No matter how many times I work in a resource-limited setting I am always absolutely blown away by the ingenuity of the medical staff I work with. They take being prepared to a whole new level. My brain works in a certain way(and if you're in critical care, chances are you may think in the same manner)--it goes like this: identify the scenario, identify all possible options to manage the scenario, proceed down the best path, anticipate EVERYTHING that can go wrong, assume it will, take solace in being prepared when it does go wrong, be relieved if it does not. It means your brain is going a mile a minute but externally you remain in control, block out the noise and map out your next move seconds before you execute it. So why all the back story on how the brain of an Intensivist works? Let me tell you.
What you need to know before you read on: Intubation means placing a breathing tube in someone's mouth which goes into their trachea and allows a ventilator to breathe for the patient. In the best of scenarios this can be difficult, in the worst of scenarios this has the potential to be terrifying. Hemoptysis is when a person coughs up blood. Coughing up blood makes it challenging to see the vocal cords when you are trying to intubate someone as the vocal cords are one of the landmarks to identify so you know where to put the tube. The word hypoxic refers to a patient having low oxygen levels. OK, read on.
Rounding in the afternoon on our patients. We had our eye on the young lady with questionable severe malaria versus severe sepsis (widespread life threatening infection ). She looked more sleepy. Her respiratory rate was 40-50 breaths a minute. She needed to be intubated, and asap. The process of intubation should always be controlled, have all of your supplies ready, have back up supplies ready because again, anticipate things can go wrong. Problem 1: limited back up supplies for intubation. OK, I knew we had enough of what we needed. We proceeded. Everyone was assigned their role. We made sure we could give enough oxygen to the patient with a mask. One of the supplies we keep ready is a catheter for suctioning, this catheter should be able to suction sputum or blood whatever is in the way to clear the view to see the vocal cords. In the US the oxygen is provided by a connection in the wall that is connected to a larger more central supply of oxygen. I don't ever think about the tank behind the wall or that the supply may run out. Here, the supply of oxygen is via a large tank. The patient received a significant dose of medications to make her sleepy. I open her mouth and blood is in the way. The suction stops working. The power goes out. The oxygen supply runs out, but the team is prepared with another, because THEY KNOW, they know this is a possibility. The tube goes in successfully. Initial sigh of relief followed by the deafening sound of the monitor, the beeping which in my head is translated into a voice yelling "THE PATIENT IS HYPOXIC". Of course this can't go smoothly. There is a clot, sitting at the base of the tube, probably dislodged as the tube entered into her airway, blocking the flow of oxygen. We suction and suction, using a syringe now to manually suction--a large clot emerges and finally the beeping slows and stops and the patient is oxygenating. My own pulse slows. And the room audibly exhales.
so what's the lesson? When you think you're prepared, When you think you have imagined every scenario, think again. Each possible scenario must be tailored to the physical environment you are in. Know what you have, know what you don't. Remember your limitations. Remember that you do not do this alone, and the day you think that you will fail. It's a team effort. This team rocked the worst case scenario. I'm proud to get this opportunity to learn from my colleagues here. They continue to teach me how to REALLY be prepared, they continue to teach me to think outside of the box. These medical trips are never unidirectional--they're fully bidirectional, the education goes both ways!
The oxygen tanks that were ready and waiting to be moved (requiring multiple people to do so).
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