I Broke Rule # 1

"We just intubated him a few minutes ago. He was a restrained driver in a partial rollover. There were several witnesses who saw him driving erratically. They thought he might have passed out because his van went through a red light, barely missing a few cars, before sideswiping a pole and rolling onto the passenger's side in a ditch. He climbed out on his own and sat down by the van before EMS got there. They found him generally functional and breathing okay, but he seemed weak and disoriented. There are no obvious signs of trauma. He was confused and really drowsy on arrival. Dr. Benton was concerned about his ability to maintain his airway, so we intubated him. We used 100 of succinylcholine and 20 of etomidate. I just started fentanyl at 200 mics and propofol at 10 mics for sedation."

It's 9:16 p.m. Angie is halfway through her 3p-3a shift, and I'm here to cover her for her 30-minute lunch break. I glance at the monitor which shows a sinus tach at 112. RT is checking the vent settings. O2 sat is 100%. Skin color is good. The BP on the monitor is 212/118. "Has he been hypertensive? Is that BP before or after you intubated him?"

"Yes, he has. That BP was before. It's cycling every 10 minutes. It's starting again right now."

While the cuff inflates, I ask, "What have you got for IV sites?"

"There's an EMS 18 in his left AC, and I put a 20 in his right hand. Labs have been sent. Dr. Benton wants the CT brain ASAP. I already called, and they can take him now."

I'm not surprised when the BP comes in at 108/74. That would be a good reading for most patients, but not for a guy who was nearly double that number a few minutes ago. Propofol is notorious for dropping BP, but it hasn't been running long enough to have much impact yet. According to the literature, the succs-etomidate combo isn't supposed to cause a precipitous drop in BP. Etomidate is generally touted as having little impact on hemodynamic stability, but I've seen this kind of a drop in multiple cases through the years. I've researched it several times, finding little support for my suspicion that etomidate has a bigger impact on BP than the literature suggests, especially when it's administered as a rapid-push bolus.

Angie is clearly concerned by the big BP drop. She offers to postpone her break, but Mr. Granger is her only patient and it won't get any better this. I'll be one on one with him in CT with RT there to manage the vent. There is one liter of NS running wide open which should help prop up the BP, but I cut the rates in half on both drips as we head down the hall to radiology just in case. I cycle the cuff once more just before moving Mr. Granger over to the CT table. He's down to 88/52 with nearly 300 ml of NS already infused. I stop both drips, hoping to stem the plunging BP and get the CT done quickly. It takes about one minute to position the vent, IV lines, and staff to slide the patient smoothly onto the CT table.

Suddenly, without any warning, in less than a second, Mr. Granger sits straight up and lunges off the CT table away from the ER stretcher toward the open floor on the far side. Fortunately, the radiology tech is a big guy, about 6' 3"and 260 lbs. He catches the upper torso and muscles Mr. Granger back onto the table where four of us wrestle him down. Interspersed between our communication with each other, we take turns telling him to "relax" and "hold still." His BP is up to 112/78, and his HR is up to 136 during the agitation.

We lost the right hand IV site during the lunge, and I move the propofol to the distal port on the NS line, running it up to 30 mics to shut him down. Three or four minutes later, Mr. Granger slips back into a calm, unresponsive state, but his BP drops off rapidly as the agitation subsides. Some patients can handle much higher doses of propofol. Apparently, he can't. His BP is back down to 84/60 with half the NS bolus infused. I drop the rate to 5 mics. We strap him to the table and try for the CT, but he starts thrashing again before we can finish the study. The cycle of too little sedation and ensuing agitation plays out one more time before I call the charge nurse asking for either a different sedative or something else to support the BP. She's there in a few minutes with 100 micrograms of phenylephrine, a short acting vasopressor that gets us through the CT. The tech announces that there's no obvious bleed, and we head back to the ER with the phenylephrine wearing off, the propofol cut to 5 mics, and a 79/54 BP.

As we park the stretcher in the trauma bay, Mr. Granger starts thrashing and tries to sit up. RT grabs his right arm and I grab his left. In a moment of exasperation, I get right in front of his face. "Mr. Granger, you're in the hospital. We're trying to help you. Stop fighting us. Do you understand me?"

He makes clear eye contact. He nods. His body relaxes.

Are you kidding me? After what we just went through, is this suddenly going to be this easy? The words are screaming in my head as I stare back at him. "Can you cooperate with us?"

He nods again.

Wow. . . I ask several more yes-no questions, and he responds by nodding and shaking his head, clarifying his current ability to understand and cooperate. I shut off the sedation and have RT wait with Mr. Granger while I get Dr. Benton back in to reassess him. He goes through his own list of yes-no questions for several minutes, also reaching the conclusion that Mr. Granger is alert, oriented, and his brain is functioning just fine.

Mr. Granger's labs roll in showing hemoconcentration, elevated BUN and creatinine levels consistent with dehydration, but no other significant abnormalities. We extubate him, and he explains that he's been up since 0400 working in the heat. He's had only two small bottles of water and nothing to eat all day. He remembers feeling exhausted before passing out at the wheel and wrecking his van less than a mile from his house. His family at the bedside confirms his story, adding that he seems normal now.

We run in another liter of NS and give him some juice and crackers. He ambulates with mild soreness and turns down an offer to be admitted for observation. Remarkably, less than one hour from the knock-down drag-out wrestling match in CT, Mr. Granger is discharged and walks out of the ER with his wife and daughter.

I can't help smiling as he leaves, but inwardly I chastise myself for forgetting my own rule number one: Communicate. In the excitement following the lunge in CT, we tried to manage and control Mr. Granger. In the heat of the battle, I ordered him to hold still. I never really tried to communicate with him. I can only wonder how much easier it might have been if I had gotten in his face and talked to him while we were in CT like I did when we got back to the ER. I know better of course, but this time I got it wrong. Communicate first. Resort to managing if communication and cooperation fail.

A few weeks later, I find myself in a similar situation, covering another RN and taking a newly intubated patient for a CT thorax on the way to ICU. Same doc, same drugs, and we start down the same hypotensive pathway. This guy is 420 lbs. His massive girth leaves us less than an inch of clearance to get him through the CT donut hole. He starts stirring and fidgeting. This time I do what I should have done with Mr. Granger. I get in his face, confirm his ability cooperate, and talk him through the CT without sedation. It goes shockingly well.

It's always a temptation to just control intubated patients. I admit that I usually don't want them trying to communicate. I want them sedated for convenience if not simply for therapeutic reasons. When lives are at stake and patients are persistently uncooperative, disoriented, combative or hostile, we may have no choice but to control them. And we are good at control when it becomes the last resort. But these two encounters strongly reinforce my conviction about rule number 1: Communicate. When plan A fails, and we're forced to re-evaluate, it's not always bad. There's also a brand new opportunity to communicate, to get cooperation, and possibly a much better outcome.