Remember back in October when I was bloggin about how slow it was here at Shoreline? Those days are long gone. I haven't been able to do any blogging at work, which is fine, because I've been enjoying facing some of the challenges that have come my way lately.
Just this past weekend I had a call from ER that a 500 pound man was being brought in who was in respiratory distress. Learning from past experiences, I brought the BiPAP machine with me, and as soon as I saw the patient lying on the cart swallowed amidst about ten EMTs who were called in to help carry this man, I knew instantly that BiPAP would be indicated. He appeared rather obtunded, in obvious respiratory distress, and he was snoring horribly loud (audible gasping actually) and he had long periods of apnea.
As the EMTs transferred this man on the "big man's bed" we brought up from the basement, I got my ABG kid ready to go, and was ready to perform the procedure when I heard the doctor say, "I think he looks almost hypoglycemic. I bet his sugar is only 24" I didn't wait for the result, and just barely pierced the skin when the results came back: "It's 24," the nurse said. "Wow, you were dead on, doc."
"All right, give him some dectrose, and, Rick, you don't need to do that ABG," the doctor said.
But I wanted to get one anyway. This man looked like he had an elevated CO2, and he presented the quintessential example of a man about to crash. I wanted to get the ABG. "Oh, I'm already in," I said. "Yeah, but if you miss..." the doctor started, and I said, "Oh, I got it." Despite the size of the man, he had arteries the size of a tree trunk. He was an easy poke and easy draw.
After I was finished, I turned around and saw an elderly lady being wheeled in. I presumed she was this man's mother, considering the EMTs had talked about her. I asked her how tall she thought her son was, and she told me. Good. Before I get back I'm going to check out my cheat sheet to determine this man's ideal tidal volumes.
I force myself to determine ideal tidal volumes, particularly on very large patients, because I know for a fact that some doctors want to set tidal volumes based on a patient's weight. Man, if they did that to this guy they'd blow him up to smithereens. So I've learned to be prepared with my tidal volumes, and proof that I'm right.
As soon as I had the results I started to plug my BiPAP into the respective outlets, and the doctor said, "Let's hold off on that for now." But he's having periods of apnea. Even if you get his sugar under control, he's still gonna be in trouble. He needs BiPAP. Well, okay, fine. I started to the lab. When these results come back, he'll have no choice but to order me to put this on.
The ABG results: CO2 95, pH 7.01, HCO3 38, PO2 90% on 100% NRB.
These results, particularly the high bicarb level, coupled with the fact this man did not smoke, provided proof that this man was a classic case of Pickwickian syndrome. I've seen it a few times, but this man had an extreme case of it. "He's got Pickwickians," the doctor said. "Put on the BiPAP." Bingo.
Lo and behold, once the BiPAP on, it appeared to me exactly what this patient needed.
Yet, the doctor said, "Based on those gases, he might need to be intubated." Ahhh, he does not need to be intubated. Why is it that some doctors are so quick to intubate?
Keeping my cool, I said, "That's a possibility. He's breathing quite well on this machine."
"True. And his vitals are good too," he said. "Yeah, lets keep him on this so long as his vitals continue to look good." This is a tactic I learned from one of my senior co-workers long ago, trick the doctor into thinking something you wanted to do was his idea.
"You think he's getting good tidal volumes with that."
"He's getting great tidal volumes. 550 to be precise. And, based on my calculations here," I showed him my cheat sheet, and the high and the low tidal volume for a patient the height of this man. "See, a 550 tidal volume is perfect for him."
"I didn't know you could measure a tidal volume on this machine."
"This machine is a lifesaver," I said. "It's prevented many patients from needing the vent. So long as he maintains a drive to breath. If he loses that, then we'll have to intubate."
"This is pretty cool. We may not need to intubate him then." He appeared so happy at this moment, I thought he was going to hug me. He was undoubtedly impressed.
"I bet he is like that every time he sleeps," I said, "I bet you are right on about the Pickwickians." He made my ego go up a notch, so I had to return the favor.
He was right about the Pickwickians, though. The next night, the man was going apneic even with the BiPAP on, and while he was apneic his sats would drop down to the low 40s. So we'd wake him up. And, when he was awake, he was perfectly fine, with a sat in the high 90s. He was also aaox3 by this time too.
But man, every time he fell asleep, he would go apneic, and his sats would drop. To me, he gave the impression of Ondines. You know the story of Ondine. According to Wikipedia, Ondine was a "water nymph who had an unfaithful mortal lover. He swore to her that his "every waking breath would be a testimony of [his] love", and upon witnessing his adultery, she cursed that if he should fall asleep, he would forget to breathe. Eventually, he fell asleep from sheer exhaustion, and his breathing stopped."
I was simply waiting for this man to stop breathing when he was asleep. He did not have Ondines, as Ondines is more of a disease people are born with and is more of a congenital disorder. This man had pickwickians disease.
This is a disorder caused due to obesity, and when the person falls asleep all the flappy skin and adipose tissue collapse the airway causing the apnea. Sometimes BiPAP works, but sometimes it doesn't. In the case of this patient, so far, his BiPAP was not working so well. As I read further about Pickwickians, I learned that a trach and a ventilator at night would probably be indicated for this patient, unless he lost a lot of weight.
After watching him go apneic and having to wake him several times, I had the RN call the doctor, of whom said, "Well, I guess there's nothing we can do about it right now."
Well, what can we do aside from traching him. The best thing we could do was just keep waking him up and hoping he didn't fall asleep and not wake up. Since this man came in on Friday night, I had to deal with him all weekend. It made for an interesting weekend, especially considering on Sunday night I had to intubate the exact opposite end of the spectrum, a 56 pound man with cerebral palsy.
I'll be honest and tell you that I was slightly anxious here because we rarely ever deal with people the size of this man. In my 10 years in this business, I have set up a ventilator on one pediatric child. And, I knew for a fact this doctor was sweating inside, however spirit of equanimity she showed on the outside. Working together as a team her and I, It was the most enjoyable experience for an RT who is rarely challenged working for a small town hospital.
"Does he talk?" the doctor asked the EMTs.
"The caretaker said he does not talk, but he communicates with his eyes," the EMT said. "He cannot move without assistance, but he is normally 'cheerful and full of life, she said'"
"Based on my pediatric calculators for tidal volume," I said to the doctor as I was setting up my ventilator, "we should probably use a tidal volume between 150 and 300." I said probably, because this little man was small and deformed, all scrunched up there on the bed. I cringed even at the thought of intubating this man, and so did the doctor. But it is not our call to decide who not to intubate. We had our hands tied. We had no choice but to do this.
The ABG results: pH 6.90, CO2 90.
Needless to say, this and the other guy took up so much of my time I pretty much ignored the other patients. And, needless to say, only one of them needed his treatments, and I simply provided a few amps of Albuterol at the nurses station and the nurses there were more than happy to do his treatments for me.
Thus, over the weekend, I assisted the ventilations of one man who was the epitomy of large, and then a few days later did the same for a man who was the epitomy of small.
This was a challenging weekend, but one that was, all in all, fun.