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.