Wednesday, January 16, 2008

Adrenaline Rush

Something really exciting happened to me yesterday. It was pure adrenaline rush and split second decisions made the difference.
I was called to attend a patient who had a face-neck mass ; having stridor and bleeding from his mouth. He was an attendant working in UMMC and I've came across him before especially during Friday prayers. He was having airway obstruction and I was informed that he might need to be intubated in OT. I ran down to resus and was alarmed by the intense activity happening there. The A&E Specialist was in the midst of performing cricothyroidectomy and was shouting for me , the anaesthetist. Apparently the patient had collapsed and with the internal bleeding disfiguring and distorting his normal anatomy , he failed to intubate and as a result the patient desaturated.
He was half way with his needle on the in between crico-thyroid and it was in when i bagged ! Everybody was panicking as it was a rare occurence of losing the airway ; and Oh my god.. Suddenly I saw blood just gushing out from his left ear . It was like a burst pipe ;blood splurting out like nobody's business .He was bleeding profusely .. but from where ? the tumour ? a ruptured vessel ?

With hypoxia and the hypovolaemia ; the patient went into shock and his heart rate , pulsenot felt. We started CPR and it was pure volume resuscitation that revived him. It was ENT's call next if we were going to OT for exploration. ENT consultant thought it would be better for interventional radiologist to detect the bleeder and embolize.It was too risky to cut it open and search. With constant volume stabilization , it might be the better option.
I was all alone , I did call my superiors to help but it was a bad day ; everybody was busy attending to something.I enquired the ENT consultant if they could perform an emergency tracheostomy there and then because if he is to go for the procedure I need to ensure my airway is secured. The Angio room in UMMC is not exactly condusive for proper anaesthesia and the emergency airway was not exactly stable. He agreed and tracheostomy was performed maybe for the very first time in UMMC Resus room.It was messy but maybe the only option we had.

It was just about generous blood transfusion and volume resuscitation , as I needed to maintain a constant intravascular volume against the amount spurting out like mad from the other end. We pushed the patient to radiology ( which was like so far away !! ) and they were set for us. Again , being alone I had to bring the "debilitated" GA machine from CT scan room and set it up myself ( My MA and GA nurse at that time had a 7 year old OGDS in scope room ).It was just ketamine anaesthesia , my magic drug that maintained my Mean Arterial Pressure with the on board massive haemorrhage . I was looking for a just nice BP , slightly hypotensive to control his intravascular volume. It was not easy , my mind thinking hard on how to stabilize and maintain the patient alive.
Initial angio showed the ruptured distorted pseudo aneurysm of the external carotid artery. It was bleeding profusely as when the dye was injected , it just disperses when it reaches the external carotid artery. I said.. damn.. Can i catch up eith the blood loss ? His face was totally distorted by now.. the collection around his face increasing by the moment.
HC03.. Calcium.. Tranxanemic acid.. DIVC regime , 10 pints of blood went through him , you name it ! .Those were the things i kept injecting in as it was obvious patient was in DIVC. The procedure took about 3 hours and I was glad it was over. The radiologist thought that they manage to coil and control the bleeder but it was iffy at that time. Haemodynamically he was fairly stable in accordance to his current state. It was uncertainty all the way for me as the image of him collapsing kept coming to me. I was thankful that he was managable from the time of initial collapse to end of procedure.
We then sent the patient to ICU for care and passed over to my colleague. He was bleeding still and at about 1 am , my colleague txtd to infrom me the time of death. He was bleeding from everywhere by then. So bad that there was no way to control it . It was his calling. He passed away peacefully .Innalillahiwainnailaihirajiun.
Kudos to the doctors , nurses and health personnels who were involved in that case yesterday.It was certainly exciting and challenging. But it was everybody's effort to give this patient a chance to live which really inspired me to continue what I love doing.


suw_pattzy said...

this is my first time coming to ur blog.not bcoz of the Dvd..(of course not!)
kewl! i thought being Doc as profession means that u have no time for all this kind of thing..well, i m wrong heheh

drzeze said...

salam to Mafietz,
Great job bro...but despite your effort Allah shortened his suffering...Innalillah and Al-fatihah.
Thanks for addlink me here.Take care.

Dr.M said...

suw : welcome ! We are normal human beings too.. hahahaha..
drzeze : we do try our best for everybody , don't we ? the outcome , for Allah's grace.