August 2011, volume 6

“I trust my seniors”(This case is adapted from an overseas report)

Mr. A, a 35-year-old clerk with history of diabetes mellitus for 2 years, attended the AED one evening with a history of vomiting and abdominal discomfort for 4 hours. The

h d h l f i

Comments from Dr CC Cheung,Consultant, Department of

Surgery, NTWC

It was unlikely Dr A would find confirmatory signs of appendicitis so early in the evolution of the

symptoms had come on shortly after eating a meal. He was seen by Dr B, a resident specialist of the AED. Dr B documented a detailed abdominal examination which showed no evidence of an acute abdomen. Dr B diagnosed acute gastritis or early gastroenteritis and admitted Mr. A to ward for observation as the spot glucose was raised at 20.1 while ABG

illness. Dr. D had been overly reassured by her senior colleague＇s previous diagnosis. If she performed an abdominal examination at that stage, she would be able to find signs of appendicitis or an acute abdomen. The presence of a trace of blood in the urine of a young man complaining of acute abdominal pain was rather non-specific.

showed no acidosis.Dr C, a resident specialist of Surgery, admitted Mr. A and noted the abdomen to be slightly tender diffusely with no peritoneal sign. Spot glucose was 11 after insulin infusion and WBC was 12.By early morning of the next day, Mr. A felt

Learning points:

Do not be overly reassured by a colleague＇s previous comments/diagnosis. In the context of acute illness, symptoms and signs can evolve rapidly. And one should always seek to confirm the same or similar findings to a previous examination before formulating his own opinionBy early morning of the next day, Mr. A felt

increasingly unwell and developed a low grade fever. Dr D, a first year trainee of Surgery, went through the notes and found that Mr. A had been examined twice by seniors. Dr D did not perform an abdominal examination as she felt reassured by the findings of two senior clinicians. She also looked at the abdominal X-ray and felt reassured that it was essentially

examination before formulating his own opinion.

When dealing with an acute illness in an otherwise healthy person, take care to be thorough and conduct and record an adequate history and physical examination to reassure yourself that you are not missing an important diagnosis.

In any critical incident, summon senior helpray and felt reassured that it was essentially normal.Dr D also noted that urinalysis showed a trace of blood and diagnosed a urinary tract infection and treated Mr. A with a cephalosporin antibiotic, panadol and buscopan. Twelve hours later in the evening, Mr. A was i bd i l i d tt d d b

In any critical incident, summon senior help immediately and if not forthcoming, repeatedly clearly communicate the level of urgency.

If you are supervising a trainee, however competent, ensure that you (or a senior colleague) are available at all times to help out. The management of the case is your responsibility.

in severe abdominal pain and was attended by Dr D again. She noted the patient was in shock with signs of peritonitis. Emergency laparotomy confirmed the diagnosis of acute appendicitis with perforation. Mr. A subsequently was admitted to ICU and recovered uneventfully. He lodged a complaint for delay in diagnosis and treatment

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Disclaimer: All the cases that are included in this Bulletin have been adapted from sources including but not limited to: international Journal publications, MPS casebook, AIRS cases from NTWC and other clusters.  All the details have been modified to preserve the anonymity of the persons involved. Please send all comments and enquiries to Dr TANG Kam Shing (Email: tks422@ha.org.hk) 

for delay in diagnosis and treatment.

“Ventilator troubleshooting”Mrs A was 70 years old with history of DM, HT, old CVA and gout. She was admitted to the hospital for shortness of breath. She was chair bound because of her old CVA and was maintained on nasogastric feeding. CXR showed a right lower lobe pneumonia. Despite intensive chest physiotherapy and antibiotics, she further deteriorated and was intubated in the ward. In view of her poor pre-morbid status, she was not admitted into the ICU and continue on mechanical ventilation in the ward.

Two days after intubation, Dr B, a first year physician trainee, was called to attend to the patient by the y y p y p ynurses. The ventilator alarm had been beeping for 15 minutes and the patient was having a SpO2 of 87%. The patient was also in great distress

Dr B noted the tidal volume was around 150ml only but the ventilator was set as follows: SIMV+PS (VC), SIMV 15, TV 450, FiO2 0.7, PEEP 8. Dr B think the ventilator was out of order and ordered to change the ventilator. After changing to a new ventilator, the same problem was still there and Dr B wondered what’s wrong with the second ventilator.

Comments from Dr KS Tang, Deputy SD (Q&S)Mechanical ventilators appear an enigma to our junior colleagues as there are so many different modes, settings and alarms. This is especially the case for juniors in specialties not coming in contact with mechanical ventilation frequently. However, there are several basic principles that could help our juniors to survive the situation before help is available.

One of the common problems encountered is patient desaturation together with the ventilator alarm beeping in a previously stable patient. The causes of this scenario is numerous but could be summarized as ventilator problems, endotracheal tube/ tracheostomy tube problems and patient problemsproblems, endotracheal tube/ tracheostomy tube problems and patient problems.

I would first quickly listen to the chest of the patient to rule out severe bronchospasm and obvious unequal air entry as lung collapse due to sputum retention is very common for mechanically ventilated patient. Massive pneumothorax is also possible but a less likely cause than collapse. If there is no gross abnormality, I would disconnect the patient from the ventilator and manually ventilate the patient with ambu bag connected to oxygen from another source.

This serve several purposes at the same time Firstly the ventilator could be connected to the test lung testingThis serve several purposes at the same time. Firstly the ventilator could be connected to the test lung, testing whether it is actually functioning normally. If the test lung is inflating and deflating normally and the alarm is off, chances is that there is no significant ventilator dysfunction to account for the acute deterioration. If the alarm is still on with the test lung, changing the ventilator would be reasonable.

By manually bagging the patient with high flow oxygen, the patient’s SpO2 will improve most of the time, giving you time to figure out what the exact problem is. Furthermore, if you could feel great resistance to bagging, the chance of a blocked airway is high. If the airway is displaced/ dislodged or the cuff is leaking, you will see bubbles coming out and hear gurgling sound with each manual breath. The most common tube problems (tube blockage/ tube dislodgment) are then excluded by this simple maneuver. If the ventilator is functioning normally on the test lung and tube problem is not likely, I will order an urgent CXR and it will usually give you the answer. If the CXR showed no accountable changes, consulting experts for advice would be helpful.

The mnemonic of "DOPE", meaning dislodgement, obstruction, pneumothorax (tension) and equipment, could help you to recall the commonest causes in this scenario.

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Disclaimer: All the cases that are included in this Bulletin have been adapted from sources including but not limited to: international Journal publications, MPS casebook, AIRS cases from NTWC and other clusters.  All the details have been modified to preserve the anonymity of the persons involved. Please send all comments and enquiries to Dr TANG Kam Shing (Email: tks422@ha.org.hk)