21 March 2009

Curing with the knife

According to Dr Crippen, and he is right, there are three medical procedures that can be dramatically live-saving.

The three procedures are:

1. Relieving a tension pneumothorax
2. Performing a tracheotomy
3. Drilling burr holes into a skull

Dr Grumble has done numbers 1 and 3 as emergencies. He has lost count of the number of times he has done number one. He has never done number 2 as a lifesaving procedure. The reason for this is that by the time patients get to see Dr Grumble with their airway in difficulty they are usually either dead, better or can manage without the Grumble knife for long enough for somebody more expert than Grumble to deal with the problem. There are also sometimes other tricks you can do to buy time.

But Dr Grumble did once get to sharpen his knife. It was so long ago confidentiality is really not an issue so Dr G is going to tell you the story.

At the time Dr Grumble was working as a Senior House Officer in the intensive care unit of a large teaching hospital. These days such units have vast numbers of junior and senior doctors supporting them but when Grumble was a lad it was different. Out of hours Grumble was it. Any problem and he had to deal with it. The ITU had an excellent reputation. It was almost certainly the best in the land. Any major problem in the rest of the hospital and the patient would be propelled to the ITU. As the patient entered the safe haven of the ITU the accompanying doctors would heave a sigh of relief and vanish.

One evening when Dr Grumble was the only doctor in the ITU there was a phone call from one of the wards. A young boy admitted for a routine operation had suddenly taken a totally unexpected turn for the worse. The attending doctors wanted to wheel the patient straight to the ITU where the young Dr Grumble was it. Sometimes moving emergency cases seems to take an eternity but the young boy arrived in double quick time. True to the usual form, as the bed entered the portal of the ITU the doctors in attendance vanished as quickly as they had appeared and poor Dr Grumble was left with a young boy that looked to be breathing his last, a boy who moments earlier had been completely fit and well.

The history in medicine is all important (Dr Grumble only heard that later) but the young boy could not speak and his doctors had left no clues as to what might have happened that fateful supper time. Dr Grumble had certainly never seen a problem like it before but it was clear that this poor boy's upper airway was obstructed and he could hardly move any air in of out of his chest. Perhaps now, with experience, Dr Grumble would have been able to work out what must have happened but these things are very difficult and very frightening if you are the only doctor there, the urgency of the situation is not in doubt and you have no mileage.

The young doctor's most helpful bit of equipment is the telephone. You use it to summon others to help you out of a difficult situation. Dr Grumble still tells this to his most junior staff but they now only work in the day so for them it is never so frightening. In those days surgeons of all sorts were available in the hospital day and night. It's no longer the case as working hours have been slashed but then Dr Grumble could be sure that somewhere in the hospital there would be an ENT surgeon. So he phoned them and explained as graphically as he could the gravity of the situation and how he needed their urgent help. And then he waited and waited and waited. As the patient's condition deteriorated Grumble began to realise that the patient might need a tracheotomy there and then. It was a well equipped ITU. We had all the kit. Dr Grumble got it out ready and started to sharpen the knife. The boy began getting even worse. He was turning bluer and bluer (no pulse oximeters in those days). There was no more time. Eventually Dr Grumble realised that he was going to have to do something himself. The boy was not yet unconscious. Dr Grumble picked up the knife. A look of horror crossed the boy's face. He sat bolt upright and vomited. And out came a large chunk of fish and a fish bone. And from that moment on the young boy was fine. And then the ENT surgeons arrived and wondered what all the fuss was about.


Am Ang Zhang said...

That is a Child Psychiatrist’s territory! Good blog.
Quoted you in my new blog on the tragedy of Natasha Richardson.
The Cockroach Catcher

Dr Michael Anderson said...

Ugh, this is the sort of situation that gives nightmares. I've never had to do a traceostomy either, but for me, it's only a matter of time before I find myself in a situation where I get the knife out and it's a question of how well I cope when it happens.

You are so right about the telephone being your best friend. Calling for help EARLY is something that is constantly drilled into me and is right at the top of every difficult airway algorithm.

I can well relate to the vanishing trick that doctors do. When I get called down to the ward or to A&E resus, I'll be trying to ventilate a semi-conscious patient and I'll look up and people have literally vanished. I'm getting better at stamping my feet and making sure that other doctors stay around until the patient is properly sorted.

Dr Michael Anderson said...

Oh, and I'd change your list of dramatically life-saving medical interventions to have

1. Opening an obstructed airway

right at the top. It's simple, anyone can do it yet thousands die every year in this country because they have an obstructed airway and no one thinks to lift their chin.