Health care hindernace.. what better I can do..?

 Yes I know I am at one of the peripheral health care center with Icu back up, where I am bound to do my Conpulsory Senior residency in dept of general medicine. 

With very limited resources ( probably handful when compared to remote areas ) and hundreds of patients visiting both Outpatient and Emergency Room, I felt challenging and focused to deliver better health care. 

Got a call from nursing staff when I was in OPD regarding case in ER. 

I found a middle aged man gasping in air hunger sitting in mohammadian prayer position ( sitting on legs and bending forward) with Triple lumen hemodialysis Catheter  in right neck and recently operated AV fistula on right hand. Prior to my arrival nursing staff proactively gave inj. Deriphyllin, Nebulisations and oxygen support. 

In an interview with patients son, he revealed his father suffering from chronic kidney disease past few years and initiated on hemodialysis 1 month back. he also told that as they were advised not to give anti hypertensives on the day of dialysis ( though his session is at 7pm ) they didn’t give morning dose of antihypertensives and he landed up in pulmonary edema. 

With these details I presumed patient could he have Flash pulmonary edema and confirmed with my auscultation ( diffuse crepts and wheeze with BP 200/140 ). Requested nursing staff for NTG and they gently replied it is not available sir..!! Insisted them to get from ICU, mean while I gave 80mg lasix and 20mg Labetolol and still BP 160/100 repeated another shot of lasix 80mg where nursing staff is hesitated in fear of pumping lasix (200mg in 20min). Here comes an unexpected answer that NTG vials are expired in ICU.  Slowly BP settled to 140/80mmhg and patient shifted to ICU with adrenaline rush in nursing and supportive staff. 

Patient was shifted on to ICU bed he was sitting and taking breath and responded to my question in this way… 

My question : how you are feeling now sir..?

Answer : Ha.. better… ahhh ahhh ahhh ( suddenly unresponsive) 

With sudden unresponsive, stiff hands and involuntary bed wetting immediately my hands went to his neck to check for carotids. I couldn’t felt carotid for more than 5-6sec I gave a call that carotids pulse is absent. Immediately the nursing staff who is on right side of the patient started CPR. 

I went to head end to put a tube into his lungs ( intubation) and give oxygen with high pressure, I placed tube in between his cords under Disco light(flashing) vision of  dim laryngoscope while CPR was continuing. 

With out ABG facility at my center I ordered them to give sodium bicarbonate 50meq and adrenaline 1cc for max 3 shots. With my system-1 learning I gave calcium gluconate slow IV as a membrane stabilising agent. All this happened  in less than 5-10min. Then he stopped the CPR for switching I swiftly checked his carotid, it was hitting my fingers and sinus rhythm reflected in bedside monitor. 

Post Rosc BP 180/100, with pinkish-red coloured secretions from tube. Increased peep in venti and gave a shot of lasix 40mg. Secured another tube into stomach ( ryles tube ) and started him on Nicardia retard 20mg thrice daily. Now is is maintaining hemodynamic stability on ventilator. 

Intervention and analysis : 

Individual level: 

Patient : if he had taken anti hypertensive wouldn’t he landed up in this situation..?

Dialysis staff : withholding morning dose of  anti hypertensives on the day of dialysis is justifiable..?

Doctor: NTG vs labetalol in treating pulmonary edema (  could NTG decrease/prevent his risk of intubation..? )

Institutional: NTG in ER, NIV in ER, staff education ( expecting this beacuse of 10 bedded ICU with ventilator facility ) 

Challenges facing  : 

1. How to dialyse him..? No bed side dialysis and No oxygen support in dialysis room.

2. Post ROSC what would be expected neurological outcome..?

3. Ventilator settings optimisation without Blood gas analysis..?

4. Heart status purely by ECG. No scan available. 

Thanks for reading my story.. will update you the progress. 

 #Day2 : 

patient was off sedation and paralytic, moving limbs with plasters on closed eyes. slowly opened plasters and asked him should i remove tube from your mouth.. he gently nodded yes..!!

lungs were clear on auscultation and extubated after seeing this xray..