Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER by Pamela Grim Page B
Authors: Pamela Grim
Tags: BIO017000
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at Helen and then at the respiratory therapist. The answer is so simple it makes you want to cry.
“Pneumothorax,” you say in awe.
Everyone looks at you, blank-faced. Then they look to the respiratory therapist who, oblivious to it all, is still fussing with the pop-off valve.
“Pneumothorax. The kid's got a pneumothorax.” But as you say this suddenly you are not sure. It's possible, but there are other potential causes, all of which at this panic-stricken moment escape your mind. A pneumothorax is one thing, though, that could explain what is happening. It is also something you could fix.
You backtrack over to the view box and peer up at the x-ray. Was it there and you missed it? You search the image and think there is perhaps a little line there, in the apex of the left lung. Perhaps. Not clear.
A pneumothorax occurs when air is trapped in the lining of the lung. This can happen if the lung lining ruptures for any reason, and artificial ventilation is a very common reason. A simple pneumothorax causes the lung to collapse, making it harder for the patient to breathe. There is also a special kind of pneumothorax called a tension pneumothorax that can be more dangerous than that. Tension pneumothoraxes have a paradoxical effect. Every time the patient breathes, the amount of air in the lining of the lung
increases,
causing the lung to collapse more and more. Eventually the lung will collapse down to a useless stump. The more the patient struggles to breathe, the worse the pneumothorax becomes. The patient becomes cyanotic—blue. Having lost blood pressure, the heart can no longer pump blood.
If the condition is not corrected, the patient will die. Right in front of you.
The pressure created by the Ambu bag can easily cause the lung wall to rupture and a pneumothorax to develop. Maybe that's what happened here.
Treating it is simple. You must vent the lining of the lung so that the air can escape and the lung can, at least partially, rein-flate. This can be done most easily by “needling” the chest, which is exactly what it sounds like. You stick a needle in the chest wall between two ribs (second and third at the mid-clavicular line). The lung will remain partially collapsed, but the pressure in the lining of the lung will be gone. The patient can breathe again.
“Give me a twenty-gauge needle,” you tell Helen.
Carol is still doing CPR. You watch her for a moment and you doubt yourself, doubt the monitor, the Ambu bag, the needle. And yet, fiercely, you know you are right. There can be no other explanation.
Besides, you think, if it is something else, then the baby will he dead anyway.
“Hold CPR.”
You listen to the lung fields as the respiratory therapist bags. There are breathing sounds on both sides—that doesn't rule out a pneumothorax, though. The chest is so resonant that it's easy to be misled. You listen closely. It does seem to you that the lung sounds on the left side are a little softer than the ones on the right. “There,” you say aloud and point with the needle. You are talking to yourself, trying to steady yourself, steady your nerves.
A 20 gauge needle—a little longer than this baby's finger. You unsheathe it from its hub and brace your fingers against the baby's chest wall. It's all of one piece, aiming, inserting, pushing deep through the muscles, and then a slight pop. You are either in the lining of the lung or in the lung itself. The difference is literally life and death.
Air, you swear to God you feel air.
“Restart CPR?” Carol asks you.
You raise a hand. “No, wait,” you say. Everyone turns to the monitor. The heart rate is 65…
65…64…64…64…68…69…
There it is, the comeback. In a couple of heartbeats the rate is over 70, over 80, 85.
“Pneumothorax…” Carol sighs. “A tension pneumothorax.”
As you palpate the baby's neck, you feel, clearly, unequivocally, a carotid pulse, a brisk carotid pulse. Let's face it, in your heart you hear a
“Pneumothorax,” you say in awe.
Everyone looks at you, blank-faced. Then they look to the respiratory therapist who, oblivious to it all, is still fussing with the pop-off valve.
“Pneumothorax. The kid's got a pneumothorax.” But as you say this suddenly you are not sure. It's possible, but there are other potential causes, all of which at this panic-stricken moment escape your mind. A pneumothorax is one thing, though, that could explain what is happening. It is also something you could fix.
You backtrack over to the view box and peer up at the x-ray. Was it there and you missed it? You search the image and think there is perhaps a little line there, in the apex of the left lung. Perhaps. Not clear.
A pneumothorax occurs when air is trapped in the lining of the lung. This can happen if the lung lining ruptures for any reason, and artificial ventilation is a very common reason. A simple pneumothorax causes the lung to collapse, making it harder for the patient to breathe. There is also a special kind of pneumothorax called a tension pneumothorax that can be more dangerous than that. Tension pneumothoraxes have a paradoxical effect. Every time the patient breathes, the amount of air in the lining of the lung
increases,
causing the lung to collapse more and more. Eventually the lung will collapse down to a useless stump. The more the patient struggles to breathe, the worse the pneumothorax becomes. The patient becomes cyanotic—blue. Having lost blood pressure, the heart can no longer pump blood.
If the condition is not corrected, the patient will die. Right in front of you.
The pressure created by the Ambu bag can easily cause the lung wall to rupture and a pneumothorax to develop. Maybe that's what happened here.
Treating it is simple. You must vent the lining of the lung so that the air can escape and the lung can, at least partially, rein-flate. This can be done most easily by “needling” the chest, which is exactly what it sounds like. You stick a needle in the chest wall between two ribs (second and third at the mid-clavicular line). The lung will remain partially collapsed, but the pressure in the lining of the lung will be gone. The patient can breathe again.
“Give me a twenty-gauge needle,” you tell Helen.
Carol is still doing CPR. You watch her for a moment and you doubt yourself, doubt the monitor, the Ambu bag, the needle. And yet, fiercely, you know you are right. There can be no other explanation.
Besides, you think, if it is something else, then the baby will he dead anyway.
“Hold CPR.”
You listen to the lung fields as the respiratory therapist bags. There are breathing sounds on both sides—that doesn't rule out a pneumothorax, though. The chest is so resonant that it's easy to be misled. You listen closely. It does seem to you that the lung sounds on the left side are a little softer than the ones on the right. “There,” you say aloud and point with the needle. You are talking to yourself, trying to steady yourself, steady your nerves.
A 20 gauge needle—a little longer than this baby's finger. You unsheathe it from its hub and brace your fingers against the baby's chest wall. It's all of one piece, aiming, inserting, pushing deep through the muscles, and then a slight pop. You are either in the lining of the lung or in the lung itself. The difference is literally life and death.
Air, you swear to God you feel air.
“Restart CPR?” Carol asks you.
You raise a hand. “No, wait,” you say. Everyone turns to the monitor. The heart rate is 65…
65…64…64…64…68…69…
There it is, the comeback. In a couple of heartbeats the rate is over 70, over 80, 85.
“Pneumothorax…” Carol sighs. “A tension pneumothorax.”
As you palpate the baby's neck, you feel, clearly, unequivocally, a carotid pulse, a brisk carotid pulse. Let's face it, in your heart you hear a
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