Saturday, July 26, 2008

CCU

The first week of my hospital placement was in the Critical Care Unit - this combines the Cardiac Care Unit, High Dependency Unit and the Intensive Care Unit.

Most of the week I've been helping to look after the Intensive Care patients, and the Consultant Anaesthetist, Dr West (not her real name) who's turn it was to work in CCU for the week ensured I missed nothing. I'm very grateful to her, because there are some anaesthetists who really do not like paramedics, because they don't believe we should be intubating. This consultant was clearly not one of them. Anything going on that was even remotely interesting, she either sent someone to get me, or came and fetched me herself.

Most of the patients in CCU are sedated, intubated and ventilated. The drugs and fluids dosages are calculated down to the microgram per kilogram per minute. Vomit, urine and bowel movements are measured to the millilitre so they know exactly how much is going into the patient, and how much is coming out of them. This is to make sure that the proper fluid balance and acid base balance is maintained. The calculations are mind blowing, and it will need someone far cleverer than I to tell you much more about it.

I was invited to watch a patient having a tracheostomy. This is where a hole is surgically created in a patient's neck just below the thyroid cartilage (adam's apple), and is done so that they can wake a patient up, while maintaining full control of the airway without the patient having the discomfort of a tube sticking out of their mouth. It was done using a bronchoscope - a fibre-optic camera inserted into the ET tube so the anaesthetist can see exactly where the tracheostomy is going to be. The tube is pulled back so that it sits just in the vocal cords, allowing the trachy to be made in the correct place.

The Sister in charge told me where to stand so that I wasn't in the way, but could still see clearly what was happening. The anaesthetist had a couple of other doctors to assist her, as well as a chap who was wearing a badge that idientified him as being on work experience.

"Steve, don't stand there, you won't be able to see the anatomy of the airway when I 'scope him," said Dr West, and directed me to stand just behind her right shoulder. To the others, she said, "Steve's a Paramedic, and he'll be doing harder intubations than we will ever do in theatres, so I'd like him to see this. We can get the patient into the position that suits us. Steve will be lying on the floor, in the dark, and sometimes in the rain or even snow to intubate." The other doctors looked at me with blank expressions. What was behind those expressions I don't know, but I felt a little embarrassed.

She inserted the laryngoscope, moved the tongue to the left, and lifted. Standing just behind her and looking over her shoulder, I could clearly see the epiglottis, and the larynx with the ET tube passing through it.
"Steve, can you deflate the cuff* please?". A 10ml syringe appeared in a nurse's hand out of apparently nowhere and was held out for me. I delflated the cuff, and Dr West carefully pulled the tube back.
"Ok, inflate it again. You won't be able to get the full 10mls in, but don't worry." I re-inflated the cuff until I felt resistance against the plunger.
"That's enough," said the Dr.
The procedure then went ahead, with me watching events closely on the monitor. I watched them insert a needle, confirm it was in the right place, then insert something called a Rhino Horn to widen the hole made by the needle. Then the Tracheostomy tube was inserted and sutured into place. Then Dr West "hoovered" (her words) the airway, including right into each lung, to clear it of secretions and other gunk, some of which was quite thick mucus. I was able to see easily how the airways divided up inside the lungs. The whole operation took 15-20 minutes.

Yesterday, I was walking back to the unit after lunch when I was spotted by Dr West.
"Steve, come with me," she called down the corridor to me. I hurried after her, and we went into one of the operating theatres. There were a lot of people in the room, some of which I discovered were medical students.
As I neared the operating table, I saw a small baby, who appeared to be just a few days old. She'd obviously been anaesthetised, and the consultant anaesthetist already there was "bagging" her - breathing for her using a bag and mask.
Apparently they'd been having some difficulty intubating her. The anaesthetist in the room looked dejected.
"It's the first time in 15 years I've failed to intubate a baby," he said, picking up the tiny larygnoscope to try again.
He inserted it, and spent a few seconds trying to identify the vocal cords. I watched the monitors intently, with my attention flitting between them and watching what the anaesthetist was doing.
"This is really tricky," he muttered.
"Oxygen saturation is still 100%, keep going," said Dr West, then added, "Steve, keep an eye on the monitor - tell us the moment the Sats start dropping." Again to the crowded operating theatre she announced, "Steve'a a paramedic." Thankfully, she didn't add the difficult intubations line - probably due to the problems being encountered with intubating this little baby. In any case, in a crowded room of medical students, I was grateful for the omission.

From that moment, I glued my eyes to the monitor. The anaesthetist continued to try to see the anatomy of the airway, but was clearly having problems. Then the oxygen saturation dropped to 99%, which I announced.
"Damn," muttered the anaesthetist, removed the larygoscope, and started bagging. By this point, the saturations had plummeted to 83%. I held my breath, watching the monitor and willing them to rise again as the baby was bagged once again. Finally, after what seemed like an eternity, but in reality was probably no more than 10 seconds, the sats shot back up to 100%.

They ventilated the baby for a bit longer, then Dr West was invited to try. Again, I glued my eyes to the monitor, with only very quick glances to see what was happening. Dr West picked up a tube, inserted it, took out the larygoscope, connected the bag and squeezed. The stomach inflated.
"Shit," she said, taking the tube out and ventilating the baby again.

After a few more attempts, they got a fibre-optic scope to have a look at the airway. They found the vocal cords, and they were very inflamed and almost closed. This wasn't because of the attempts being made to intubate, but rather an existing infection. It was this that was causing the difficulty intubating.
After consulting the surgeon, it was decided to abandon the operation, wake the baby up, and send her to another hospital that had better equipment and paediatric anaesthetists who would have a better chance to intubate.

This was useful for me to see - probably not necessarily for the reason Dr West had intended, but it proved to me that even very experienced Consultant Anaesthestists who intubate numerous times every day sometimes don't manage to get the tube in. I'll remember that whenever I fail to intubate a patient for whatever reason.

I'm in A&E next week to get my cannulas and infusions signed off, then theatres for the two weeks after that for intubations and LMAs.


*the cuff on an ET Tube is like a balloon that surrounds the tube, and is inflated to a) hold the tube in place and b) prevent any fluids such as vomit from getting in to the lungs.

3 Comments:

Blogger MW said...

Steve for the more technical aspect of the anesthetic (sp) see http://thejuniordoctor.blogspot.com/

9:48 pm  
OpenID elmblog said...

Wow, your a lucky chap Steve. Teachers like that are worth their weight in gold!
I hope I get someone similarly enthusiastic when I'm on my prac in a few years time :-)

12:52 am  
Anonymous Anonymous said...

Steve, you might be interested in blogging about those international air ambulance services that are accessible online. I think they're worth blogging too.

4:04 pm  

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