Emergency Medicine Files - Holding a Hand

Saturday morning (0500am) at work, a patient called into the E.R. stating that she had been awakened by her tongue swelling, and was curious on what to do. The charge nurse explained to her that since she was taking Lisinopril for high blood pressure, it would be wise to come into the E.R. and get the situation checked out. It was a good thing she did.

After driving themselves into the hospital, instead of calling 911 for an Ambulance, the patient seemed uncomfortable, but otherwise none the worse-for-wear except for the discomfort and anxiety of her tongue being swollen.

What would unfold before our eyes was clinically amazing.

The patient, a 40'ish y/o African American female, had been taking ACE inhibitors for her high blood pressure for over four years. ACE inhibitors, such as Lisinopril, have rare side effects such as dizziness, anaphalaxis, and hives.. A person can be taking the med for years and never have a negative side effect, and then, one (random side effect) may occur with literally no warning.

What was taking place before our eyes was that her airway was quickly closing. In a short amount of time, her airway would be closed completely, and she would suffocate to death. This formerly stable patient, had now become top priority.

With tears in her eyes, she (the patient) acknowledged the importance of letting us sedate her and put a tube into her trachea before the swelling completely prevented her from breathing. It was a strange emotion to witness.

 

The only other time I had witnessed this weird emotional perception was over five years ago when one of our patients was already intubated and on a ventilator.. The difficulty was that although the patient was paralyzed and was awake and responsive; that particular patient had a DNR (Do Not Resuscitate) order that the staff was previously unaware of.. The attending physician was asking the patient to make a choice. Stay on the ventilator and live, or have us honor his DNR and previous decision, and take him off of the vent, to where he would suffocate and die.

Needless to say, the reality of the situation hit both patients the same way and they chose for us to do everything possible for them to live. The difference between the two cases is that Saturday's case was a temporary bridge to prevent the unfortunate demise of an otherwise healthy patient. Regardless, time to contemplate was not an option.

As the patient was sedated with Etomidate, she turned out to be one of those few that clench their teeth tightly shut when sedated with Etomidate, thereby preventing our access to preserve her airway. With the clock ticking, respiratory therapists were "bagging" the patient while alternate meds were retrieved for further sedation.

Diprivan was pushed through her I.V., as well as Versed, which sedated the patient further and provided a relaxed/hypnotic state for the patient. As the resident physician attempted to intubate the patient, the difficulty of a swollen airway coupled with the heavy-set nature of the patient provided for a more-than-complex task. The attending physician took over.

While beeps, buzzers, and alarms were sounding; complimented by everyone's procedural medical jargon; I felt that amidst all of the 'gray noise' that we were creating, my primary inclination had led me to ...Hold her hand.

There was a four-fold benefit to what I had chosen to do:

By speaking directly to the patient and holding her hand, I was extending a sense of human compassion to her while she endured the panic of the situation. By someone 'being there' I was hoping to provide a calming hand to reduce her anxiety and reduce her clenching, thereby facilitating the intubation. By holding her hand I could feel when she would begin to squeeze my hand. This indicated that she was regaining muscle tone and needed more anesthetic. -And lastly, If it was me; in her shoes, I would hope that someone would just stop a moment, and hold my hand..

The attending physician assumed position for the actual intubation and placed the tube in the trachea, just where it needed to be, and just in time.

After the tube was sunk,(in place) I believe we all breathed a cumulative and audible sigh of relief. The patient was placed on the vent and administered additional therapeutic meds before being sent to the I.C.U.

It is important to note that medicine is about clinical data, practice, objectiveness, statistical values, procedural applications, and outcome percentages. Medicine is not what is perceived on shows such as 'E.R., or Grey's Anatomy'. Although these shows provide entertainment value, they do not provide much else. I've never, nor have I ever seen others; cry over every third case, carouse around with other staffers, get involved with patients, or anything else of the like. That is TV-land, not reality.

Over the past ten or so years I've had bouts of cynism and empathy; (depending on the level and frequency of bogus patients) However, I've clearly noticed that the best professional practitioners extend a higher amount of consistent empathy than many others. When this is combined with professional excellence; I believe it is a recipe for success that is mentorable.

A buddy of mine recently stated this of me in the closing of an email while I was in Haiti: "You've always had more heart than brains. But that's why your my brother". Although flattered, (I think) I prefer the explanation provided on a plaque I've noticed at work:

Excellence

"Excellence is the result of caring more than others think is wise; risking more than others think is safe; dreaming more than others think is practical, and expecting more than others think is possible".