Yesterday i was mountain biking all day in Mont St-Marie. When i practice something that is very challenging and at the same time very pleasurable, i enter a flow state. Flow is a state of mind when our consciousness is deeply involved in what we are doing. Time perspective changes, it can accelerate or it can slow down but we forget about time, we become what we do and it is a source of great satisfaction. It happened yesterday as it often does when i am practicing a sport i love.
It also happens in many things i do, my work especially. This morning, i received a gentleman who had an accident. He comes in in shock and short of breath, he is also comatosed. I quickly assess his condition clinically and with bedside ultrasound and, from the combination of shortness of breath, shock and absent lungs sounds in one lung, i suspect he suffers from a tension pneumothorax. I ask for a large 14 gauge needle and i stuck it in his chest to decompress the lung. While the team is preparing the equipment, medication and venous access required for intubation, i complete my assessment. I also suspect a brain bleed, the main reason for his altered consciousness. When we are ready, i use a curare to paralyze my patient. Using a paralytic is a double edge sword: it can facilitates intubation and mechanical ventilation but if i fail to intubate, since the patient can’t breathe anymore, he can also die because of me. I am confident in my ability to proceed and i have working alternate plan. In any case, we can always go back to bag-mask ventilation as we have verified that, with his anatomy, it is feasible. So we push the medication and wait half a minute. When he stops breathing, i have but a few minutes to secure his airway before irreversible brain damage would occur. I take my time, i insert the glidescope and, while whistling, i slide the tube in. Yes, i whistle. Whistling takes my analytical mind out of the moment and i can do what i do best: perform under pressure. When we think too much, flow does not happen. The whole procedure does not take 30 sec.
As expected, after intubation the patient crashes, his blood pressure droppes. Mechanical ventilation is difficult on a perforated lung and tends to worsen the problem. The large needle i have left in his chest is not enough. So i ask for a scalpel and chest tube kit. Usually, putting a chest tube in a thorax can take half an hour. But when a patient is dying, every minutes counts. So we must work rapidly. I stay very focused and very calm: cut, dissect, dissect, penetrate, insert a finger in the chest and guide the tube inside the cavity. Again, this procedure is done very rapidly, just a few minutes, maybe two or three. Then reassess. Blood pressure is up but only temporarily and it drops again. I feel a great chemistry with my coworkers. We are working together as a team. Each member doing his job gracefully but also anticipating the needs of others. I know i am where i should be, doing the work i love with people i care about and who share my passion for this work we do together. I could not save a life alone, it is a team effort.
Reassess. Think of other causes of shock. Not everything in trauma is related to trauma. The patient is mechanically ventilated. The pneumothorax is drained. He is comatose from a suspected brain bleed. But he is still in shock. EKG is normal so the heart is good. The orogastric tube does not drain gross blood so it rules out upper GI bleed. Repeat an ultrasound: no free fluid so no belly bleeding. Check the aorta to rule out dissected aneurysm. We did everything right so the only thing left is to give him fluids and try to stabilize him to go to the CT scan. Unfortunately this does not happens.
He goes into cardiac arrest. Start CPR. Give him medication. Look for an abnormal heart rhythm called ventricular tachycardia that we can defibrillate. Nothing. But the medication kicks in. Success! His heart starts again. At this point, i’m pretty sure this patient will die. Cardiac arrest in this condition after an aggressive resuscitation is not good. Epinephrine just bought us a few minutes by stimulating the heart. We keep resuscitating him for 20 min but he is in refractory shock with recurrent pulseless electrical activity. I ask the team to continue the same treatments to keep him as stable as can be. I have to talk to the family…
I enter the family room. I meet his children. They are adults. I explain what happened and what i suspect. I tell them that after 20 minutes of resuscitation, a cardiac arrest and refractory shock, the likelihood of survival are low. I take the time to tell them that at this point, to die is not the worse outcome. For many, the worse outcome would be to survive in a totally dependent state, unable to move, unable to communicate, unable to feed oneself. Basically most people would prefer to die than to spend the rest of their life in a bed with a diaper and be fed puree 3 times per day. I ask them what their father would want: keep going and do everything to ensure survival whatever the outcome OR let go and die peacefully. They cry. I accept their pain, it’s part of my job. We go together to his bedside. They see the state he is in: tube in the chest, multiple wounds, ventilator, etc. We agree to stop everything. I explain that once we stop everything, he will most likely die soon after but i can’t promise what will happen 100% because his life will not be in my hands but in his.
We give them time to be with their father. Once they have said goodbye, we disconnect the ventilator, remove the tubes, stop the IV’s, close the monitor. A few minutes later, my patient dies. I declare him and i go tell the family. They cry. I tell them they did the right thing by letting go. I give them all a big hug.
And i leave them and i go see another patient. Unfortunately, I cannot stop. I’m the only doctor working in this emergency room at night. There are other lives i must care about, other sick people to help.
This was one hour of my work, one hour of my life, one hour of my flow.
Working in emergency medicine is very hard but it is also very rewarding.
I love this job, i love the team i work with and i love the patient who, although they do not know me, trust my competence and put their lives in my hands.
I continually try to be the best i can be.
Thank you to all the members of the team who worked with me today,
It is a privilege to be working with you.
Thank you.
Original post Facebook, september 2015
Martin Pham Dinh 