30 September 2011

Absit Omen

So it was just last week, that I bitched, and I quote, "Where's all the pathology? I haven't seen a AAA in years. That's just not fair."

Yeah, you all know EXACTLY where this is going now, don't you?

The very next day. The very next day. I know it's just confirmation bias, but this is why people have superstitions. Naming calls.

This wasn't the most challenging diagnosis I'll make this week. The paramedics called it in as a "probable ruptured AAA." Which, in retrospect, certainly saved his life. Because we were ready on arrival. He looked unwell, a typical pasty, sweaty, ashen obese middle-aged-to-older guy. I barely spoke to him beyond the necessary few words and threw the ultrasound probe on his belly. Too fat -- couldn't see squat. His vitals were OK, so across the hall to CT he went. I was there when the images came across and I saw this appear on the screen:

AAA

A lovely ten-ish centimeter aneurysm with lots of clot within it and lots of free blood/hematoma in the abdomen.

And the rest went as you might expect, except that it went beautifully. We had 8 units of blood standing by, large bore access, and the vascular surgeon on his way to the ER. When the patient suddenly said "I'm starting to feel lightheaded," the nurse reassured him that it was just the pain medicine, but I knew better. Moments later, he was pulseless and I was intubating him. He got six units of blood via the rapid infuser and as soon as the OR could be made ready he was out of the department. Door to door, 38 minutes. Alive and with a pulse.

Funny aside: I got back from CT before the patient and I briefed his wife on the situation and plan. I warned her, "Now, a lot of things are about to happen really fast. A lot of people are going to swarm over him and it's going to get loud and chaotic and I want you to know in advance that this is more or less normal in these situations. This is serious but we're going to take good care of him." How little did I know! As a result, while her husband crashed, the wife sat there smiling, assuming that this was just what I warned her about. (Fortunately the chaplain came by to take care of her.)

Anyway, it was thoroughly exciting and satisfying. After the patient rolled, the staff were all exchanging high-fives, the orienting nurses were standing around all wide-eyed, and the charge nurse drawled, "I feel like I need a cigarette."

The awesome thing was that I barely needed to give an order. EVERYBODY did their job perfectly:
The medics made the call (and got 2 16-gauge IVs)
One tech ran to get the blood
Somebody (I don't know who) called the OR
Someone (of their own initiative) got the rapid infuser ready
The trauma coordinator RN came over to run the infuser (she knows it better than anybody)
The HUC got me past medical records just in time to give them to anesthesia

As much as I'd like to take credit, all I did was tell them to give lots of blood and put in the tube. It was totally a team effort, and it was a thing of beauty to behold. But it probably is a good thing we don't have to do this every day.

Now, since it worked so well before, what should I wish for next? I know! "Man, I haven't had a good precipitous delivery in forever! Those are so much fun!"

Y'all can thank me on my next shift.

7 comments:

PJ Geraghty said...

If you didn't already, be sure to follow up with the EMS crew to let them know about the outcome as well.

rlbates said...

Glad there was a good outcome

Er Doc said...

Its a good thing you work a a large hospital with lots of resources. Even in my medium sized community hospital he would have been dead

LeggRN said...

What a team to be proud of! Makes me pucker a little at the thought of a similar pt in my ER, although something other than urosepsis would be nice every so often.

ExpatDoc said...

Odds of survival once ruptured is taught to be 50/50.

With those odds, even if they come in alive and talking, I always warn the family to plan for the worst and pray for the best outcome.

Elizabeth said...

You're probably safe-West Seattle bridge almost had the precipitous birth the other morning.

VinceRN said...

I love it when things go like that in the ER. Big Suburban Medical Center where you work is one of the few places I've seen it happen regularly. They do pretty good work there.