disaster concluded

so for those of you who have been following these disasterous events, you'll remember i reinserted an et tube into the man's tracheostomy, thereby allowing him to breathe and then went home in full confidence he'd be wonderfully looked after in icu.

so i arrived at work the next morning, almost expecting adulation because i'd saved the guys life (we surgeons tend to have ego problems). imagine my shock when i heard he was dead!!! what had happened??why wasn't i called if he'd collapsed or if he lost his airway again??? what had happened is the following:-

although there was an icu bed as i'd been informed, there were no available nurses to man the bed (they have similar overtime pay problems in this province to what the doctors experience) so the patient was not given the bed. this had not been conveyed to me. what then happened is a total calamity. in the ward, where the patient ended up, he developed a mucus plug in his tracheostomy tube, couldn't breathe and died. no one even realised until it was all over. this is a simple thing to prevent. all that needed to happen was that his trachi pipe needed to be suctioned intermittently through the night. not exactly high intellect stuff. anyone can do it. but if it doesn't happen when it's needed the results can be dire.

when i wrote the post disaster on disaster, one of the things i wanted to comment on is the feeling this sort of thing causes in us, (or me) the surgeons. firstly i felt the total tragedy of the unnecessary loss of the life of someone who died who didn't need to. it's sort of like hearing that the guy you met at the pub last week was hit by a bus just after saying goodbye to you. you don't really know him but you feel the intensity and finality of the situation. it's terrible!!!

then there are another two feelings. the one is a feeling of guilt. shouldn't i have done more? should i not have stayed to make sure my medical officer did in fact get the guy to icu? should i not have gone to suction the trachi myself? how could i have foreseen this??? etc. etc. etc.

lastly, there is a feeling that all the work we did was futile. this is where the normal person on the street may miss what i'm talking about and even consider us a bit heartless. but remember that this is my job and just like the advertising executive who spends nights preparing a presentation and in the end doesn't get the deal will feel a sense of disappointment, i felt sabotaged. after all i'd done, someone dumps him in the ward and everyone including the nurses on duty get a good night's sleep. it's more than just frustrating!!! i suppose the problem is when we have a work associated disaster, usually someone ends up dead. somewhat like the mafia i suppose.

i feel i have so much more to say to fully express how i feel but words seem to fail now

disaster on disaster

recently i was involved in a case which i want to talk about on so many levels. therefore this posting is probably going to be very disjointed. a peripheral hospital sent us a patient that they said had severe stridor (an inspiratory noise usually denoting an upper airway obstruction) what they didn't tell us was that the guy could hardly breathe at all. he arrived and my medical officer quickly made the evaluation that a tracheostomy needed to be done and immediately. he phoned me. i was not on call or even standby, but he told me he couldn't get hold of the other guy. my mo had assisted in a tracheostomy recently and i told him to go for it (see one do one teach one principle). he said he would, but i could hear he was a bit nervous so i came in. in theater the man was in severe distress. he could only breathe if he sat up and leant forward. i injected his neck in this position with local. (you don't want to put this type of patient to sleep unless you're sure of getting an airway or he might asphixiate and die.) i then started the procedure with him in almost a sitting position. i decided to do this one because of the distress of the patient and i'd be able to work faster than the mo.

i dug into the neck as fast as possible. but i couldn't find the trachea in it's normal position. where it should have been was a transverse pulsating artery about the size of my little finger. in retrospect i think it was an aberant right carotid artery which ran anterior to the trachea, but i'm not sure. i reflected it inferiorly and much deeper down and travelling in the wrong direction (the trachea is usually more or less parallel to the skin, with a slight slant posteriorly. this one dropped posteriorly almost at right angles at the level of the abnormal artery) was the comforting corrugated feeling of the trachea below my finger.

at about this stage the patient became disorientated due to hypoxia (lack of oxygen) and started fighting. fighting for his life as he saw it. the anaesthetists had no choice but to put him to sleep. i continued my endeavour while they tried to intubate him from above. i heard them saying they could see a pedunculated tumor at the base of his tongue that formed a ball and socket valve over his airway. the cause of all his problems.

with much sweating and swearing i finally got the tracheostomy pipe in, casually asking the medical officer why he didn't do this one alone (a joke, just in case i get flamed). we sent him to the ward. it was the most challenging (surgical talk for difficult) tracheostomy i've ever done.

i felt my adrenals slowly recover, shrinking back to only twice the normal size. i went home and had a beer.

about 3 hours later, the same medical officer phoned me. he started with an apology that once again he couldn't get hold of the other guy, but the patient had removed his tracheostomy pipe and he couldn't get it back in again. immediately i headed off to the hospital. i went straight to theater. there i found a very pale man. the patient also looked off colour, but he was blue. the pale medical officer told me surgery was not for him. if i didn't think he'd take it badly i would have laughed. the patient seemed to almost be in exitus. not good!

to be continued.......