I don’t really understand what a *trigger warning* is exactly, but I suspect this is the kind of post that should have one.
I wanted a call and for my sins they gave me one.
For all the posturing, all the bullshit that I talk around the table at shift trade, all of the clinical judgment I profess to have, all of my training, the initials after my name, my years of experience, the sense of confidence I have that may be based on nothing, all of the expertise I think I have, I got a call that forced me to take a hard look in the mirror the other night. The call went bad, the call went to shit.
When a call goes to shit nothing works right, you get tunnel vision, mistakes are made, options are overlooked, a cascade effect of errors rapidly gains momentum. I could use a different term than “goes to shit,” I could say it went poorly or that mistakes were made, but it would be a lie; it would not capture the feel of the call. It went to shit.
The patient had a significant head injury. Part of me wishes the patient was dead when we got there. I know that is a strange, maybe shocking, even inappropriate thing for a paramedic to say. I mean no malice by it, simply that it might have been better for him to have a quick ending than to linger like he did for several days.
No one expected the patient to be alive after the two plus hours it took to gain entry, but he was. Not only was he alive, he was conscious . He was conscious but unable to talk. He could look at me, stick his tongue out and squeeze my hand but he couldn’t talk. I have to try not to imagine what it was like, laying there for two and a half hours wondering if he was going to die, wondering if help was going to come. I try to console myself with the notion that perhaps there was not enough of his brain left for him to fully understand his situation. God, I hope so.
We discussed RSI’ing in the bedroom, or on the way to the hospital and we elected for the later. We had planned to get him out of the cabin, go to the hospital and put him in a helicopter to a level I trauma center.
People were taking our bags and equipment out to the ambulance and getting the gurney and then just like the boxer-poet Mike Tyson writes about I got punched in the mouth.
Things rapidly went to shit. Seconds ago the patient that was following commands is now vomiting, posturing, his eyes are rolled in to the back of his head.He is an alligator doing a death roll and my suction catheter is the unlucky gazelle that wandered too close to the watering hole, trapped in his jaws. Except the alligator is also vomiting.
This meant it was time for plan B which was RSI RIGHT NOW. This was not going to be the gentle, kind RSI that I usually like to perform; this was going to be the rougher, “OhFuckThisGuyIsGoingToDie” kind of RSI.
IV attempt one is a failure, IV attempt two is a failure, IV attempt three sort of works. It is a 20 in the wrist and it flows really really slowly, when it does flow. An IO is established in the leg. Things are getting chaotic, there are guns everywhere, there are cops in camo everywhere, there are bright lights everywhere, cops are asking me if I want to shut down the highway and land a helicopter on it. I don’t want to shut the highway down, I want to go to the landing pad at the ER 4 miles away. If he lived two and half hours and then is expected to live through a thirty minute flight then a four minute transport won’t matter much.
The drugs are on board and my partner tries to tube him. Within seconds blood and vomit is everywhere, it covers everything. Everything is a slippery mess, everything we touch is contaminated. The jump bags have exploded. Everything in the bag will need to be thrown out when we get back to the station. The patient is now de-sating, well below the 90% we try to never go below. My partner gave it a solid attempt and I cannot fault him for not getting the tube. He could have positioned the patient better, but it is hard to make yourself take the time to do that when the patient is dying right in front of you. The patient is starting to become bradycardic, I am starting to become tachycardic.
This is the first time I say it in my head, just a whisper, “shit”.
We bag him back up to the upper 90’s with brown blood and vomit spraying everywhere. I want to leave that back bedroom very badly but I cannot. I don’t think I can move this patient without some sort of airway, I don’t think he will survive the trip to the ambulance without it.
I decide to take a look at the airway. I go in with the blood covered king vision video layngoscope and I can see the opening of the glottis, but it doesn’t look right. I try to pass the tube but it will not go through, it is right there but it will not go in. I try every trick in the book. I try the bougie, I try direct laryngoscopy, I go back to the non-channeled video blade….nothing works. I can see the hole but nothing will go in there. The patient is now “satting” in the low 80’s and headed lower quickly. What the hell am I doing? I know I can’t let him get this low, but he needs an airway. He needs an airway badly. He needs an airway before we can get out of here.
There it is again, a bit louder inside your head this time….“Shit.”
I just need to get this tube and we can get the hell out of here, I just need to get this tube and he can be someone else’s problem. I should have realized I was never going to get the tube and it was time to get the hell out of Dodge. It was time to get the hell out of Dodge several minutes ago.
We bag him back up and without doing anything different I try to intubate again. I tell myself this is the last time and we will put in the king tube if I don’t get it. I don’t get it.
I put the King tube in except it doesn’t really want to go in. The other medic on scene was able to get it in with a laryngoscope, but it isn’t really working, it works just enough to fill me with doubt, I am unsure if it should be pulled out or left in.
I realize this is an area that is lacking from every scenario I have every used in training. We always tell people that the tube is “good” or “not good” we never tell people you can’t tell if it is working, we never say “it works…sort of…maybe…some of the time…I don’t know.” We never answer the question of “is the tube good?” with “who the fuck knows..”
We talk of adding elements of realism to training, we talk about using high fidelity simulations, I believe this may be the scenario I present at our next training:
“we’ve gone ahead and sprayed a gallon of beef stew all over everything and dumped out the jump kit on the ground for you, we have also gone ahead and rolled several key pieces of equipment like 10cc syringes and the mask to the bvm under the bed. Your patient is a 55 year old male, you are killing this patient, nothing you do is working and you only realized it far too late, past the point of no return. Panic is setting in and you feel guilty about even trying to save him, you have been on scene far too long already, you are only making things worse and you are wondering if everyone thinks you are a bad paramedic …you still don’t have a reliable airway… he has no allergies and his only medication is lisinopril….Annnnndddddd Gooooooo!”
He is fighting the king tube and the ventilations, brown fluid is spraying everywhere. He is coughing and gagging, the ETCO2 reads 70 then it reads 4 then 0 and then back up to 68 only to drop to 0 with no wave form seconds later. His stomach keeps getting bigger. The stream of brown fluid coming out the tube won’t stop no matter how much suctioning I do.
Everyone is thinking it. The cops are looking at me wondering why the fuck are you still on scene. I’m asking myself the same thing, why did we not go to the hospital 15 minutes ago? How did things spin so out of control here?
It is now a mantra, a meditation on how things have gone so very wrong, “shit….shit…shit…”
I consider pulling the king tube but it still sort of works…..sort of, enough to get him out in to the ambulance and out of the chaos of the bedroom. We give him some more ketamine, fentanyl and succinylcholine so he stops fighting the ventilations and it is easier to bag him. Maybe things will be better in the ambulance I tell myself, knowing they won’t.
Vomit Springs Eternal
In the back of the ambulance the king tube is a gurgling spring of shiny brown gravy that will not stop, it is a vast endless aquifer of filth.Our attempts at ventilating him aren’t doing anything at this point besides blowing more vomit in to his lungs. I pull the king tube and try to intubate again on the way to the hospital. The opening is right there, I can see it.
I realize he is still in the board and I can’t raise the head of the gurney. This is it, this is how you fail, this is how you kill a patient. It is only a matter of time until he arrests; frankly I am surprised it hasn’t happened yet.
I am quickly running out of options. I have no more king tubes. I have no more bougies, the video laryngoscope is trashed, who knows where the direct laryngoscope is. The inside of the ambulance is a war zone. How did things get like this? This kind of shit doesn’t happen to me, I am a good paramedic.
Panic is setting in. There is an urge to just give up, to just admit defeat.The thought of I’ve done enough damage to this patient crosses my mind. I don’t think my partner has any idea how close I came to just saying “Game over man…Game Over” and to just sit there and watch the patient pass away. In hindsight, I’m still not sure that it would have been that bad of an option.
“The procedure was a success but unfortunately the patient died.”
The “cric kit” is out but I don’t want to “cric “this guy because I know it is not going to end well. I know I will kill him if I do it. I know I would be justified in doing it. I also know I am about to enter the realm of no return. everything I have done, (or not done) can be undone, can be managed up until this point. If I cut his neck I committed, there will be no more plan B, there is no turning back from that, it either works or he dies choking on his own blood.
By some miracle his “sats” are still in the acceptable range.
I make a last stand, I slam two NPA’s, one in each nare and by some miracle we are able to ventilate him using two-person BVM technique and get him to the ER. We get to the ER and that is when things somehow got worse…To be continued in the next post.
I was never going to get the tube on this patient. It is of some conciliation when I found out that the anesthesia department at my hospital once tried to do a surgery on him, sedated him and after looking at his airway woke him up and told him they weren’t doing the surgery on him…ever and he should never come back there. My mistake lies in not realizing I was in a battle I could never win, not realizing that I was getting sucked in to a failure vortex, not realizing that I had tunnel vision.
I can sit around a training room and tell you what I did was wrong. I can post on internet forums how I would go straight to cutting the patient’s neck and performing a cricothyrotomy if presented with the same scenario again. Until the other day I could tell you how I would never make these mistakes if I was given this scenario.
While I can recite the airway algorithms to you and I can tell you that if you can’t get the ET tube on a patient move on to plan B,C,or D, I could not do it.
There are few things as seductive as the idea of one more attempt at an intubation in a patient that desperately needs an ET tube, especially when you can see the opening of the glottis. If you get that little piece of plastic in the right place all your problems are solved, the world is once again a good place and you can move on to other issues. If you get the tube that others cannot when things are going to shit you cannot help but feel like a hero. If you get the tube you have fixed a problem that you played a part in creating, if you do not get the tube you have made things worse and it is your fault.
I have made mistakes before but they have been easier to recover from, they have been simple mistakes in math or dose, simple mistakes where I thought I grabbed one thing but grabbed another, or simply forgetting to do part of a procedure. This is different, this mistake is one where my judgement as bad, my thinking was bad, I had poor judgment and I boxed myself in to a corner.
I’m a realist, there was never going to be a day where this patient showed up at my station and shook my hand, I know that even if he survived this patient would never have a normal life again. While I can sit here and tell you that I understand I was only trying to help this patient I feel guilty. I always thought there would come a day where I would find myself feeling guilty for not being able to save someone, for not being a good enough paramedic, for making a horrific mistake. I feel guilty for playing a part in either prolonging this patients death or worse prolonging their living. I know people will try to be supportive about it telling me that I was there to help and it wasn’t a situation I created. While it is true I did not create the situation my actions certainly led to it being worse than it needed to be.
For as much bad came out of this call there is some good that came out of it as well. Lessons learned will be in part II….
I have spent several days now debating on if I should hit the publish button or not on this post. When you screw up in medicine you are going to experience many emotions, most of which are unpleasant; shame, guilt, disbelief, and you are going to feel like you are an asshole and everyone thinks you are a shitty provider. If you make a mistake, go ahead an beat yourself up over it, mope around the house for while and feel like an asshole, feel like you are a phony, grieve for yourself and then get over it. If you’re not getting over it after a period of time that you feel is appropriate then get help or this will gnaw away at you like cancer.
It is important that if you do make a mistake you realize you are not the only one who has made mistakes. It is important that we share what we have learned from these experiences with each other.
I’m going to hit the publish button now, I still don’t know if it is the right thing to do but I hope it is.
Take care of yourselves out there,