Saturday, November 14, 2009

The Mother of all Asthma Attacks

I was on call in the delivery room. The phone rings and the secretary announces that there is a woman in the maternity ER in critical condition.  All eyes were on me.  "Oh, you mean me?" By the looks on the midwives and obstetricians faces the answer was affirmative.
I hastened down 4 stories and entered the ER. "Where?" A nurse pointed to an examination room.
Entering the room, I make eye contact with the senior obstetrician on call, a good friend, "what's the story?"
"A nurse from medicine, 32 weeks pregnant, just got off her shift with her husband, also a nurse when she fainted, they brought her in here."
One look at the woman tells me that she is having the "Mother of All Asthma Attacks"(tm). She is very agitated and is literally turning blue.
"Let's intubate, give her 100% oxygen, draw up 200 mgs Propofol and 100 mgs scoline." While the nurses prepare the syringes, I connect the bag-mask-valve apparatus to oxygen.  The patient is making an effort to lie down (usually, patients with breathing difficulty try to sit up) a sure sign that she is about to crash.  The syringes ready, I nod to the obstetrician, "Give it all."  He injects the contents of both syringes, within seconds the woman is motionless, anesthetized and paralyzed.
This is the moment of truth, I call out: "cricoid pressure" (to prevent aspiration of stomach contents). I place the laryngoscope into her mouth - a perfect view of the glottis, the entrance to the trachea.  I see the snowy white bands of the vocal cords forming an upside down "V".  The epiglottis just above poised to cover the glottis during swallowing to prevent aspiration.  The two buttons of the arythenoid cartiledges at the base of the glottis.  Most importantly, the void between the vocal cords, the space where the endotracheal tube is to be inserted.
Without averting my eyes, I extend my hand, "tube!"  My friend places the tube in my hand in the correct position for intubation (God bless him!). I slide the tube into the trachea, remove the laryngoscope, inflate the cuff, attach the bag, squeeze and simultaneously auscultate over the epigastrium.  It feels like ventilating a brick wall.  Left lung breath sounds, very wheezy, very very.  Right lung sounds the same.
The pulse oximeter, measuring the patient's oxygen saturation, changes tone from tenor to alto to mezzo-soprano, to soprano - 100% oxygen saturation.
We start giving bronchodilators.  Eyebrows are raised when I employ a trick I learned from one of my professors: Intranasal salbutamol. Unorthodox, but effective, especially with such extreme bronchospasm. Given usually by inhalation, in such conditions, little drug would get to the bronchi, but given intranasally, the drug is instantly absorbed into the blood stream and flows to the bronchi by the back door so to speak.
The obstetrician does an ultrasound, the fetus is very sluggish, he voices his concern that the fetus suffered severe hypoxia along with the mother.
Within a few moments the drugs take effect and it is easier to ventilate.  After 15 minutes there are no signs of bronchospasm. A repeat ultrasound shows normal fetal movement.  Everyone sighs with relief.
The ICU doc on call comes to transport the patient to the unit.
The next morning after an exhausting call, I visit the woman in the ICU, she is extubated and fully conscious. I introduce myself and tell her my version of the events of evening last.
The ICU docs congratulate me on the "save". The senior says, "You realize you saved her life?"
I somnolently nod through the post-call haze. I think to myself that it was just plain luck.  She was lucky that the asthma attack occurred so close the hospital.  Had they made it to the evening rush hour traffic, the results might have been much more tragic.

Oh, yeah, and happy second blogoversary to The Sandman.   


Risa Tzohar said...

What a hero! But, you must write more often...

Chrysalis said...

Excellent! And congratulations on your 2nd year!

Unknown said...

Risa - thanks but I'm no hero. I do what I've been trained to do. Anesthesiologists are the experts at airway management. My point really was that the patient's survival was a matter of just good luck in being close enough to the hospital to be treated in time. As far as my writing, I do my best with the little free time I have.
Chrysalis - thanks.

Chrysalis said...

Don't forget, it's the right people put in the right place at the right time. ;)

Baila said...

Wow. That read like an action sequence in a movie. I'm so glad the woman is okay. Yadonegood.

Oh, and Mazal Tov on your blogiversary. I hope you celebrated...

Unknown said...

Baila - Thanks. I celebrated by some uninterrupted sleep in comatoast mode.

Lioness said...

See, this is why after long busy periods I dread coming to your blog, I'm instantly sucked into the vortex!

You're being too- ach, it is your job and that was your training but not every single one of your collegues would have been able to save them, you know that, yes? Maybe it even was the intranasal salbutamol - btw, INTRANASAL SALBUTAMOL, can I tell you how much I am in love with the idea? I wonder if it's ever been tried in severely asthmatic cats, hmmm...

I love your blog!

Unknown said...

If you ever encounter a severely asthmatic cat let me know. I will never meet such a creature since my daughter the poet is severely allergic to cats.

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