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Mindful Practice

A fine line

Smith, Ian M. MMS, PA-C

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Journal of the American Academy of PAs: November 2013 - Volume 26 - Issue 11 - p 1-2
doi: 10.1097/01.JAA.0000436985.51671.1f
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The day started like most other days. I was back in the ICU after being off service for several days. As usual, I checked morning labs and radiology reports while discussing minor checkout with a surgical resident. Little did I know what drama—and lessons—that day would bring.

I've worked in critical care since I started as a PA. Being in critical care is humbling and challenging—challenging emotionally, and sometimes even physically. Before PA school, I was an EMT in rural eastern North Carolina. Then I was a Marine. Between what I saw as an EMT and in combat, you might think I'd be used to harrowing experiences. Instead, I learned that no matter how many times a person's life is in your hands, it never gets easier. The protocols and algorithms become second nature, but on the inside you still shake. And that's good—it means you're still in touch with your humanity. Mistakes are costly in medicine, just as they are in combat. Most often it's others who pay the costly price when we fall short of perfection.

During rounds that morning, we changed ventilator settings, adjusted medications, and moved patients forward in their course of treatment. We worked efficiently, and we felt like our team was making progress—until we made our way to bed 9. The patient was a man in his early 30s who had been in a motor vehicle crash several days before. He was ejected from his car and found unresponsive. He had sustained multiple orthopedic injuries, cardiac contusion, manubrium fracture, lung contusions, rib fractures, and a closed head injury. Despite his severe injuries, he seemed to be improving, and the next step was getting the endotracheal (ET) tube out. His sedation had been weaned, and he was now able to communicate, although minimally.

During rounds that morning, however, something was clearly not quite right. He was increasingly tachycardic and began complaining of chest pain. His electrolytes and other labs were not concerning, but we couldn't fully communicate with him. After chest and heart assessment, the next appropriate step was an ECG. We discussed whether the issue was simply inadequate pain control, but we agreed it was better to be safe and order the ECG after increasing his pain medication. The ECG tracing revealed sinus tachycardia—no surprise there—but the bedside nurse also called me to report hypotension on the monitor. This seemed to coincide with the administration of pain medication, except the patient continued to mouth that he was having chest pain. This made me pause. After thinking it over, I ordered a bolus of crystalloid, an echocardiogram, and cardiac enzymes and then moved on to rejoin the team on rounds. After we finished, I returned to the echo tech who was performing the ultrasound on our patient in bed 9. The finding alarmed us all as we saw his heart struggling to beat against a crushing amount of fluid bearing down on the failing muscle. A large pericardial effusion had formed, and the man was fighting for his life. I immediately called the attending, and we began scheduling him for emergency surgery. Our quick intervention saved the patient. Even just a few hours later, we would have been too late.

That feeling that something is not quite right is hard to define. Intuition, instinct, and reflex have been used in an attempt to describe it. But the first two imply that people either have it or they don't, when instead it is a derived and practiced response to a clinical scenario that experienced providers learn not to ignore. I was successful that morning because I followed my feeling that something was not quite right. The man lived because I went with my gut. But my instincts are learned reactions that are continually being developed. Sound confidence comes from familiarity with a situation and knowing how to respond. Unfounded confidence can be deadly.

Later that same afternoon, the respiratory therapist asked for my help with a patient who had developed a leak in the cuff of her ET tube. A leak is usually minor, but for this patient it could escalate quickly into a serious problem. Like the earlier patient, she had been in a car crash and suffered serious injuries, but her ventilator settings continued to increase over her first few days in the ICU as her pulmonary contusions continued to worsen. She couldn't be weaned from the ventilator and was now on airway pressure release ventilation, a setting that keeps an amount of pressure forced upon the lungs for a prescribed time before releasing and resetting. This setting is typically used in acute lung injury or acute respiratory distress syndrome, and it involves high inspiratory pressures. An ET tube without a cuff in this patient could end disastrously.

We tried to repair the cuff using an ET tube cuff repair kit, but it didn't work. We then decided to try an ET tube exchange over a Cook catheter. This small tube is made to thread down through an ET tube, and a new ET tube can be exchanged over top while keeping the catheter in place. The Cook catheter has a narrow lumen that can be used for ventilation if necessary during the exchange. The exchange is usually performed with anesthesia personnel present in case airway compromise occurs, so we called the anesthesia fellow and then began collecting the various implements necessary for the exchange.

As we waited for anesthesia, the leak began to worsen and stress levels started to rise on my team. We were concerned for the patient and her airway, but we were also impatient to move on to other tasks, which were just as pressing. Finally, the team asked how I felt about exchanging the ET tube. I had seen it done several times but had never performed the procedure myself. I hesitated. I admitted my inexperience, but my team was confident in my abilities. I didn't want to let them down. We discussed the procedure briefly again, but we didn't discuss the ventilator settings or what would happen if the tube could not be exchanged, which proved to be our downfall.

The catheter went down without issue and we removed the ET tube over top, ensuring we kept the catheter in place. I quickly passed the new ET tube over the catheter, but as I pushed it further down, it became stuck and would not pass the posterior oropharynx. I got a sinking feeling as I tried again. The patient's oxygen saturation started to fall. The beep-beep of the SpO2 on the monitor began to drop in tone, indicating further decline. We started to bag her through the tube while continuing attempts to pass the new ET tube. As her sats fell further, I decided to withdraw the catheter and begin bag-valve-mask ventilation while placing an oral airway. We called for anesthesia's assistance overhead while the patient's oxygen saturation hovered around the 60s. Luckily, anesthesia was nearby and there within moments to replace the ET tube via oral-tracheal intubation. As relief washed over us and the patient's oxygen saturation began to steadily climb, the attending physician took me aside and graciously explained the common airway mistakes I had just made. Always have a plan A, a plan B, and even a plan C. I had ignored my instinct to wait for help and fell prey to my overconfidence from the morning's success. Overconfidence had almost cost my patient her life.

We all mess up. It is part of the human experience. To recognize and learn from these missteps is vital. As James Joyce wrote in Ulysses: “A man of genius makes no mistakes. His errors are volitional and are the portals of discovery.” While I cannot pretend to be a genius, I can take responsibility for my actions. I chose to proceed with the exchange just the same as I chose to order the echo—two actions which had dramatically different outcomes.

Confidence is an essential trait in medical providers. Patients put their lives in our hands. This is a massive responsibility, which should be accepted with humility and gratitude. But patients also require that providers have confidence—they need that in order to trust they will be okay, to know we will take care of them, to believe we will do what is right and necessary to ensure their health and safety. Confidence is a requirement. Overconfidence can be deadly. We must know the difference and ensure we walk the fine line for our patients.

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