It’s all about timing

It was a Thursday afternoon in a small hospital ER. I was across the street, working in my office, when I got the phone call. “Sean Carter, 37, has arrived here by EMS. He’s having a really bad asthma attack. Not sure it’s all seasonal, or if he aspirated, or what. He’s not doing well, can you come over?” The advantage of my office location—if I looked out the office window, I could tell if the patient’s lips were blue. This time, they were, and that was with 100% high-flow mask on! I ran over and assessed the situation. Read: The heart's rhythm and blues This young chap was sitting up, struggling to breathe, and tiring out (the red flag we all know about). Vitals: pulse 120 regular, BP 140/100, Sat 76% on oxygen, temp normal. He had a pronounced expiratory wheeze. His trachea was midline. No leg swelling, no signs of chest trauma. His EKG showed sinus tachycardia, his CXR hyperinflation only, and his bloodwork a mild eosinophilia. Sean had been in the ER before, but never intubated. Sean got lots of Ventolin by inhalation, but his tubes were so tight, that wasn’t working. He was given IV solumedrol, and subcutaneous epinephrine, but that wasn’t working either. Sean was going to flame out and ruin my Thursday night bridge game. I knew he was looking at an ET tube and time in the ICU. I knew that ventilator pressures would be high, with the attendant risk of barotrauma (pneumothorax). I was glad he was young and otherwise well. I recalled that the mortality rate from severe asthma hadn’t changed in decades. Read: The puzzling world of brain tumours After my IM fellowship, I did a year of Anesthesia (in Winnipeg). This proved handy when I ended up running an ICU in small-town Mission, B.C. I was happy with the smooth sedation, sux-paralysis and intubation that Sean got. Of course, his life depended on it going right! Bagging him was interesting: even with lots of in-line Ventolin, he was tight. I spoke with an anesthetist locum visiting our wee hospital, and we agreed to give him a general anesthetic (Halothane) in the OR. (1) This gas is a bronchodilator, and it worked like a charm. After 40 minutes, he was manageable (although we had to deal with some freaky ectopics along the way). The next day, he was weaned from ventilator support, and extubated—never to be so lucky again. About a year later, Dr J., the surgeon at our site, came to me at lunchtime. “I just operated on this young girl’s Meckles’ diverticulum. Pretty simple. Now she’s gasping for breath. Can you fix?” I ran down to the surgical ward to see 28-year-old, Anne, struggling for air. Her x-ray showed a white out—ARDS and nothing else. (2) She turned around with an ETT, and a day or two on a ventilator. Why ARDS? I never found out. Her prognosis without critical intervention? Dire. She was just in the right place at the right time. Well, we both were… Read: Aspiring aspirations References: 1. Volatile Anesthetics and the Treatment of Severe Bronchospasm. J Mondonedo et al. Drug Discov Today Dis Models 2015 Spring 15: 43-50 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698912/ 2. ARDS, an Update and Review. G Rawal et al J Transl Int Med 2018 June 6(2)74-77 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6032183/

Casebook of a Community Internist

It’s all about timing

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Hector Baillie

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