, as are the nurses and doctor, and not have a clue what to do.

The EMTs informed us enroute the patient would need to be intubated as soon as he arrived in the ER, so we had all our stuff ready. And when he arrived he was blue, moderately labored, but I had seen people in worse condition not be intubated.

Whether or not the patient would be intubated was completely dependent on the doctor on duty. In my opinion, probably 90% of doctors would have intubated this guy right away. But, we weren't dealing with any normal doctor this night, we had doctor Krane, one of the best doctor's in critical situations.

Instead of panicking and intubating, she ordered me to set up BiPap. Considering how the patient looked, I rushed upstairs to grab the infamous Vision BiPap system instead of using the LTV 1200 that was setting next to the bed for such circumstances.

To be honest, the only reason I didn't use the LTV was because I forgot it was there. Up to this date, I had never had a problem using it as a BiPap, although I had read about problems other RTs at other institutions had had with it.

Once the Vision was set up, the patient's SpO2 jumped from 40% on a NRB to 98% with only 60% FiO2 dialed in. And, within a half hour, the patient noted that he was breathing fine.

But, his X-Ray was whited out. According to Dr. Krane, the patient was in ARDS possibly secondary to bilateral pneumonia, but, she said, even that was difficult to diagnose at this juncture. And, secondary to being hypoxic so long, the patients cardiac enxymes were starting to rise, indicative to cardiac damage.

The patient needed to be shipped. No problem, right. As soon as the EMTs arrived the patient would be out of my hands, especially since the EMTs in our area now have their own ventilators.

When the EMT arrived pushing the LTV 1200, I felt completely confident this would be a quick and easy transfer, until Bill said, "Gosh, Rick, I've never set this up as a BiPap before."

"I have," I said confidently. "I'll set it up for you."

I pushed the button, and the damn thing would not go into BiPap. Bill and I felt equally stupid. Finally I gave in, and called my boss, hoping she would remember. What she told me was exactly what I had already been doing.

"Well, come down here anyway," I said to Boss, "We could use a fresh brain."

Bill and I laughed at that, considering he had been up for 24 hours at this point, and if it weren't for this transfer he'd probably be on his way home by now. And I was in the last half hour of my 12 hour shift. I was quite beat, as it was a swamped night. We were both burned out.

Just as Boss arrived in the ER I realized what hadn't before, and Bill and I removed the vision mask from the patient and set the LTV BiPap on the patient. According to the vent, everything was working fine. But the patient was panicking. "Take this off. This isn't working," he chimed.

The nurses were trying to fix the mask, but I knew the problem was with the machine, even though all indicators showed it was working. The patient was getting the dialed in VT, RR and pressure.

I felt especially stupid because I was the one who trained every one in my department and the EMTs how to use this vent as a BiPAP. I suppose my mistake is that I disregarded warnings that it didn't work well as a BiPAP more so because I had used it on other patients and it had worked just fine then.

I checked the internal settings. Everything was set appropriately. The machine was simply not working with this patient.

Then a lightbulb went on in my head:

Flow. It's not giving the patient enough flow. Isn't that the big complaint about using the LTV as BiPAP. This patient isn't getting enough flow

"It's not the mask, you guys," I said. "This isn't working. Take the mask off."

I set the Vision back up, and the patient was fine. "Ah, much better," he said.

It had occured to me then that we had never tranferred a patient before on BiPap. We had always just intubated patients. But, as Dr. Krane assured the RNs, "This patient is doing fine on BiPap, he doesn't need to be vented."

And she was right. He was awake, alert, orientated and breathing fine on the BiPap. So long as he didn't need to be suctioned, and so long as he wasn't a candidate to vomit, he would do just fine on the BiPap.

But, we needed to transfer him.

"Can we send him on the Vision?" Bill said. He lifted it right off the stand. "I think this will fit in the rig."

Sometimes in this job we have to jury rig.


The Anonymous Therapist said...

I had a similar embarrassing moment the other day. I had just gotten a vented patient post-op, and I attached the vent and began replacing the anesthesia tape with our tube holders. Somebody mentioned, "Hey! His sats are dropping." I stared at the patient, and everybody was trying to figure out what was wrong.

After a good minute or so, the anesthesiologist whispered to me "You forgot to push 'start' on the vent."


Freadom said...

It happens to the best of us. LOL

About ten years ago I took a job at another local hospital. This was back in the day we used water traps instead of heated circuits. I cut the tubing to insert the water trap, just like I would here at Shoreline, and realized the circuit didn't fit the traps, and also didn't fit anywhere near the Y. The feeling was, "Oh, shit! Now what do I do?"

Glenna said...

I've done it too. I picked up a patient in severe respiratory distress one time in the ICU, also not intubated and on the Vision and everything seemed to be so right except the patient's sats. Plenty of flow, great mask fit, etc. Uh huh. Then I finally noticed that I'd forgotten to plug in the O2 line. It happened we had some students working clinicals that night with us and I told them "Let this be a lesson to you. Seriously, EVERYBODY makes stupid mistakes so when you make a mistake don't feel bad. Just correct it as quickly as you can." Everyone in the room including the nurses and my team leader laughed, agreed, and started telling stories. We all stare stupidly at something once in a while before we figure it out!

Anonymous said...

For my first extubation as a student, I forgot to deflate the cuff on the ETT when I pulled it off. Needless to say, the patient was "speechless"....