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Diagnosis Deconstructed

Diagnosis Deconstructed: Counting Up: One, Two, Three, Four…

Morchi, Ravi MD

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doi: 10.1097/01.EEM.0000419516.73596.62

    She is still going. Leaning over her, my ear to the end of an open plastic tube, I can hear it. It is sort of an odd situation to sit still and do nothing about a patient with no obtainable blood pressure.

    Five, six, seven, eight…. The therapist motions with a purple ambu bag. “Not yet,” I say. “Not yet.”

    She is still going. With a stethoscope on her chest, I hear the soft creak of a door opening. Only it is continuous. No change in pitch and no change in intensity. Not yet.

    Moments earlier, a code white was called overhead. Upon entering the pediatric resuscitation room, I saw a teenage girl with endotracheal tube in place, the respiratory therapist bagging. Our pediatric emergency medicine fellow stood above her at the head of the bed looking down at her chest. The monitor behind him displayed sinus tachycardia at 190. The blood pressure reads “---/---,” but her chest was not moving.

    “I can't tell if I'm in,” he said. “I can't hear breath sounds. Do you want to take a look?” I was already taking a look. Today the best look is from a distance. Our fellow was too close.

    Minimal mist in the tube. No frothy gastric contents. The respiratory therapist was a six-foot tall-man using two hands to bag a 14-year-old girl. This was the problem.

    Nine, ten, eleven, twelve…. Still creaking by stethoscope. Softer but persistent. I look up to make sure she is not connected to the vent or a bag. The end of the tube standing tall in the open air. Simultaneously, I feel her carotid. Life coming back? Softly and slowly.

    The therapist motions with a purple ambu bag. “Not yet. She is not ready. Not yet.” I raise my palm.

    Earlier, standing at the foot of her bed, the problem was apparent. “You are in. No need to check again,” I said. He put the laryngoscope down, “Then?”

    I looked at the man standing next to us. Two hands clasped around the ambu bag, he had to put strength into it. He was sweating and anxious. Anxiety translated into multiple rapid squeezes of positive pressure, as though he could breathe the life back into the child. I wondered if he had kids of his own. He was putting everything into his craft at that moment. Was he doing this for all children? Children who shouldn't have to die. But every squeeze moved her closer to death.

    “She tough to bag?” I inquired.


    “Looks like it.” I put hands on the ambu bag. With compression I could feel what he felt. A massively over distended pulmonary parenchyma pushing back on my palm. Plateau pressures had to be extremely high. Air could not get out.

    Time to act. This is an emergency. Our field was built on these very moments. Little information, a person veering toward death, and only us to decipher the problem. To step in and save a life. To be dynamic in a moment when others are frozen and fearful. Time to bring this child back to her family, the dinner table, holiday memories, her high school graduation, her wedding, her future children. Let us not keep her waiting. It rests on us now. Time for emergency medicine to start.

    I removed the ambu bag, and the life-saving procedure began. Stop moving. Just stand there. Wait. Do nothing. Take your own pulse. Take a deep breath of your own. But do not dare to give her one. Just listen. Lean over her and listen at the open end of her ET tube. Place your stethoscope on her chest and hear the door creaking. It will stop eventually. It has to. And so we began waiting and counting. And we arrived here. Thirteen, fourteen, fifteen, sixteen….

    She is still going. The therapist motions with an ambu bag. “Not yet. She is still going.” I compress her chest to see if active expiration will help. Still creaking. Her carotid pulse is getting stronger. She is on her way but not with us yet.

    Asthma kills. We have many medicines for it, and patients may be more educated than ever. But asthma retains its lethal arsenal: bronchospasm, mucosal edema, and the most common finding at autopsy, diffuse bronchiolar obstruction from mucous plugging.

    Massively distended lungs, like two overinflated party balloons. Every alveolus engorged and busting at the seams with air trapped in its lumen. Alveoli in this state compress the network of pulmonary capillaries winding between them. Capillaries without a muscular coat on the outside and normally accustomed to the low intravascular pressures of a pulmonary circuit cannot stand up to the high luminal alveolar pressures now present on all sides. They collapse. Pulmonary vascular resistance rises. Blood can no longer flow through the vascular bed. So the right heart distends and bows forward. It is greatly enlarged at the time of death.

    Obstructive shock from pulmonary hypertension because of capillary compression. As far as the right heart is concerned, this could be a massive pulmonary embolism. But in this case, we know better than the RV; her problem is palpable at the bedside by way of an ambu bag.

    Some alveoli give up and rupture. Leaking air into the pleural space and secondary tension pneumothorax complicates the picture. Meanwhile, the catecholamines surge through the bloodstream of the doctor and respiratory therapist. And more air, more death bagged into the patient. Seventeen, eighteen, nineteen….

    It is quieter now. Not much at the open end of the tube. Not much by stethoscope. The therapist motions with an ambu bag. “Go ahead.”

    Much easier to bag. Air enters, and we can hear it. Carotid pulse is back. Blood pressure is cycling. Her oxygen saturation is 100%.

    Twenty seconds later, we give a second breath. Chest rises. Air enters. Only now can we appreciate that the left chest has decreased inspiratory sounds compared with the right. The tube is not far enough in to be a right mainstem. But to be sure, we order a chest x-ray for evaluation of tube depth and the possibility of a left-sided secondary pneumothorax.

    The therapist prepares to put her back on the vent. Her I:E ratio needs to favor E. She needs to be sedated and maybe paralyzed. Her brainstem cannot have a say in the respiratory cycle. The immediate future is critical; she needs time to release everything she has been holding. We need to start slow, at least for the first few breaths, and ramp up later. “What vent rate do you want to start with, doc?”



    “Yes. Three.”

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