A day of motivation

So far every day has been motivational…motivating me to keep trying to make the hospital and healthcare in general safer, to keep pushing others to be a part of the movement, to come up with better ideas of how to make it safer, and to stand up in clinical scenarios when needed.  Today reminded of a near miss experience I had last year.  As I thought about it over the last couple days, I realized how incredibly close I came to being a doctor who stood by and let a patient die.  Too close, and 5 doctors would have been standing by her bedside when it happened…1 ER attending, 1 ICU attending, 1 ICU fellow, a 3rd year resident and me, the least senior of them all.  It all started 30minutes before signout…I had been there for my whole shift, I was tired and ready to get everything together to go when she was brought in by EMS. A 4yo asthmatic in severe respiratory distress.  She only had one dose of albuterol, so we immediately put her on continuous albuterol, got an IV and basic labs.  By 7am she was improved and signout started.  The attendings changed and I was the only one left who had seen her when she arrived, had gotten the whole story and started treatment.  I gave the intensive care unit a call to let them know she would need a bed, to which they replied we don’t have any, so I said no problem she can stay in the ED until they did.  As I was finishing up her note, the attending ICU Doctor and the fellow appear.  I over hear the attending saying, “we are going to intubate your asthmatic”.  Intubate?! What is he taking about…does he mean my patient, the one he hasn’t even seen in person, and just told me they didn’t have room for in the PICU?! I got up and walked over the join the conversation. “Why are you intubating her?”, I asked. Because her VBG was crappy he replied. I told him I know but like I mentioned in the phone she got the VBG when she first arrived and we have not repeated it, and clinically she is looking better. His reply was, “well I have a fellow”.  As in he has a fellow who needs the practice? Did he really just say that? So I went to the fellow who I knew and liked, and asked her why we were intubating a patient they had never seen? And her reply baffled me, she said “I don’t know”…What?! You don’t know why you are about to do a procedure on a patient and you don’t think that is a problem? So I went back to the ICU attending again and questioned it only to be ignored…in retrospect I wish I had laid across my patient until he gave me a satisfactory answer but I didn’t.  I was the least senior resident and had just protested 4 times with no real acknowledgment.  So here we are sedating and paralyzingly MY patient to intubate her.  I refused to the leave her side. After the fellow incubated her, her breath sounds were unequal, so they pulled the tube back but there was no change in breath sounds, so the attending pulls the tube and starts bagging her.  But she isn’t getting better she is becoming more and more hypoxic.  He gives up bagging her and reintubates only to have the same exam, unequal breath sounds…and now she is on 35% on her oxygen saturation! He continues to try and bag her with no improvement. The ED attending looks like a deer in the headlights, the fellow and senior resident have no suggestions and are just standing by watching the horror unfold, while her mother obliviously watches from the bottom of the bed.  This child is hypoxic, not getting better and is either going to code or have a hypoxic injury if we don’t fix this.  The PICU attending suggests calling for the other PICU attending as back up…how can we wait the minutes it will take for him to come?! There are already 5 doctors here…how many does he need? As I am looking at my patient, the first asthmatic I have ever seen intubate I start wondering where the albuterol is? I say is there albuterol connected to the bag mask? The respiratory therapist says no… So she hasn’t had any for about 15minutes? I tell them she needs albuterol! The nurse quickly brings over an ampule of albuterol and he bags it into her lungs and suddenly her oxygen saturation starts coming up.  Her breath sounds are better and she isn’t hypoxic.  I was both relieved and in shock… I almost watched him kill my patient for a procedure I didn’t think she needed.  Afterwards there is grumbling that she shouldn’t have been intubated by others, but where were they when I was objecting? Why was no one listening to me or supporting the concerns about intubating her before this happened? What if she had died? Why is there no protocol about albuterol use and intubating an asthmatic? We were all lucky that day, that it was a near miss and not a catastrophic event.  That little girl is a happy active bubbly 4year old who is doing well, but it could have all ended horribly wrong that day.  The culture, the unspoken hierarchy, the cocky attitudes, and the lack of protocols all collided and almost killed that little girl.  If I had left on time, signed out my patient and left, perhaps she wouldn’t be here. I definitely don’t look at that event and think wow I did such a good job saving her with albuterol…I look back and think I should have prevented her from ever being intubated and needing to be saved in the first place.  She is my motivation, and she is my story.  I hope she is the only patient I ever harm.