So im having a good night shift, couple drunks to stitch up, febrile kiddies.
Then our beige phone goes, You may have a red phone, ours is beige, the colour of terror.
70 y/o female, poorly responsive, D+V, pulse 20 bpm. ETA 5 minutes, unable to get IV access. call back but no response. Crap, As im flying solo on nights and this sounds like a bit of help would be appreciated I get the switch to call the boss in. (Go ahead, shoot me)
So pt comes in, shes big, really big. GCS 13-14 more drowsy than anything. “I feel like im going to die” The night nurse bless her goes “I hope your wrong” Pt was cool to the touch, couldnt get a temp. Unable to get a BP, P 20-25 sats 91% on RA. Denies chest pain. but not exactly with the programme.
She has no veins, none. ambos had 4-5 goes nada.
So I think, going to take a while to get access and she need some rate. #ATROPINE IM, not cause ive read anything but cause makes sense to get something on board. moment of humour and as nurse draws back first before injecting, then goes “bugger no blood”
ECG comes back its a bit unclear, not a stonking inferior MI. Were now about 5 mins down the line of me trying to get access.
So I finally manage to get a tiny canula into her wrist (read paeds 24g) and give a IV dose of atropine, some response pulse up to 40, can get a BP now on NIBP 70/35. Reception has found her on the computer. and god bless the GP they have a summary on our new Health pathways info. it reads:
Type 2 Diabetic, very poorly compliant, HTN, very poorly compliant. (at which point i wondered what ”very” poorly compliant meant..) Chronic Renal Impairment. has date of last meds collected, was yesterday…So shes prob had according to computer, 190mg metoprolol(Betaloc), Diltiazem 180mg daily, Inhibace plus, Metformin 1g TDS.
Boss arrives and continues the search for a line, brief discussion re:IO. goes, “do you think IO is an option?” “maybe but were not going to do that”
At this point delving for better access i manage to feel a good radial pulse, so bugger it. pop a cannula in and get bloods off.More atropine and really not getting any BP with it despite pulse coming up. so calls made to place a pacing wire.
Labs are back:
|pH||7.07 L||7.35 – 7.45|
|pCO2||32 L||34 – 45||mm Hg|
|pO2||139 H||80 – 100||mm Hg|
|Base Excess||-21 L||-3 – +3||mmol/L|
|Actual Bicarbonate||9 L||23 – 29||mmol/L|
|Sodium||136||135 – 145||mmol/L|
|Potassium||6.2 H||3.5 – 5.2||mmol/L|
|Chloride||114 H||95 – 110||mmol/L|
|Total CO2||9 L||25 – 33||mmol/L|
|Anion gap||20||10 – 20||mmol/L|
|Urea||16.4 H||3.2 – 7.7||mmol/L|
|Creatinine||251 H||45 – 90||umol/L|
Nothing too exciting, her renal function is better than when last tested, not too sure about the potassium as might be haemolysed some but not high enough to jump on it. Gas was thought to be from poor tissue perfusion rather than DKA and her sugar aint too elevated. but getting rate up and getting some perfusion is prob first task whatever the cause.
So we wander to radiology and the boss goes, “done a pacing wire?” “uh, no”(im very articulate on nights)”you will have in about 20 minutes” I do the worlds fastest reading of the procedure. and away we go.
Gown, Glove, prep and go. Get excellent flashback and im in. wire goes in nice. Feed, curls, #Sweat feed twists, #SweatSomeMore. Wonder about how hot it is all of a sudden and that lead is bloody heavy and hot. So after a bit more work get a good position but with a pretty curl in the artium. nice response without too much voltage. Boss joins in to improve it but cant help the kink and decides he will just leave it.
Then for central line. So same but on the other side except advace introducer to maximum depth get little blood but can’t hold the bloody thing down enough to get the guidewire in. discretion being the better part of valor I give up. quick CXR to show my handiwork and no pneumo and off to HDU.
Gas-man arrives, read wonderful scottish anestetist with a great sense of humour. “Boy if you couldnt get it in there you better learn how real men put in central lines” So Uss guided jugular goes smoothly. Hes happy she has an art line in and even gets a good trace #stoked.
patients Bp still not cutting it despite rate of 90. so we started a dopamine infusion to which she responded well. decided with the metformin on board and bad perfusion not for noradrenaline. Also started cefuroxime.
And today i come to work shes doing well still brady when pacer is dropped back but less so 40-50. weaned off the inotropes. troponins didnt rise any higher so it looks like was drug related.
So questions for anyone reading do you remember your first pacing wire, art line, or central line? how did it go? or was it so long ago that the dementia has already claimed it? What would you do different? (its ok my goal is to learn)