Here are three inspiring medical stories of doctors going all out to save their patients from Dr. Weingart’s Podcast 100 – What is Critical Care and What is EMCrit? of EMCrit.
First Case: A patient with DKA: Do not use succinylcholine for rapid sequence intubation for any clinical situation. Use rocuronium (safer and fewer gotcha’s”)
Second Case: A patient with abdominal and back pain discharged from ED and returns the next day with ruptured abdominal aortic aneurysm: The discharge from the ED the day before for non-specific abdominal and back pain was not a medical mistake. It was, I think, an appropriate disposition.
Here’s Why:
Abdominal aortic aneurysm is difficult to diagnose on physical exam (really, impossible). Non-specific abdominal and back pain is a very common diagnosis in EDs and primary care. Leaking abdominal aortic aneurysm as a cause of that pain is very rare.
The only way that the diagnosis could have been made on the first ED visit, would have been with point of care ultrasound. Many EDs and (most?) urgent care and primary care offices do not have point of care ultrasound.
Even if an ED or office has an ultrasound scanner, the decision to go and get it and perform a abdominal scan involves a significant time commitment. Time that has to be taken from the care of some other patient.
Until ultrasound scanners are truly portable and powerful, ultrasound, even point of care ultrasound, is not practical for every patient presenting with non-specific complaints.
Third Case: An 18 yo girl who could not be adequately ventilated. She was placed on ECMO and the doctors and nurses saved her life. These tremendous new life-saving technologies make primary care physicians work even more important. See Why We Make the Commitment below.
The three cases discussed below in Dr. Scott Weingart’s outstanding lecture are inspiring tales of emergency medicine specialists going all out for their patients.* (See Resources)
The point of these stories for primary care doctors and nurses is this: These cases show outstanding clinicians going all out for their patients.
To be able to perform all the specialized procedures used in these cases would require a tremendous commitment of training time for primary clinicians. That commitment may not be an appropriate use of time and talent for primary care clinicians who do not routinely care for ED patients or hospitalized patients.
Here’s What We Primary Care Physicians Can Commit To
What we primary care clinicians can and must do [following the examples of these wonderful doctors] is dedicate our selves to going all out for out patients by doing the following: Have the equipment and the skills to immediately provide outstanding basic and advanced life support to our all our patients should a life threatening emergency occur.
And Here is Why We Make the Above Commitment
I am an internist and I also care for pediatric patients. And I have spent the bulk of my career in what are now called critical access hospitals. These are small hospitals often remote from tertiary care centers.
These hospitals have, in my experience, outstanding clinicians (doctors, nurses, and technicians [lab, respiratory, imaging]. But they don’t have lots of extra clinicians to care for complex patients who suddenly arrive at their doors. They and their complex patient(s) are on their own for at least an hour [before a tertiary transport team with additional resources can arrive]. And usually it takes much longer.
But primary care physicians and other clinicians, even in major cities, need to be able and equipped to handle sudden life threatening emergencies. This is because the paramedics make be unable to arrive for up to half an hour or more (occasionally). In rural areas, the time of arrival can be much longer.
So we, the primary care doctors and nurses, need to be ready at any time to deliver high quality basic and advanced life support. Because nothing can help a patient who has died, not ECMO, not skilled ventilator management–nothing.
And Here Are The Inspiring Stories
11:00 – 14:00 Case 1 – A Resuscitation Case: In a small Australian hospital a 39 yo man came into the ED in florid DKA. Because he is so sick they decide to intubate him and use succinylcholine as part of RSI package. He promptly arrests. They begin ACLS and they even lyse him thinking perhaps it is a pulmonary embolus or an acute myocardial infarction. They get him back and the potassium comes back at 10! They initiate treatment for hyperkalemia but he arrests twice more and they get him back each time. The retrieval doctor on the transport team [the small hospital’s physician had made arrangements to transfer the patient to a tertiary care ICU] arrived to find the patient again in cardiac arrest and markedly hyperkalemic. The local hospital had no dialysis capability. The retrieval doctor decided [because he wanted to give this young man every possible chance to live]to perform peritoneal dialysis for the hyperkalemia during CPR! He did and the patient survived to make it to the tertiary care ICU!
14:00 – 16:30 Case 2 – An ED Case: A 50 yo man with abdominal pain (who had been in the ED the day before) returned with abdominal pain and promptly arrested. They perform ACLS and get the patient back. They perform an immediate bedside ultrasound to figure out the etiology of the arrest and find ahuge abdominal aortic aneurysm and clearly he needed immediate surgery. The vascular surgeon was called and promptly came to the ER. The patient needs immediate surgery. “But before they could even move him, he codes again. And the emergency physician turns to the vascular surgeon and says ‘we have to do something, this is a young man. . . [and he was fine yesterday] let’s open his chest. And the vascular attending says no; we have to let him go. He’s already coded twice.” Despite the vascular attending being present and advising against it, the emergency physician [actually his EM resident] did an emergency thoractomy and crossed the clamped the aorta at the [level of the diaphragm] and pumped in blood. They got the patient back and he went to the operating room. “He had his triple A repaired and he walked out of the hospital completely intact neurological status back to his family.
16:30 – 18:43 Case 3 – An ICU Case: An 18 yo girl who fell out of a golf cart and suffered a traumatic subarachnoid hemorrhage [her only injury]. She suffered severe neurogenic pumonary edema requiring vent settings of 40/0 and severe neurogenic cardiogenic shock. Her ICP was so high that she was ventilated upright on Stricker frame and had a laparoscopy and an open abdomen to lower the ICP. But it wasn’t working. It seemed that the doctors were out of magic. Dr. Thomas Scalia thought “if we didn’t have to have her on 40/0, we could drop her ventilator, then her ICP would come down. We cannulate her and go on ECMO.” Because she was being ventilated upright on the Stricker, they had to stand on a ladder to put in the internal jugular catheter. She lived, went to college, became a nurse practioner and now practices with Dr. Scalia.
Resources:
(1) Podcast 100 – What is Critical Care and What is EMCrit? June 9, 2013 by emcrit. Dr. Scott Weingart.
