Ben Johnson was a final-year medical student. He was very excited at the prospect of working in the trauma center because this would be the first time he would function like a real doctor. It was his first night on call. Everyone was busy in the operating room so he was relieved that there had been no new patients admitted. At 10:15 p.m. there was a loud ring on the emergency phone. Ben's heart raced. Jennifer Kung, a trauma nurse, answered the phone and was getting a report from the paramedics at the injury scene. Jennifer wrote several abbreviated items of summary information on a board where incoming cases are posted for all to see. Ben noticed on the board that the incoming patient was a pedestrian struck by a car. Expected time of arrival was 5 minutes. Jennifer did not know the patient's name. Magically to Ben, nurses, physicians, and technicians appeared from the operating room area, from the group of previously laughing and joking nurses around the coffeemaker, and from the entrance doors to the resuscitation area.
Ben knew the surgical staff members. Stuart Kennerley was a second-year resident physician who had graduated from medical school just over 2 years earlier and had about a year of on-the-job training. Although Ben did not know it, Stuart had several other patients who were admitted to the trauma center earlier on his mind; he also had not slept for more than 2 hours without interruption over the past 36 hours. Stuart came to the resuscitation area from the operating room where he was helping the surgical attending physician and another surgical resident physician with an operation on a patient admitted earlier. Stuart knew they needed help performing the surgery and wanted to assist them, but he was sent to admit the new patient. He called Ben over, asking him to be in charge of the incoming patient admission: "We don't have a lot of information on this patient, but it doesn't appear to be a critical injury." Ben did not know all of the people who would be working on the new patient. He recognized the two trauma nurses, but did not know much about two other people who came to assist in this patient's admission. "They must be anesthesiologists," Ben thought.
When paramedics brought the patient in, Ben realized that he was severely injured. The paramedics reported that the patient had been struck by a fast-moving car, causing head injuries and a broken leg. While at the injury scene, the paramedics started cardiopulmonary resuscitation; they could not put in an intravenous line to supply fluids to the patient because he was an intravenous drug abuser and had "used up " his veins for his drug habit. Ben was surprised that those critical items of information were not mentioned before the patient's arrival, nor were they listed with the summary information on the posting board.
Stuart felt overwhelmed because the patient's injuries were much more serious than he had expected, so Ben, given his level of training, really could not be fully in charge of him. Stuart wished that he had more time to organize everyone and get more help, including a neurosurgeon to examine any potential neurological injuries to the patient's head and neck. This was the first time Ben had worked with the anesthesiologists who were giving oxygen and ventilating the lungs of the patient referred to as John Doe because he had no identification. While that was being done, Ben and Stuart were trying to put in an intravenous line to prepare John Doe for possible placement of a tube into the chest to drain blood that might accumulate after the injury.
As Ben was trying to put in an intravenous line, he could not hear instructions from Stuart because of the noise from all of the activity around the patient. When the blood pressure and other vital signs monitors were connected to the semiconscious, moaning John Doe, several loud alarms went off because he was struggling and had to be restrained, all of which interfered with the functioning of the monitors. The neurosurgeon was paged; until she arrived and conducted the neurological examination, the team had to wait. Only after the neurosur-geon's examination could the patient be anesthetized. Ben was eager for that to happen so he would not have to hold down the struggling patient and could proceed with his plan. Bob Koone, the anesthesiologist, was concerned about the struggling John Doe, who ran the risk of injuring himself and the people around him. He was receiving adequate oxygen via a facemask, but Bob knew his condition could deteriorate soon without the life-saving interventions. Those inter ventions were needed immediately, but first the patient had to be anesthetized. Did the surgery people have a plan, he wondered?
Bob was glad that he had come with an experienced resident anesthesiologist, George Blank. Where is the neurosurgeon, they wondered? When the neurosurgeon finally responded, 7 minutes after John Doe's arrival, it seemed that all the alarms were sounding from his monitors as well as the alarms from monitors connected to patients in nearby treatment bays. The neurological examination was brief, and found serious injuries to the brain. Rapid diagnostic procedures and emergency interventions were needed. John Doe was anesthetized. Bob, the anesthesiologist, asked George, the resident, to pass a breathing tube into John Doe's windpipe that would be attached to a device that would breathe for him. This would allow Bob time to prepare the next steps in treating John Doe.
George found it difficult to see the structures inside the mouth to insert the breathing tube because John Doe's throat was bloody from his injuries. The first two passes of the tube mistakenly went into the esophagus (connecting the mouth to the stomach) instead of the trachea (connecting the mouth to the lungs). On the third pass, George felt he inserted the tube into the trachea. Bob watched with some anxiety and waited for some indication from the monitors confirming that the tube was in the patient's trachea. A high-pitched alarm was sounding that George wanted to silence, but he could not reach the patient monitors to reset them. "One of the surgeons is listening to the chest to determine if the breathing tube actually is in the trachea," thought Bob, the anesthesiologist, as he saw Ben placing a stethoscope on the chest. The sounds from the patient's chest could provide an early indication of where the breathing tube was placed; however, this method is not failure-proof, and listening to the chest requires training. Using a stethoscope, one should hear equal breath sounds on both sides of the chest and no breath sounds in the stomach if the breathing tube is properly placed.
George did not realize that Ben was a medical student who was not qualified to perform the important task of verifying breathing tube placement. When a misplaced tube is uncorrected, the patient's lungs do not receive oxygen; a patient will suffer brain damage and die if no oxygen is received for 5 minutes. Ben listened to the patient's chest. George, the anesthesiologist resident, asked Ben: "Did you hear breath sounds?" Ben nodded his head. Then Ben listened to the stomach, although not sure what he was supposed to hear. He heard sounds again there. He said, "It's also going in here too" No one seemed to hear that comment, however. Bob, the anesthesiologist, because of the noise from the alarms and from laughter and chatting in an adjacent area, did not hear what Ben said about the breathing sound from the patient's stomach.
The gold standard of confirming the placement of the breathing tube calls for the monitoring of the patient's exhaled carbon dioxide. When the breathing tube is properly placed, the carbon dioxide from the patient's lungs flows through the breathing tube and can be measured. When no carbon dioxide is detected from the breathing tube, one can be certain that the breathing tube is misplaced. The positioning of the breathing equipment set-up would not allow Bob or George to easily connect the breathing tube to a carbon dioxide monitor. They trusted Ben's judgment and proceeded to tape the breathing tube in position, as they do after successful placement.
Stuart, the second-year surgical resident physician, had assumed that the breathing tube was properly placed and had started cutting into the patient's chest to place the chest tube to drain the blood. The alarm sounded from the pulse oximeter, a monitor measuring the oxygen concentration in the patient's blood by means of sensor clipped on the patient's finger. The alarm suggested that John Doe was not receiving adequate oxygen. Bob looked at the reading on the pulse oximeter. It displayed 50%, and then 40%, with a normal reading being above 95% and close to 100%. This was too low; perhaps the reading should not be trusted because the patient was struggling and moving about which could have caused misplacement of the finger sensor, Bob reasoned. He checked other monitors and noticed that the automated blood pressure monitor was attempting to obtain a measurement, but for some reason had not succeeded in the last several minutes.
Bob and George waited, becoming anxious because they did not know John Doe's status. They did not communicate their concerns to other team members, such as Stuart and Ben, who were occupied with placing the drain in the patient's chest. Finally, John Doe's blood pressure and pulse oximeter monitors displayed a set of readings that were very abnormal. By this time Bob suspected that the breathing tube was not placed properly and patient had not been receiving oxygen. Bob asked George to reconfigure the breathing circuitry so the exhaled carbon dioxide could be monitored. There was no carbon dioxide detected in the breathing tube. It was now quite clear that the breathing tube had been misplaced into the esophagus. The patient had been without oxygen for 6 minutes! If he were not to die from the injuries from the motor vehicle crash, he surely would die from the prolonged undetected misplacement of the breathing tube.
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