Bilateral Pneumothorax: The Pressure Is On

 There's pressure everywhere.  These last two weeks have been the busiest two weeks in the history of our hospitalist group.  We have been averaging over 110-120 patients a day at the start of the day.  We have 7 daily rounders to see all these people.  And we've had an extra body at 8 at times.  This has pushed the limits of published efficiency data suggesting that a maximum of 15 total encounters a day equals maximum efficiency of work.  Some groups have out of control census all the time.

We are also a growing group.  Constantly.  Our numbers go up every year and we must constantly be on our guard to make sure staffing is appropriate for the busy times and the lighter times as well. In these last two weeks, the census explosion is from the influenza outbreak.  The worst I have seen since the West Nile outbreak in 2003.

I have no doubt in my mind.  In the last week,  I have personally taken care at least 7-10 patients with the flu or suspected flue and hypoxemia.  It has afflicted old and young alike.   I have taken care of 30's year olds with no medical problems and the flu.  I have taken care of 90's year olds with COPD and the flu.

But the pressure of the rising census was nothing compared to the pressure I experienced one night.

I accepted a patient from another hospital with advanced COPD on chronic home oxygen use and steroids.  I accepted this patient on transfer from another hospital for increasing  asthma dyspnea and shortness of breath.   The patient is a frequent flier to the medical system due to the very poor underlying lung function (end stage I would say) from a self reported over 100 pack years of smoking.

The patient told the nurse practioner that the last time she felt like this she ended up on a breathing machine,  and she wanted to be transferred to our hospital ASAP.  When I spoke with the NP I was described a patient who did not appear unstable.

 She was actually alkalotic by pH.  Only on 2 or 3 liters of oxygen.  Her white count, however was elevated.  But then again,  that may be due to steroids.  There was no focal infiltrate and the NP related a concern for possible influenza.

So I accepted the patient, to a general care floor for close monitoring, in case the patient decompensated.  I went on my sweet little way admitting other sick and not so sick patients in the wee hours of the night.

Then I get a call from our house supervisor RN.  I was notified that the patient had to be intubated in route by squad and she would be going to the ICU.  Sounds good I said.  An intubated COPD patient is generally a stable patient.  A protected airway.  A controlled environment,  to some degree.

Except when it isn't.

I was literally finishing up admitting a young gentleman in his 40's with acute onset bilateral proximal occlusive iliac vein thrombosis with swollen legs when the RN tells me I'm needed immediately on the other end of the ICU pod.

The squad has just rolled in and the patient was very tachycardic.  And suddenly out of no where,  brady into asystole.  Code Blue was called.  ACLS was started immediately.  Epinephrine, CPR,  check pulse, check rhythm and on and on.  The real deal. The patient just went form stable to critically unstable in the course of an hour.

It became apparent that something was seriously wrong here.  She  had very distended neck veins.  Her neck was turning purple,  much like a blue berry. Her compressions were becoming stiffer and stiffer and her abdomen was becoming stiff as well.  This wasn't working.  Our ACLS resusitation wasn't doing a thing.  At all.  I thought intubation may be compromised,  so I had the respiratory folks extubate and bag her.  As we progressed,  others suggested pneumothorax.  On several occasions I listened intently for breath sounds.   Something very difficult to do during a code.  She had breath sounds both sides.

The patient had limited vein access for giving cardiac resuscitation drugs and for drawing blood.

I quickly place a right subclavian central line in a semi sterile technique do to the emergent nature of the procedure.  I was able to place the line,  with active CPR ongoing and able to establish an access for ACLS medication administration.

However,  nothing was working.  After several more doses of epinephrine through the central line,  I decided to bite the bullet (as we call it).  I was in a no lose proposition.  I have never needled a patient before.    I have never seen it.  I have never trained for it.  This is not what internal medicine trains for.  The ER doc was tied up in a stabbing trauma.  There was nobody else but me. The EMT indicated his experience on the field, so I told him to go for it.  Needle her I said.  He took a routine 18 gage needle,  felt out the 2nd intercostal rib space on the left anterior approach and stuck that 18 gage  it into her chest wall.

And there is was,  a hissing sound like none I have ever heard.

I asked him to needle the other side as well.

Same song and dance. Diagnosis?  Tension Pneumothorax.  Bilateral  At this point, CPR continued for a while later and then there it was.

A rhythm

A pulse

And a blood pressure. Hypotension causes you to try and die.

I asked an RN to call our intensivist in to place bilateral chest tubes.  He knows when I call him,  I really need him.  It is a rare day that I ever call in a physician in the middle of the night, unless I need an emergent procedure or I am inexperienced in the management options of an  acute life threatening illness. When I finished her admission,  I went on to complete my two  other folks waiting for their doctor

a combative drunk who overdosed and may have meningitis and

a young guy with subacute psycosis (2 months)  and a tylenol overdose of 25 grams.

Here was the patient's chest xray after she was needled (you can see them)

Notice the needles jutting out from the 2nd rib at the top of each lung.

This is what kept her alive.  A tiny little 18 gage internist needle.  

This is something I will never forget.

I guess on this night, it's not how big your needle is, but how you use it.