Emergency Drill #3
This is the third in a series of emergency drill posts to use in those quiet moments when you’re waiting for a patient to arrive or when the CEPOD board is looking suspiciously empty.
The idea is simple:
- Treat it like a mini SIM
- Run the drill
- Talk it through
- Remind yourself of the protocols
- Feel more prepared for if and when it actually happens
You can fly solo and test yourself, or rope in a colleague and take turns being the examiner.
It makes for a perfect CBD with a consultant if you're looking to boost your LLLP portfolio as well.
Enjoy.
Setup
It is 11:43 pm and you have just finished inducing a 33 year old man, who is undergoing emergency laparoscopy for a suspected ruptured appendix.
Your colleague is covering labour ward, but since nobody was labouring she had been keen for some airway practice, she had joined to intubate the patient and is now tying the tube in place while you slowly give the antibiotic.
BLEEP BLEEP BLEEP
The dulcet tones of Enya emanating from the speaker on your anaesthetic machine are suddenly pierced by the shrill of the emergency bleep erupting from both of your scrub top pockets.
"ANAESTHETICS TO SHILEY WARD"
Your ODP fetches the emergency airway bag and you start running while your colleague calls the on-call consultant to let him know that you're attending an airway emergency, and both on call anaesthetists are now occupied and unable to attend further calls.
You arrive on the ENT ward to find a scene of utter chaos.
Begin
Nurses and healthcare assistants are clamouring at the door of a darkened side room, and you can hear the occasional raised voice emanating from inside.
Upon reaching the door you see at the centre of the mayhem a very distressed patient sat bolt upright, with a look of sheer terror painted across his decidedly grey face, making no noise and pointing at the tracheostomy tube in his neck.
What do you do next?
To begin with, you need a workable environment in which you can actually help.
Currently you're looking at a patient in extremis in the middle of a darkened side room full of people who may or may not be doing anything useful.
- Announce that this is an airway emergency and that you need space to work
- Turn on the lights
- Locate the nearest source of oxygen
- Find the tracheostomy kit
Hopefully all tracheostomy patients in your hospital will have some form of tracheostomy kit or box that travels with them, with all the bits and bobs inside to handle any emergency that might arise.
If not, there's an excellent QIP for you.
Now is also a good time to ask someone to call a member of the ENT team if they're not already there.
You manage to force yourself into the room past the crash trolley and a quivering medical F1 who is searching instinctively for an ABG syringe, turn the lights on and switch the excruciatingly high pitched bedside alarm off.
You look at the patient, his neck, and the monitor, and several things become clear all at once.
- This patient cannot breathe
- There is no noise coming out of either his mouth or his tracheostomy tube
- The non-rebreathe mask on the patient's face is not misting
- His saturations are now 83%
What do you do next?
The first question to answer is 'is the patient breathing?'.
In this case the answer is 'sort of but not really', which falls into the 'yes' side of the algorithm, because the 'no' side takes you down the CPR route.
Your patient is making excellent respiratory effort but clearly has no patent airway with which to use it.
- You are already applying oxygen to the nose and mouth with your non-rebreathe mask
- You should also apply oxygen to the front of his neck as well
Next you need to assess the patency of the tracheostomy.
The first step is to remove the inner tube of his tracheostomy tube.
While simultaneously explaining to the patient what you're doing, you unclick and cautiously remove the inner tube, whereupon two things happen in very quick succession: