There are few times in a medical career where one truly makes a difference between life and death, certainly in the role of a radiologist. It is on these days that one appreciates the value of years of training and the deep fulfillment of being in the medical profession, and also appreciates the value of the team.
And some days the Gods are with you and others they are not
This day the stars were well aligned and the Gods were with all of us.
Such a day occurred on September 29th 2009, at the end of the day when all staff were packing up to go home, and I was futzing around with teaching files and the like. Jesse Olson the senior technologist and Okland Lopez a junior technologist popped in
?Dr Davidoff I know you are not on call but I think this patient needs urgent care ? ?Okland took the X-ray and was kinda worried. I think he has a large pneumothorax.? Jesse said.
I took one look and realized that not only was it a pneumothorax but it was a tension pneumothorax ? a life threatening condition
?Where is the patient Jesse??
Oh he is sitting comfortably in the waiting room
So I popped into the waiting room which was empty but for a 49 year old man who was fingering away at his iphone.
He looked comfortable, unperturbed
On questioning ? he had mild discomfort, with a little wheeze and shortness of breath that had been present on and off since a recent flight from San Diego, and his doctor was concerned about pneumonia or a pulmonary embolus. I explained to him that he had a serious condition, and that we were going to take him straight down to the ER. He started to look anxious, but accepted the diagnosis and realized that he had a life threatening condition. I asked our nurse Barbara Robery to accompany him to the ER and I proceeded to call the ER to alert them of the patient and his emergent diagnosis.
As I sat down at my console to report the case, I heard a blood curdling scream from Barbara, calling my name from the patient waiting room.
I ran and found the patient slightly dazed, but alert. Barbara reported that he had had a 15 second seizure and that his pressure had fallen to 70 mmg and pulse was slow.
He truly was on the edge of hypotensive collapse, and so I went to the CT scan to get him on the table for an urgent chest tube placement
All lights off! Shit! All machines shut down, no technologist in sight ?Second thought ? ? have to go to fluoroscopy for the chest tube! ?
A radiology colleague on call ? Dr Ralph Panek- heard the commotion popped in and offered help. At this stage ? the direction was clear ? Chest tube ASAP ? do not pass go do not collect anything ? chest tube ASAP
The patient was still mentating ?
Rushed back to the patient ? and Larry Frederick (our CT technologist) on his way out of the door ? heard the commotion, and realized that he may be needed. At this time he was helping Barbara get an iv ? take blood pressure and pulse.
CT scanner was rebooted ? lights were turned on and all hands were on deck Jesse Okland, Larry, Barbara.
As we were getting equipment together ? thought best that I phone the patients wife, mother of three children 22, 16 and 14. In as calm a voice as I could muster, and trying to discuss the seriousness of the matter without provoking excessive anxiety I told her of the situation. I was in sound mind to ask the patient to speak to his wife as well which he was able to do. Short and sweet hello ? ?I think I am going to be OK? or something like that.
Barbara pointed to the blood pressure
55/22mmhg and the patient was still mentating but starting to look a deathly color of blue and gray .
We left the room for the initial CT scan to localize best position for the catheter.
In walks the chief of radiology Dr Girard ?? Why put an 8F ? double that! Get a 16french in ? ?
?Yes boss if you say so!?
The 16F catheter popped in perfectly, and the beautiful hiss of decompressing air put relief on everybody?s face as the frown of concern and the hype of the moment suddenly took the turn that was needed. The patient?s color started to return almost immediately as we had, in just a single hissing moment, snatched him from the jaws of disaster.
The catheter was fixed to the skin with an underwater seal, Vaseline gauze place over the insertion site, and all was neatly bandaged
On repeat scan ? his lung volume without suction had returned to almost 70% of normal, but the large bore catheter was touching the left ventricle and deflecting off it as it curled back to the posterior pleural space. I was concerned for arrhythmias or perhaps even trauma to the heart.. My first thought was to undress the bandages, pull the catheter back, and rescan.
In walks Dr Anderson, the cardiothoracic surgeon on cue. ?Nah he says ? should be fine ? leave as is.?
We put the patient on suction repeated the scan and lung was almost totally reexpnded. Oxygen saturations were normal, pressure was normal and color back to normal of this patient who now felt great relief with his breathing .
Wow ? we were drained but fulfilled. All the pegs were in place ? all the people of the team were there ? or if they were on the rightful trip out of the door at the end of the day ? they were at the right place at the right time and stepped up. From the referring physician who asked for a ?wet read? because of a hunch that all was not well, to the junior technologist through his senior to the CT technologist, and the nurse, the chief of radiology and then the thoracic surgeon?all in a space of about 10 minutes
A man?s life was saved ? a man with a family and a wife who by virtue of a genetic whim had the misfortune of have an apical bleb that burst
He waited for a week to come to the hospital
His time could have come but he had the good fortune as did we ? that the Gods were on our side that day