Accidental Extubation and spontaneous ARDS

I was having a wonderful conversation with one of my favorite patients when my beeper sounded: "We need you stat in ER."

"Shit!" I said ruefully, "You're breathing okay right now, right?" She looked fine, but I had to be sure.

"Yes, you go right ahead." She was such a great patient and, unlike some patients, I trusted her judgement.

I stopped the treatment and rushed to ER. I busted through the double doors, a strong horrible stench hit me, and Bee the nurse shouted from across the room:

"They need you in Cat Scan!"

"Cat Scan?"

"Yes. Cat Scan. A lady is coding."

"Oh, shit!" Not knowing for sure an airway box was in CT, I grabbed one and busted back through the double doors and started walking fast. Ahead, a skinny man in surgery scrubs burst from the CT room.

"Oh, RT, get me a size 8," he shouts. "Now!" I realize now it's Bob the acerbic anesthesiologist.

"Okay, just a minute."

"No, I need it now!"

"Hugh!" I busted open the box and started shuffling through it looking for the tube while still walking. This is ridiculous, I thought. "You'll have to wait till I get in there."

"No we need it now."

"What's going on here," I said as I enter the room with Dr. Bob breathing down my neck. He was standing beside me now like a little kid, panting for his ETT. I handed it to him.

"We extubated her," one of the surgery nurses said. She was bagging. What in the hell? I thought. How could somebody be extubated in CT when I didn't even know there was an intubated patient. Hello, I'm the lone RT working, I'm supposed to know this kind of stuff. And there's no code, as Bee told me.

Bob crouches by the head of the patient on the CT table, shouts for the nurse to stop bagging, and easily slides the tube in.

I secure the ETT with an ETT holder. "So, what happened again."

"We brought her from surgery. She started wriggling, seizing, and, well, you know."

Then it clicked. I thought this was an ER patient. I thought this was a patient they were working on and didn't tell me about for some inexplicable reason. Why an intubated patient from surgery would need a CT I had no clue. I did not inquire. Then I noticed the old gooey ETT lying askew on the side of the patients head: it had tape on it. Aha.

"So, Bob, maybe next time you'll put one of these in before you transport your patient," I joked, pointing at the ETT holder. To my amazement he smiled.

The excitement was over, and I was starving. I had lunch on my mind. The beeper went off: "Need you in ER."

"Shit!"

I stumbled through the ER doors, grabbed my sheet, grabbed my EKG machine, and headed for my patient. On the way, however, I was overcome again my a horrible stench. I looked into a room and saw a thin, scraggly bearded man sitting up on his bed. He literally looked like something that was scraped off the street. Turned out he was.

I pray to God I don't have to do an EKG on that guy, I thought, and proceeded to my patient. I did a quick EKG and, back at the nurses station, hand it to the doctor. He reads it. "Hey, Rick, could you do an EKG in room four?" He said, kindly, and with a smile.

"Oh sure." I grab the machine and start for room four when it hits me: it's that guy. Why is it every time there's a gross patient they always seem to find a way to get RT involved. I suppose if he's homeless he could be malnourished. His electrolytes could be off, which equals indication for EKG.

"Could you tell me about this patient?" I ask the nurse out of range of the patient.

"Well, we just plucked maggots off him," she whispers.

"Maggots?"

"Yeah, he had poor circulation in his legs. About two or three months ago he went to a doctor and the doctor had his feet wrapped. When he came in, he had garbage bags wrapped over the bandages," she made as though she were going to puke, "It was awful."

"I'd hate to have your job."

"So did I." She smiled.

"So now you want me to get involved." I took a deep breath, and proceeded to do the EKG.

An hour later I was upstairs because Dr. Young ordered a STAT BATH. I reluctantly volunteered. Mickey, a former EMT of 30 plus years and who was now an ER assistant, also volunteered. He had a good idea that we place a sheet in the tub so we could use it to get him out and into the wheel chair. It turned out to be a great idea. It was a horrible job, but a great idea.

I digress though. I was off the next week. When I came back, almost immediately after I received report, I was called stat to room 208.

"What's going on?" The patient was in low fowlers, obtunded and appeared to be laboring. He was gray. I checked his sat, it wouldn't pick up. Of course this was before the rapid response team was in effect. "Does he have a pulse? Have you checked a pulse."

"Yes," the nurse assured me. "His pulse in 90 and his BP is 120/80."

"Does he always look this way, obtunded I mean."

"No. He was fine my last check." Mental note: acute mental change.

"Okay, well that's a good start. But he sure don't look good. Is he a DNR? Did you call the doctor?"

"He's not a DNR. We did call the doctor." I look at the patient again. Now I realize this was the guy with the maggots. I thought about asking if they checked his sugar, but second guessed myself. This would later come back to haunt me.

The patient looked like shit, so we all conclusively decided that I should place the patient on an NRB and do an EKG and a blood gas. What's the old saying, better to do now and apologize later. The patient bled so bad I had blood dripping on the floor. After holding it 5 minutes I gave the job to the nursing supervisor.

The ABG said: ph 6.98, PO2 45 (before NRB), CO2 35 and ? bicarb. The machine did not pick up the bacard, probably because it was so low. My initial conclusion, although I'm not the doctor I usually try to make an educated guess, was this man was in respiratory failure secondary to sepsis. Because he was leaking so bad I'm certain he's in DIC.

By now Dr. Young, our surgeon, was in the room. He's one of those quiet little guys with poor bedside manners. "That's a venous blood."

"No, it came out pretty good."

"It's venous blood. Look at that pH. It's venous blood."

"I'm quite sure it's not venous blood."

"It's venous blood." He looks at the patient. "Why did you call me? He's fine."

"He's not fine. He's labored," the RN says.

"He's fine. Why do you call me for this."

Now the Internist on call enters the room. He looks at the ABGs, "Those are venous."

No they are not, I think but do not say. "Look, even if it is venous blood the pH will still be similar to arterial blood. Look, this guy is in failure."

"He's fine." Both Doctors leave the room. Fine, the only reason they don't want to come in here is because this guy is homeless and he's gross, and they don't want to be bothered.

I never leave the room. The nursing supervisor and I discuss the patient, and we both agree something is obviously wrong. And, five minutes later, the patient codes. Both doctors come back into the room. And, guess who comes in to intubate? Dr. Bob.

He slides the ETT in easily and, before I have a chance to secure the ETT, the head nurse said, "We need to boost him down the bed: one, two, three...

"WAIT!" I shout as they scoot the patient away from me, as my hands and the ETT stay in the same place. The patient is now extubated.

"What the fuck!" Dr. Bob yells. He reintubates the patient in a swift moment. He holds the ETT while I secure it with an ETT holder. "Next time you intubate a patient, be sure to secure the ETT with one of these before you move him," he said, pointing at ETT holder.

He smiles and exits the room. He got me back.

I redrew the ABG. By the time I got back the patient was dead.

The second pH was 7.00. I was right. And, after reading the autopsy a few days later, I learned I was also right about the sepsis. The autopsy also identified ARDS. Oh, and his glucose was 18 which, I learned, if a patient is not on insulen means liver failure.

This was one of those cases I couldn't get out of my mind. What did we do wrong? I wished I had asked about the sugar check. I thought about labs. I checked, and the patient didn't have any labs ordered the day before, nor sugar checks, both of which would have set off alarms.

A week later I ran into Dr. Peterson, an Internist who came into the cave to read EKGs. After I explained the situation to him he said:

"Patients do not go into spontaneous DIC or ARDS. It simply does not happen. And this would never have happened with one of my patients. You don't simply send someone to the floor and not order any tests, regardless of who the patient is."

I never did get into trouble for drawing ABGs without an order. Perhaps because those two doctors knew I was right.