On call scare 2...

Yesterday was my first on call in Queen again after like a month in SMC...started my call after office hours by resuscitating a patient who was also an anaesthetist's nightmare (so commented Pang)... Chinese man...big size...short neck..receding chin..TMD less than 3cm...you get the idea..so anyway, this uncle presented with one day history of recurrent vomiting and shortness of breath...came to casualty, oxygen saturation was only 70-80% on high flow mask 15L/min...ABG was bad...medical referred for ICU admission...boss asked to assess the patient at casualty to see how bad the patient was...

Uncle was already drowsy and very tachypnoiec when i saw him...but he was still responding to my questions..so anyway, decided to intubate him before bringing him up to ICU...while they were preparing for intubation, i think Uncle became unconscious and when we put him supine, he vomited copious amount of coffee ground fluid (Ryle's tube was not inserted yet...dang!)...so we quickly gave scoline and i tried intubating but it was next to impossible...Cormack-Lehane IIIb...i could only see the epiglottis but couldn't see the vocal cords even with all the manoeveures...and it didn't help that his vomitus kept coming out...suctioning was practically useless...i used the bougie and still failed twice...tube went into the oesophagus...and we were losing Uncle..coz he went asystole and we had to start CPR...

So i called Pang for help...good thing he hasn't left the hospital yet...God bless him...so he came and finally we managed to secure the airway after another 2 attempts...but Uncle already aspirated his vomitus...we resuscitated for almost 40 mins...defibbed him 4 times...his pulses finally came back..but BP was unrecordable..so we started on IV dopamine...he kept going into VT....but then it reverted back to some junctional rhythm...

So anyway, medical decided to ventilate him in the chronic side since his prognosis was bad..and there was only 1 bed left in ICU...so when Uncle was finally stable enough to be sent up to the ward, i went to check on him...that's when another drama happened..

There was another patient in the chronic ward who self-extubated himself that afternoon...breathing effort was ok..GCS about there only...he was probably having hepatic encephalopathy...so liver man was on Ventimask 50% and ABG wasn't too great either..and he refused to cough out his secretion...so while i was checking on Uncle, liver man's relative suddenly came up to me and told me that liver man stopped breathing and has turned blue...i was like..shit!! not another one...but yea, he was blue, apnoiec and pulseless..thus another CPR was initiated...but i had no idea how long liver man was already hypoxic...turned out, his oxygen tank ran out of oxygen..which was probably why he became hypoxic and eventually apnoiec...and the houseman on call wasn't around..

And his wife thought he was just sleeping...luckily he wasn't a difficult intubation case...got the tube in...continued CPR...came back after 15 mins...but his brain was probably gone by then..though he had spontaneous breathing again after about half-hour..so there were 3 ventilated patients in the chronic ward last night...all with very grave prognosis...

By morning..i had to start Uncle on IV adrenaline coz his BP was unrecordable...his IV dopamine ran out...but the nurses were too busy to change the syringe (well, guess it's expected if there were only 2 nurses taking care of 30 over patients)..but it was changed eventually...i ran in fluid and all...his BP picked up...but i fear all my effort would be in vain...

2 CPRs in a call...that only equalled one of my call when i was still a houseman...sigh....guess i can live with it..but the 2 patients may not live much longer...