July 1, 2021

We Are Brave

Earlier in my career, I was working in a rural emergency department (ED), enjoying my shift and the camaraderie that comes along with a small team of efficient rural health-care workers. A patient presented with reported hemoptysis at home since the night before. Hemoptysis causes some concern in my head and chest, but  in my brief experience, it is usually over-reported and nothing to write home (or your AAWEP newsletter) about. However, hemoptysis in a rural ED (and following the theme “brave”) lead us into bloody, treacherous, oxygen- deprived waters. Are you nervous yet? Me, too. Let’s take a deep breath and be brave together.

My patient, whose details have been altered to maintain privacy, looked alright as I walked into  the room. Reportedly, the patient had coughed up so much blood the night before that it filled the bottom of a garbage can, but only noted blood on tissues since. The patient was pleasant, speaking in full sentences and in no acute distress. Nursing was assessing vitals, which were coming back as normal. Overall, it seemed we were in a good place.

Because we always prepare for the worst, especially with airway complaints, I did an airway assessment. The patient was an airway nightmare; morbidly obese, a current tobacco user with a diagnosis of COPD, and the owner of a thick tongue with a Mallampati of 4. Our patient could barely open their mouth, but when they did, I noted blood on their tongue and teeth. I think to myself, “This could get bad really quickly,” as I run through my resources and plan to get the patient out of the ED before they need an airway. My lung assessment revealed crackles to the left and decreased air movement in the bases. Are you thinking what I was thinking? We could be headed down a scary pathway. We started our workup and eventually performed a CT of the chest which showed possible bleeding on the left. As I was waiting for the read from radiology, the patient had an episode of hemoptysis greater than 30 mL, and their oxygen   saturation dipped to 85%. Our patient recovered with nasal cannula at a couple liters per minute, and the hemoptysis quieted. I was nervously but bravely wading into shark-infested waters as I considered the fiberoptic bronchoscope, which I had never used without supervision of an attending, and an awake intubation which I had only seen as a resident.

Deep breath, stay calm, be brave.

I considered my resources again; I am the only physician in the hospital. I have a young respiratory therapist as back-up for the airway. I have a two experienced ED nurses and an ED technician. I decided I would be prepared, but we would intubate only if absolutely necessary. I recalled our Tele-EM consult and promptly got another ED physician involved in the case for support to help trouble-shoot what is now a stable patient that could rapidly turn into a crashing and terrible airway disaster. After I send the page, I reassess my patient and find them 89% on room air. Room air? I had placed them on oxygen. Upon discussion with nursing, after the patient’s oxygen normalized, they thought it would be okay to remove it. I replaced the oxygen and informed nursing of my reasoning and stated my critical concerns for  the patient and the potential need to control their difficult airway.

Tele-EM phoned back and appreciated the complexity of our situation. After our discussion and review of the case and resources available, we decided to transport the patient via air ambulance to the nearest facility capable of awake intubation with ENT at the bedside. The patient, however, wanted to go outside for a cigarette and refused transport and transfer. In fact, they said they were done with our ED visit and wanted to go home. The hits just keep coming with this case, don’t they?

I sat down to convince the patient and their spouse to accept the transfer and continue care here in our ED. Nursing had stepped out of the room and stated as they left, “If they don’t want to go, we shouldn’t force them.” After a lengthy discussion regarding my concerns and the risks and benefits of transfer and continued medical care, the patient agreed, and the helicopter arrived and flew them to the accepting hospital where five physicians safely performed an awake intubation in the ICU. Patient crisis resolved — but what about the team crisis? What about that break down of teamwork and communication? It had already been a mentally and emotionally trying case with multiple hurdles, but I had one final challenge. I had to unite and lead my team.

Just prior to the conclusion of their shift, I requested the three staff members involved to have a moment of discussion for debriefing. Like most debriefings, I started with an open question asking how they thought the case went and where they thought we did well and where we could improve. It led to an outpouring of emotional concerns, confusion, and expressions of fatigue and burnout. There was confusion as to if I was going to intubate, and none of the staff thought we had resources. There was confusion as to why the patient was critical, as the staff had not appreciated the severity of the situation. In the end, I shared my evaluation of our work, where I want us to be in future cases, and where I and we could improve. The staff shared some introspections and realizations of their contributions to the complexity of the case. All were heard and felt more optimistic at the conclusion. I effectively and bravely established myself as a competent leader by having that difficult discussion with my team. We have had many critical situations since and have had effective and efficient communication and teamwork for our patients. It was a growing experience for me personally and for the team as a whole.

I was recently listening to The Joe Rogan Experience podcast, and I heard a saying that stuck with me as an emergency medicine physician still early in my career. He essentially described mixed martial arts fighting as complex decision-making with dire physical consequences. I thought, “That is truly emergency medicine: complex decision-making with dire consequences.” We may not be in an octagon, but we are bravely fighting for our patients, our staff, our  communities, and even ourselves. We muster up courage daily to step into the octagon of the emergency department and lead ourselves, our staff, and our patients through some of the toughest moments in their lives.

We are brave.

Alecia Gende, DO, CAQ-SM
AAWEP Chair-Elect
Emergency and Sports Medicine
Mayo Clinic Health System La Crosse, WI

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