“In a nutshell, yes.”
“Yeah, right! Like that’s ever going to happen! No way, man. I’m out of here.” He sat up and pulled out one of his IVs.
“Mr. Cotard, I think you’re making a big mistake. Any minute now your throat might begin to swell. If it does, you could suffocate.”
“I already told you, there’s nothing wrong with me. I’m going home.” He started tugging on his remaining IV.
“Hang on,” I parried. “What’s the big rush? Why don’t you stay a little while and let us keep an eye on you? If nothing happens, we’ll let you go.”
“Okay,” he agreed grudgingly. “I’ll stay for 10 minutes, max.”
With each passing minute he grew more restless and agitated. We had to continually remind him to leave his oxygen mask on. Eventually his oxygen sats began to drop.
“If we wait much longer to intubate you, it may be too late.”
“Not a chance!”
Moments later his voice started getting raspy. The ER nurses and I exchanged worried glances. Vocal cord swelling. Not long after that he developed stridor, a high-pitched inspiratory wheeze indicative of a precariously narrow upper airway.
“That noise you’re making each time you inhale tells us we’re running out of time. We have to intubate you now before your airway becomes completely obstructed.”
“No way!” he squeaked. “Stay away from me!”
“All right then, at least let me give you something to help you relax a bit.”
“Okay.”
I drew up four syringes of RSI drugs: thiopental, succinylcholine, pancuronium and diazepam. My patient eyed the syringes suspiciously.
“Are you sure this stuff is going to help me relax?”
“I guarantee it.”
I injected the thiopental and succinylcholine into his IV port. Within a minute he was unconscious and paralyzed. I then squeezed a pediatric-sized ET tube through his flambéed vocal cords, hooked him up to a ventilator and shipped him off to the closest burn centre.
We were later advised his inhalation injuries were so severe he required mechanical ventilation for more than a week. His subsequent convalescence was uneventful.
As you can see, occasionally we're forced to override an irrational patient decision in order to save someone from themselves. These situations have the potential to ignite ethical and medicolegal firestorms. Whenever I'm caught in this type of quandary my guiding principle is to do whatever I feel is morally imperative and save the worrying about potential repercussions for later. In other words, do the right thing! So far this axiom has not let me down.
How Come She’s Not Breathing Anymore?
One night I was paged to the Special Care Unit to evaluate a teenage girl in respiratory distress. The nurse caring for her informed me the patient had presented to the emergency department earlier in the day after having ingested a large quantity of unknown pills. She had been treated with activated charcoal and observed closely in the ER. Nothing untoward had happened, so after a few hours she had been transferred to the unit for further monitoring. Her breathing had started to become laboured a few minutes prior to my being contacted.
The patient’s breathing was rapid and shallow. Despite maximal supplemental oxygen, her sats were only 80 percent. Examination, bloodwork and a portable chest x-ray failed to reveal any obvious cause for her abrupt deterioration. I wondered about the possibility of a pulmonary blood clot. Before I could pursue that line of thought any further, her respiratory status took a turn for the worse. I decided to intubate.
I selected my airway tools and calculated the appropriate RSI drug dosages. While the nurse got the medications ready I studied the patient’s mouth and neck in an attempt to gauge how difficult it was going to be to intubate her. Her receding chin, small mouth and big tongue all suggested the procedure would be technically challenging. If I paralyzed her and then found myself unable to get the tube in I’d be up the proverbial creek. Like the saying goes, bad breath is better than no breath. I therefore decided to do an awake intubation, meaning I would numb her throat and upper airway with the topical anaesthetic Xylocaine and then gingerly advance the ET tube into place. Once the tube was in, I’d quickly sedate and paralyze her in order to eliminate the possibility of her inadvertently yanking it out. I went over the plan with her in detail. She said she’d try her best to cooperate.
First I flattened her tongue with a tongue depressor and sprayed the back of her throat with Xylocaine. A minute later I instructed her to lie down. I then slid the laryngoscope blade to the back of her throat and sprayed the zone between the posterior throat and the voice box. This caused her to cough and splutter so much I had to withdraw the scope and give her a minute to recover. On the next attempt I was able to get the blade a bit further down, but when I began spraying she reached up and tried to grab my hand. Not good. I removed the scope again.
“Are you okay?” I inquired.
“Yes. Sorry about that – it was just a reflex,” she panted.
I turned to the nurse and whispered: “This looks like it’ll be a tough intubation. I’m going to want to give her the thiopental and sux to sedate and paralyze her as soon as the tube’s in place so she doesn’t pull it out.”
“Okay, I’ll have them both ready.”
I went in again. This time I saw a sliver of the epiglottis, which is the lid of the voice box. The vocal cords lie directly beneath it. When I squirted the epiglottis with Xylocaine she started coughing violently. She then began twisting and rolling around on the bed. I withdrew the scope and waited for her to settle. When she calmed down I asked, “Are you okay?” No answer. “Miss Pickwick?” Silence. Something was wack. Was it just my imagination, or did she appear to be unnaturally still?
“Hey, wait a minute – how come she’s not breathing anymore?”
The nurse checked the patient’s IV line and gasped.
“I inserted the loaded syringes of thiopental and succinylcholine into her IV port and left them there so we’d be able to inject as soon as you got the tube in! Both syringes are completely empty – she must have self-injected just now when she rolled over!” Yikes!
Her oxygen sats entered free fall. I asked the nurse to apply firm pressure to the patient’s cricoid cartilage to reduce her risk of aspirating stomach contents. In the meantime I attempted to ventilate her lungs with the Ambu bag. Even using both hands I couldn’t get a good seal with the mask. Her sats hit 70 percent. I put the laryngoscope back down her throat and hunted for her vocal cords. I could barely see the epiglottis, never mind the cords.
“O2 sat 60 percent!” shouted the nurse. A multitude of monitor alarms started beeping simultaneously. I went into Hulk mode and pulled on the laryngoscope so hard, it’s a wonder the patient’s entire body didn’t lift off the bed. Miraculously, her vocal cords popped into view. I vaguely recall my hands trembling a little as I guided the ET tube home.
Miss Pickwick went on to a complete recovery.
Let Me Help You With That, Doctor
A while back I was called to the medical floor to see a patient who was developing pulmonary edema, or fluid on the lungs. Despite aggressive medical therapy and BiPAP she was becoming increasingly short of breath. She needed to be tubed and put on a ventilator. I set out my equipment and assessed her airway. Her anatomy was favourable and there was nothing to suggest she’d be a difficult intubation. The only wrinkle was that if I knocked her out with thiopental, her already-lowish blood pressure could bottom out completely. I elected to sedate her lightly with midazolam, paralyze her with succinylcholine and then slip the endotracheal tube in. Once the tube was in place I’d sedate her more heavily. I explained the game plan to her and she gave me the green light to proceed.