Acute Pulmonary Edema
Several minutes later an entourage burst through the big double doors. As she rolled down the hall flanked by EMT’s this morbidly obese seventy-eight year old woman was obviously in severe respiratory distress. They had her sitting bolt upright on the stretcher (always a bad sign around here) with portable CPAP covering her face. She responded only to noxious stimuli and struggled with each and every breath. As we changed her over from EMS CPAP to our own BiPAP we witnessed a transient rapid desaturation to 80% on room air. Otherwise Oygen saturation was never a problem. While on 100% FiO2 pulse ox consistently measured > 97%. pO2 matched the FiO2 once an arterial blood gas was obtained.
Versus COPD Exacerbation
What to do? Further history elicited from family and the Home Health Aide raised the possibility of Acute Pulmonary Edema, but also made it at least as likely that this woman was suffering an exacerbation of her COPD.
Does it even matter?
Eliciting the cause of our patient’s impending respiratory failure would have been no easy feat. A discussion on the finer points of differentiating the two conditions could go on for pages. Arguably, for a patient with impending respiratory failure, an elevated BP, otherwise normal vital signs and a normal ECG, it may not immediately matter. One could even initiate management for both. In this specific clinical setting, with this particular history, physical exam, and bedside ultrasound, we pursued a presumed cardiac etiology with Nitrates, diuretics, and a trial of BiPAP.
Lock ‘n Load
Despite our best efforts the patient’s mental status continued to decline and work of breathing appeared to increase. I decided to intubate after a brief telephone discussion regarding goals of care with a family member. Now I had a problem. While preparations were wrapping up (meds had been drawn up, oxygen, suction, BVM had all been prepped in advance) I had to decide who would perform the intubation. On the one hand, this would likely be a high-risk intubation and I always enjoy a challenge. But then there was the junior resident at my side. A hard working kind of guy who had demonstrated outstanding clinical knowledge over the past few shifts, he was itching to go.
With the handy-dandy video laryngoscope in my left hand, suction then ET Tube in my right I slipped the tube quickly in and confirmed placement with continuous ETCO2 and CXR. No desaturation, no complications, and significantly improved mental status within a few minutes requiring increasing analgesia and sedation.
As the sun rose over the end of our shift I felt I had to explain my choice to the intern. We got into a good discussion of airway management and, frankly, he was surprised I even brought it up.
Conflict –n. discord of action, feeling, or effect; antagonism or opposition, as of interests or principles: a conflict of ideas
As it was relatively early in the academic year, and this resident had not yet completed his dedicated Airway rotation (here, one month of Anesthesia), the decision in this case was really was very easy. I have no regrets. But what would happen in the future, were I to supervise a slightly more experienced resident than the one mentioned above, or if we were in a less acute situation? The grayness bothered me. How would I do right by the patient while maintaining the integrity of a training program? Or in other words, is there a rational, ethical way to tease out the intubations that could – or should? – be performed by the junior learner from those that must be done by the most experienced person in the room? How do we maximize patient safety while facilitating active learning?
Since you’ve made it this far, please share your thoughts below. Whether you consider yourself more of an educator or a learner, what criteria do you use? How do you decide who should intubate in a training situation?
Part B will be posted next week building on any comments and a brief review of the literature.