Intubation

Author Question: Medically Induced Coma

/ Jordyn Redwood / Leave a comment

Terry asks:

The information you sent me last time has been great for my story! One thing I forgot to ask though, and it is very important to the ending is this: When my character finally comes out of his coma I need to know two things:

1. He was put into a drug induced coma because of a head injury suffered in an automobile crash. Is it possible he can come out of that coma on his own? Like just open his eyes after about two weeks?

2.  When they finally take the breathing tube out of him how long will it take before he will be able to speak? I want him to be able to tell about what he went through in the coma from his perspective as soon as he can.

I thank you in advance for any and all info you can give me. I really appreciate your help. Your site is THE BEST for writers!!

Jordyn Says:

Hi, Terry!

Thanks for sending me your question.

In your first question it’s hard for me to tell if you mean is it possible for this patient to just wake up from a drug induced coma— like the drugs are still infusing? If that’s the case, then no. The medications would have to be stopped before the patient would have a chance of waking up. In fact, the type of medication on board often plays into whether or not a patient can be declared brain dead.

If a patient still has narcotic and/or sedative medications in their system they cannot be declared brain dead. So first, the medication(s) given has to wear off. Most often, these medications are given as continuous infusions and are weaned down slowly and not abruptly discontinued. If after that has happened then yes— a patient may just open his eyes.

More often, patients are slow to come about. The first time they open their eyes, it might only be for a brief period of time. They may have muscle movements first. Generally, the medical team knows they’re improving when they can respond purposefully to pain by first pulling away from the stimulus, then by trying to push the stimulus away, and then by opening their eyes and understanding and following commands. It’s usually a slow process– from days to weeks (and even months to years) depending on the type of head injury the person suffered.

In regards to your second question, how long before he can speak? If he is awake and able to speak then he should be able to speak right away if the brain injury did not affect the speech sensitive areas. Some patients are extubated (or taken off breathing machines) and they’re not fully alert and responding to commands, but may be breathing adequately enough that they no longer need a ventilator. Many of these patients do have a trach in place, though.

That being said, if your character is awake and alert, his voice will sound soft, hoarse, and strained. His throat will hurt. He may have some trouble swallowing. His voice won’t have the same strength right after the breathing tube comes out as it did before. It will take some time to return to normal. The shorter the intubation the more quickly the patient’s voice should return to normal.  However, he should be able to share his story.

Good luck!

Author Question: Causes of Respiratory Distress in a Ventilated Patient

/ Jordyn Redwood / Leave a comment

Terry Asks:

My question is what would make a person in a drug induced coma go into respiratory distress? My character is having really strange dreams/nightmares in his comatose state and I want to introduce a dark force (ie death), that is trying to take him. At the same time, in the hospital that dark force is actually a respiratory distress, but I can’t find any information on what would cause him to go into distress or how that would be handled by the doctors and nurses.

Image by Simon Orlob from Pixabay

Jordyn Says:

A patient in a medically induced coma will also be intubated (a tube inserted into the trachea to help the person breathe) and will be ventilated by a machine.

There is a pneumonic that most medical people run through when a person on a ventilator develops trouble breathing and it is the D.O.P.E. pneumonic. I first learned it in Pediatric Advanced Life Support (PALS) that is a class taught by the American Heart Association.

I’ll give you what they stand for and the medical treatment the nurse/doctor would take.

D: Dislodgement: Dislodgement means the tube is somewhere it shouldn’t be. The endotracheal tube (ETT) could be out of the patient (termed accidental extubation) or it could have migrated into the right bronchi thereby only ventilating one lung. If the tube is completely out (or sitting in the mouth— no longer in the trachea) then the patient would need to be reintubated. If the tube is in the right bronchi, it simply needs to be pulled back a little bit until there are breath sounds in both lungs and equal chest rise when the machine gives a breath. Often times, after measures are taken to correct the situation, a chest x-ray would be taken to verify the tube is in the right place.

O: Obstruction: Obstruction can mean a lot of things. It more commonly means that there are secretions in the ETT tube that need to be cleared. If that happens, they would be suctioned out. However, obstruction can also mean something like a developing pneumonia that may require increased settings on the ventilator and initiation of antibiotics. Ventilated patients are at high risk for developing pneumonia (if they don’t have it already).

P: Pneumothorax: This indicates that one lung has collapsed. Because the lung is deflated it can no longer be ventilated properly and is causing difficulty breathing. Treatment for a pneumothorax is placement of a chest tube to reinflate the lung. The patient should improve after the chest tube is placed, but it does take time for the lung to fully reinflate. Ventilated patients are also at risk for a collapsed lung, particularly if they are on pretty high ventilator settings.

E: Equipment Failure: This can mean something is wrong with the ventilator itself. It can be as simple as the machine became unplugged. Not all ventilators have battery back-up. If this is causing the patient to have respiratory distress, we simply take the patient off the ventilator and begin to bag the patient manually via the ETT until the problem can be sorted out.

Any of these situations can cause respiratory distress in a ventilated patient. It is your choice as the author which one to use.

Hope this helps and good luck with your story!

The Good Doctor S1/E6: Killing Patients

/ Jordyn Redwood / Leave a comment

At some point in every medical person’s career, we face a time when we think or may have altered the course of someone’s life either by a medical error causing serious harm or death.

Truth is, it’s a team effort to keep patients from suffering from these complications. We are all responsible for looking out for one another regardless of scope of practice. For instance, if an EMT sees something the doctor (or new resident) is doing wrong, they should speak up to prevent harm from coming to the patient.

In this episode of The Good Doctor, the staff is dealing with an MCI or Mass Casualty Incident. A bus full of wedding guests has crashed. After several of them are treated, it is discovered that a woman is missing at likely still at the crash site.

A resident leaves with an EMS crew (this in itself is highly unlikely) and finds the missing woman. On scene, the resident diagnosis her with a flailed chest and subdural hematoma (a collection of blood on the brain).

What is a flail chest? It’s when two or more consecutive ribs are broken on the same side creating a free floating segment of the chest wall. This can inhibit the patient’s ability to breathe and also puts the patient at a higher risk of having a pneumothorax (or air collecting outside the lung inhibiting the lung’s ability to fill with air.)

The resident chooses to intubate and then drill a bur hole into the patient’s head for the swelling. Upon arrival to the hospital, the ER doctor notices that the patient’s oxygen level is low (like in the 70s— normal of 90 and above) and pulls back the tube and the oxygen levels increase.

When someone is getting intubated, it’s natural to push the tube in too far and because of the anatomy of the lungs, it will pass into the right lung. It’s later noted in the show that because the resident intubated the right lung and that’s the side that had the failed chest, the patient suffered from persistent hypoxia (or lack of oxygen) and her brain died because of that.

Was this patient’s death preventable?

Putting aside that this patient could have been hypoxic during the time she laid for an extended period of time in the ditch, this death could have been preventable if the EMS crew, who would have been monitoring the patient’s oxygen level (and so should the resident if involved in transporting the patient) had spoken up about the dramatically low level.

When a person is intubated, these are the following checks that happen to ensure the tube is in the right place.

1. Does the chest rise and fall equally. In this patient’s case, the right side of the chest would not have risen that much if several ribs were broken and the lung was deflated which should prompt the doctor to do number two on this list.

2. Are the breath sounds equal? The patient’s lungs are auscultated (listened to with a stethoscope) to determine this. They should be equal. If not, then there is a problem with that patient’s lung (one is deflated, etc) or the tube is in the wrong position. At that point, the tube could have been adjust. If the patient’s breath sounds were severely diminished on the right side (especially after trauma) then a need decompression should have been done on that side as a rescue measure to try and reinflate the lung some.

3. Are the patient’s vital signs improving? This would be primarily the oxygen level. It can take a few second to a few minutes for the patient’s oxygen levels to reach normal but they should improve. If not, then something is wrong with the tube and it should be evaluated.

4. Is there the presence of carbon dioxide measured as end tidal CO2? There are quick measure devices in the field to check that carbon dioxide is coming up through the tube. This also ensure the tube is in the right place. In the hospital setting, we will watch this number continuously.

5. Ultimately, in the hospital setting, an x-ray is done to confirm proper placement in the field but if the above items or done, the tube (or endotracheal tube in this case) should be in the right position.

If the EMS crew would have spoken up and/or if all three of the crew members had been performing their job correctly by monitoring the patient’s oxygen levels (which is a very basic thing to be monitoring) then this patient’s death could have been prevented.

It’s up to every member of the healthcare team to ensure patient safety.

Care of the Burn Patient

/ Jordyn Redwood / Leave a comment

Linda Asks:

In my middle grade novel my main character’s dad was a fireman in NY.
He was present during the collapse of the World Trade Center buildings.
He was burned severely and is in the hospital – near death.

My main character remembers his last conversation with his Dad in the hospital right before he dies.

The dad is hooked up to all kinds of beeping machines and is wrapped in white gauze.
After he talks to his son for the final time, he pushes a button for more morphine.

Questions:

Do they still wrap burn patients in gauze?
Is morphine used on severely burned people?

Jordyn Says:

From the point of view of your character– yes, burns are wrapped in gauze. They are specialized dressings, but a character aged 10-13 could perceive it as gauze only.

Yes, morphine is still used for pain.

My only concern is this character having a conversation with his dad. You don’t describe the nature of how he was burned, but a severely burned patient, particularly one close to death, is likely on a breathing machine and, therefore, unable to speak to his son.

You could change the scene to be that he’s so sick that they are getting ready to intubate the character’s father, and the medical team gives them a few moments to talk before they put the father on the breathing machine. He could still die quickly after from his injuries.