Nightmare Fuel: Trachoestomy Emergencies

Hi Everyone and Happy Tuesday!

I am here to officially introduce myself as this block’s Admin Resident! If we haven’t had the chance to meet- my name is Kaitlyn DeStefano, one of the third year residents and I have the misfortune of following the great Dan Ye, so though my POTDs will not nearly be as amazing, I will sure try. Without further delay, I want to tell you all about a case I was peripherally involved with this weekend, the wonder Dr. Mara Zafrina primarily saw and highlight some learning points I took away. 

Its Sunday afternoon, Palm Gardens has sent over its fifth trach to vent patient to Northside and we get the pre-notification for a stable trach to vent patient who’s chief complaint is bleeding from the trach. The patient arrives and EMS looks a bit panicked because- no no, this is not a stable patient, the patient is saturating in the 70s and had a little episode en route with some bradycardia though they adjusted the bag to the trach and it picked up but nonetheless, here they are standing in the hallway outside of 52. 

Before the patient even gets slotted into a location, Dr. Zafrina starts with listening to the lungs, “bilateral lung sounds” but also “feels like there is some subcutaneous air”. Okay- that’s weird. Also the patient’s face looks a bit swollen, but I dont know who this lady is- maybe thats normal for her, they get her into 52 and the show really gets started. 

The patient has saturations in the 60-70s. The patient has subcutaneous air extending around the chest into the face, eyelids, tongue, and around the mouth. The patient is starting to become more and brady with HRs dipping into the 30s and 20s. Yogi, the respiratory therapist helping us, is having a difficult time bagging the patient is meeting a lot of resistance and there is a ton of air coming from around the trach. Dr. Aghera attempts to re inflate the balloon, replace the trache bedside, once with inner cannula, once with a new trache and still the patients HR is in the 20s, we have no saturation on the monitor and the patient is becoming cyanotic. Desperate, I paged thoracic and begged for anyone to come help us. Dr. Zach Cohen replies, “get the bronch ready” and before we know it the surgical senior, junior, intern are all at bedside, shortly followed by Dr. Caifa. They drop the bronch- there are no tracheal rings, no carina. And also now, no pulse. ACLS is initiated. An airway is established from before with an endotracheal tube. ACLS continues, patient continues to be pulseless, and b/l chest tubes are placed, finally ROSC is achieved. 

Man- I knew to be scared of traches but I had NO idea how quickly this could go sour and how scared I would be in these moments even as a bystander. I thought I would do a deep dive into tracheostomies and how to troubleshoot. As good ED staff the hallmark to any unstable patients is to go back to the basics: 

• Airway: 

• Apply supplemental to both the mouth/nose AND the stoma 

• Both can be done with a non rebreather

• Determine the age of the tracheostomy and the patency of the airway above it 

• In this patient’s case I did a quick chart check and could not see when the trache was placed but could see during the patient’s January admission she was on nasal cannula only so it was at most 2 months old 

• If there is bleeding at the tracheostomy: Concern for tracheo-innominate artery fistula

• Over inflate the balloon to tamponade the bleed OR

• Apply direct pressure with your fingers at the site of the bleeding 

• Tracheostomy obstruction: 

• Common problem: Mucus plugging

• Attempt to resolve with passing a flexible suction 

• May need to remove the inner cannula and suction the outer cannula 

• Attempt to ventilate when deflating the cuff

• If unable to fix, remove the tracheostomy 

• Tracheostomy Decannulation: Bingo! This was our problem

• Occurs with partial or complete displacement 

• Can assess for this by: 

• Attempting to pass flexible suction

• Connect end tidal to the tracheostomy

• Attempt to pass a bronchoscopy for direct visualization 

• You should start to suspect a false passage if subcutaneous emphysema occurs 

• Establish a definitive airway through direct visualization either above the tracheostomy or through visually directed bronchoscopy 

• Breathing: 

• If bag valve mask ventilation is needed: 

• Apply a bag mask valve over the mouth and nose and cover the tracheostomy stoma with a wet gauze  OR 

• Apply a bag mask valve over the tracheostomy stoma and cover the mouth and nose 

In this patient, I suspect that the patient had such significant subcutaneous emphysema that was worsened by continued positive pressure ventilatory systems which increased high peak pressures, worsening barotrauma, and expanding pneumothoraces, to the point of causing cardiac arrest!  

And with that- I will leave you this nightmare fuel until we talk again! 

VOTW: In the Thick of It

HPI

A 40-year-old female with a PMH of polycystic kidney disease, HLD, and HTN presents with 1 month of episodic dizziness. She was referred to the ED by her cardiologist for an abnormal EKG, and had previously been told that she had an enlarged heart. 

Her vital signs are unremarkable. Physical exam is notable for a harsh, blowing systolic murmur. Chest X-ray shows cardiomegaly.

Ultrasound Findings

Point-of-care echocardiogram showed no pericardial effusion and was notable for septal thickening to 2.2 cm, concerning for hypertrophic obstructive cardiomyopathy (HOCM).

Echocardiography is the first-line imaging modality for the diagnosis of hypertrophic cardiomyopathy. 

Key findings are wall thickening and intraventricular obstruction. 

• Wall thickening > 15 mm (or > 13 mm in patients with relatives diagnosed with HOCM). This can be measured in the parasternal long or short axis views. 

• Interventricular septum to posterior wall thickness ratio of > 1.3 in normotensive patients or > 1.5 in patients with HTN

• Thickening usually occurs on a focal region of the LV wall

Other associated findings include mitral valve abnormalities, systolic dysfunction, and diastolic dysfunction.

• Systolic anterior motion of the mitral valve may occur in HOCM due to the Venturi effect. Septal hypertrophy narrows the LVOT, accelerating blood flow and creating a suction force that pulls the mitral valve leaflet into the LVOT. This causes outflow obstruction as well as mitral regurgitation. 

Case Conclusion

Based on these findings, the patient was placed in observation for cardiology evaluation. 

Comprehensive echocardiogram revealed findings consistent with HOCM, including severe asymmetric left ventricular hypertrophy, hyperdynamic LV systolic function (LVEF 76-80%), moderate (grade 2) LV diastolic dysfunction, LV outflow tract obstruction, moderate systolic anterior motion of the anterior leaflet of the mitral valve, and moderate mitral valve regurgitation.

The patient was newly diagnosed with and educated about HOCM. She was discharged with metoprolol 25 mg daily and is anticipated to undergo further treatment with mavacamten and possible septal reduction surgery. 

References & Further Reading

• https://coreultrasound.com/5-minute-sono-hcm-and-lvoto-2024/ 

• https://www.acep.org/emultrasound/newsroom/jan2023/motion-of-the-hocean-a-clinical-case-of-hypertrophic-obstructive-cardiomyopathy 

• https://pmc.ncbi.nlm.nih.gov/articles/PMC8423594/ 

• https://www.acc.org/Latest-in-Cardiology/Articles/2018/04/20/08/41/Imaging-in-Hypertrophic-Cardiomyopathy 

Happy scanning! 

POTD: Potpourri (LLFTP #9)

Welcome to my final POTD of this block, and the 9th installment of “Lessons Learned from The Pitt”. Rather than focus on a singular case, I’ll end with a potpourri. 

Spoilers and anguish ahead.

It is now 3pm at this ED, and the ratio of “things happening” to “time elapsed” continues to steadily increase. When the episode begins with an interrupted debrief for poor drowned Amber, followed by shots of much of the cast going through their own trauma responses (Dr. Langdon calling home, so he can hear his son’s voice, just hits different), you know that things are probably going to keep going downhill. The purpose of a debrief is to give the team a little time and space to process and recontextualize the events, identify areas of improvement within a supportive learning environment, and assess the need for further support (such as a Team Lavender consult). The facilitator (usually the attending, or other designated staff member) will gather the team members, establish that the debrief is intended to be a safe space, establish the above objectives, and then step back and nudge the conversation as needed. One of the staff (usually the team leader) will summarize the events that occurred; the rest should hit upon three areas — the “plus”, the “delta”, and the “take home”; respectively, those are the things that were done well, opportunities to improve, and learning/action items. If an official Clinical Event Debriefing form is submitted, there is an ED leadership team that will discuss those points in a biweekly meeting and try to address said action items. 

Back to the episode. With 4 hours left in the shift officially (though we all know that there are 15 episodes, so something’s coming), people start to hit their breaking points. The first two are on the patient side, and both occur in the packed-like-sardines waiting room. Mr. Driscoll, the chest pain patient who has become progressively more frustrated, hostile, and racist with each episode he continues to remain in the waiting room, finally decides he’s had enough and starts leaving after a tirade. Dr. Langdon calls Driscoll out over the speaker to tell him that he would be departing “Against Medical Advice”, with risks including dropping dead from a heart attack.

The AMA conversation is important when it comes to patient safety, as well as one’s own medicolegal protection (patients who leave AMA are more likely to have a bad outcome and more likely to sue). Patient autonomy is one of the ethical cornerstones of modern medicine, and restricting an individual’s freedom of movement without justifiable cause constitutes the crime of false imprisonment — thus, (most) patients cannot be physically stopped from leaving unless they are obviously impaired/dangerous. Ideally, before that happens, the treating physician is able to have a conversation with the patient; the discussion should allow the physician to assess the patient’s capacity to make this decision (briefly, displays understanding of their current condition, demonstrates insight into the benefits of staying vs the risks of departing including specific risks incurred by the suspected disease processes, and is able to articulate an intact thought process i.e. intact judgment regarding how they came to their decision), and then take steps to mitigate harms (such as giving prescription antibiotics, outpatient follow-up, et al.). The AMA discussion also may be the last opportunity for “service recovery”, a concept from the Patient Experience world; this can be an acknowledgement of the patient’s concerns, followed by explanations of what has happened and what can be done to improve. In this case, Mr. Driscoll has actually received a workup despite being in the ED; he’s had an ECG and troponin (plus other basic labs), with repeat troponin pending — and I don’t think anyone’s had the headspace to have an actual discussion about the plan and address his concerns with an empathetic veneer. 

The second waiting-room blowup is a fight between two women, instigated by one of them taking offense at being offered a mask for her coughing child, which charge nurse Dana steps into and ends with a dressing-down worthy of a standing ovation. This isn’t the time or place for a deep dive into the politics of masking, I’ll just say that droplet precautions were definitely around before 2020. The medical lesson here comes from the “fight bite” from our anti-mask perpetrator, who now has a tooth fragment lodged in her knuckle. Evaluation of such an injury should include assessment of the integrity of the joint capsule, of tendon involvement, of potential fractures, and of signs of infection (especially if presentation is delayed). Lacerations over the dorsal MCP joint should prompt a specific question about fights, as patients can sometimes be reluctant to divulge (they don’t know about the risk of severe infection leading to amputation). Treatment for the uninfected-appearing acute “fight bite” with no joint/tendon/bone involvement is copious irrigation, prophylactic antibiotics (usually augmentin 875mg/125mg PO BID x 7 days), +/- TDAP, healing by secondary intention, and close follow-up. Hand surgery should be consulted (and IV antibiotics considered) for signs of infection (usually with delayed presentation) especially if there is reason to suspect joint/tendon compromise. 

Back to the resus bay, another critical patient from this episode has hyperthermia and altered mental status in the context of MDMA abuse at a music festival. Her core temperature is 107 degrees, prompting the team to begin active cooling with ice-water immersion (with goal temp of 102 to prevent overshot hypothermia), as well as high-dose benzodiazepines (to oppose the centrally-mediated MDMA-induced component of her hyperthermia, as well as to prevent shivering). Later, when the patient begins seizing, Dr. Santos suggests that the patient has hyponatremia secondary to dehydration, orders 100mL of 3% saline (would raise serum Na by 2-3, usually given x3 to achieve effect), and goes above Dr. Mohan’s head to push the saline (100ml should be given over 10-15 minutes, not a 3-second push) (can also consider 1 amp of 8.4% sodium bicarb, which is in code carts and more readily available). The seizure terminates, and it’s the first resus win for Dr. Santos until Dr. Langdon returns furious and demands to know why no one bothered to come tell him about the seizure. Dr. Mohan freezes like a deer in headlights, and Dr. Santos throws herself under the bus and gives Dr. Mohan the credit for the save — prompting Dr. Langdon to go off on her, full-on shouting at her and berating her until Dr. Robby interrupts him. This is not how one should approach giving feedback to a learner — not in public, and not with such vitriol. The goal should be to communicate areas of improvement and concrete changes that can be made. If the learner has demonstrated a problematic pattern of behavior, pull them aside and address it before it becomes such an issue that you feel the need to scream at them. And if problems persist, there are people (i.e. attendings, charge nurses) to whom one can escalate.

Though Dr. Robby's response with Dr. Langdon is also not totally appropriate, shouting at him to “shut the f*ck up” when Langdon rushes to explain himself, and dressing him down in full earshot of the rest of the ED.

The episode ends with a sucker punch, delivered by a departing Mr. Driscoll to charge nurse Dana while she's stepped outside for a break. Violence against healthcare workers is a serious problem that often goes unreported or unprosecuted. Healthcare and social services workers are at the highest risk of workplace violence compared to all other civilian industries, with over a quarter of all workers facing victimization during their career. Reasons include perceptions that this is “all part of the job”, or that patients/families should be given passes due to their stress, or that they'll face censure for speaking up. Solutions include building a culture of safety and developing institutional policies. In the acute setting, early retreat and involvement of security are the best ways to protect oneself.

That's all from me today. I hope you've enjoyed this series because I've certainly had a blast writing each one!