This is the first in a series of stories about how the failure to properly implement technology has impacted patient outcomes. The story is true, but the names have been changed.
I was in the pediatric emergency department and had just finished looking at an infected ear drum when suddenly the ASCOM phone hanging from the drawstring waist of my scrub pants started buzzing. I took my attention away from the 18 month old with an ear infection sitting on his mom’s lap and glanced down at the digital screen – 11 year old respiratory arrest, ETA NOW.
As the senior resident it was my responsibility to respond immediately to all critical patients. I politely and rapidly excused myself. Seconds later I had intercepted two paramedics briskly wheeling a young girl lying on a gurney into our pediatric resuscitation room. Paramedics have seen it all, so usually they appear cool and collected regardless of the situation, but even before I caught a glimpse of the patient, I could tell these guys were having a bad day. I had never seen faces so pale and drenched with sweat. One gripped the ambu bag, squeezing it with one hand at triple the usual respiratory rate, forcing oxygen into the little unconscious body on board the stretcher. He was pleading for her life with every squeeze.
On initial assessment as we raced down the hall together I could see the problem. She had a cricothyroidotomy – an emergency procedure involving cutting a hole through the neck into the windpipe when a patient is unable to breath and the medical staff can’t get a life-saving tube into the windpipe via the mouth. Her chest was rising minimally, but I could see that the cricothyroidotomy appeared to be properly placed. I didn’t have an oxygen reading yet.
Nurses and techs were mobilizing equipment all around me and descending upon the resuscitation room to receive us. As we approached our destination I made eye contact with Jen, the head nurse, and gestured to my neck with my index finger. She knew what I meant. She called out in response, “I have the code drugs and the airway cart, do you want the video laryngoscope?”
I took my position at the head of the bed. “Go ahead,” I said to the paramedic with the clip board. That was his cue to communicate the hand-off report, which I was accustomed to hearing simultaneously while listening to the rush of air in and out of lungs. I lifted my stethoscope into my ears and placed the bell on her chest to listen for breath sounds as the paramedic rattled off, “…11 year old female with no known medical history, we were called to the scene of an urgent care center by the doctor on duty for transport due to respiratory arrest from what was thought to be severe asthma exacerbation; she had been initially treated with three rounds of albuterol nebulizers; at the time of arrival there had been several failed intubation attempts by the physician on duty and the patient was being bagged with no chest rise…”
She had strawberry blonde hair with dainty freckles, and the right side of her chest had faint sounds of air entry with each squeeze of the ambu bag. The story continued “…we attempted intubation, but we were unsuccessful on the first attempt, and then she bradied down so we began chest compressions and initiated the cric…” With my bell on the left side of her chest I heard silence, and glancing up at the monitor which had just started to pick up an oxygen signal I saw O2 65%. Nurses around me and IVs had been started on both of her arms.
“Hand me the glidescope. Jen, hold the cric in place until I say pull.”
The paramedic continued, as my eyes were focused on the video laryngoscopy screen. Her vocal chords appeared swollen – almost swollen shut. The chords themselves and the tissue all around them was macerated from so many attempts at jamming a tube into her wind pipe unsuccessfully. It appears they were knocking on a door that was closed – her chords were so swollen there was no way they could get through with a standard size tube. I grabbed a smaller size and snaked it between the chords.
“Pull, Jen.” The cricothyroidotomy tube came out as I slipped the endotracheal tube into place, connected to 100% oxygen the numbers on the monitor improved. Fifteen long seconds later, O2 on the monitor was 98%, and her lips pinked up.
The paramedic continued, “after the cric was placed she had two rounds of epinephrine…”
As I paged the pediatric ICU attending I asked the paramedic, “Do you really think this was asthma?”
“I don’t know doc, that’s what they thought she had at the urgent care. Doc at urgent care thought she had a history of asthma. They hooked her up to an albuterol breathing treatment, and 5 minutes after the doc left the room she collapsed. She was down with no airway for 15 minutes before we got there. On the way over here her dad said she had never really had breathing problems before – not like that anyway.”
It was definitely not typical for an asthma attack to progress that rapidly with no prior history. It sounded more like an allergic reaction to me, especially with her vocal chords appearing so swollen on my exam (which was facilitate by the special equipment I had in the ER that the urgent care doctor wouldn’t have access to). It wouldn’t be fair to judge the decision-making of the other physician. Hind-sight is 20-20, and often times in a severe allergic reaction the sound of the airway tightening up is hard to hear over the sounds of wheezing coming from the lungs (sounds that are essentially identical to what you would hear during an asthma attack). In an asthma attack breathing difficulty doesn’t tend to progress as rapidly as in a severe allergic reaction, and the vocal chords don’t swell shut, so giving albuterol and reassessing after the treatment is complete would be a logical step to take.
Unfortunately Annie collapsed before she was reassessed, only minutes after the albuterol was given.
Sometimes the main diagnostic differentiator between asthma and severe allergic reaction is the patient’s medical history, especially when you have to make a quick decision. If a patient has a history of severe asthma and typically responds to breathing treatments, then it may sway you to believe that this is another episode of the same (especially if there is no history of allergic reaction and no known contact with an allergen). With no history of severe asthma in an 11 year old child who comes in with severe wheezing, it would make you think this is more likely to be an allergic reaction (or you would at least have a much heightened suspicion of one) even if the patient has no history of anaphylaxis.
For the first time I noticed her distraught father, who had trailed behind the gurney and must have been seated next to the resuscitation room door by one of the nurses. It had been too crowded for me to spot him before with all the medical staff gathered around the bedside. He looked up at me, and offered, “when they asked me if she ever had asthma in the past I said yes because when she was 2 years old one time her doctor gave her a breathing treatment – she had been sick with a cold and had lots of coughing.”
Without a summary of the patient’s health history available to him, the urgent care doctor assumed that the child had a diagnosis of asthma and a history of asthma attacks, leading him to give albuterol and go see the next patient. There were no records available to the urgent care doctor to review, and how was her father to know that having one episode of wheezing 9 years ago did not equate to a history of asthma? A lack of clinically actionable information available at the right time to make a fast decision made a serious impact on his treatment plan and the ultimate outcome for Annie.
With modern technology advanced enough to capture and aggregate photographs of remote places in the world from satellite imagery that can be accessed from anywhere in the world, it amazes me that Annie’s medical history couldn’t be made available in an instant to the urgent care doctor at the point of care when it could have influenced his decision-making. I can sympathize with how he must have felt, as in my career as an emergency physician I frequently have to make life or death decisions with extremely limited information. When I have to guess, I hope I guess right, but it makes me angry that guessing even enters the equation. Technology can solve this problem and help us save lives, it just has to be implemented correctly.
I visited with Annie’s family the next day in the pediatric ICU. She had a little sister who was just 2 years younger than her. It was agonizing to watch what the family went through, clinging to hope that she might recover from her coma. Three days later they withdrew life support. She had suffered brain death from oxygen deprivation, and all the scans indicated she would never recover any functionality.