For a local
hospital with 100+ beds, we were considered by the govt as small hospital. We are graded
as community hospital - the lowest grade according to the
standard of hospital evaluation scheme.
According to the
diverting plan, we were not supposed to admit patient with severe respiratory
infection caused virus. The plan was drawn after the SARS era to more
efficiently managed such malignant wave of attack. Resources were directed to
designated hospital so that patient would be care under the best team with adequate
equipment.
The Covid rampage
had however proven the insufficiency of the planning. There was always patient
that was unable to transfer out.
Respiratory infection
caused by virus had always carried a risk of worsening into acute respiratory
distress syndrome or myocarditis and ECMO might be needed.
1+ years ago, a
nurse who worked in a medical center grade hospital in K city had collapsed
while she was going for trip to the east coast. She had collapsed in her car
and later sent over to our setting where she was comatose and shock was noted. She
had cardiogenic shock and ECMO was initiated in the ED. As her condition was
poor and ECMO usage on the ambulance was not feasible. She had succumbed to the
disease days later.
It was a difficult
time for the whole team as the patient was placed on a venoarterial mode and a
dedicated team was needed to the care for the patient. The day to day routine
of the ICU was affected. The patient was young and families were hoping for
miracle. It was a bad practice but as the patient was a medical staff; we did
our best to pacify the family.
Since then, we had
cautiously choose our patient but however some patient was difficult to turn
down.
A father of our
nursing aide had come to our ED presented with fever and cough and later proven
as pneumonia caused by influenza virus. The patient was admitted as influenza
pneumonia; it was considered as severe influenza disease and should be referred.
However family wanted to stay back and we had admitted the patient.
The patient had
deteriorated on D3 and one day after he was transferred to ICU, he was intubated due to ARDS. A referral was warranted as ECMO was needed due to poor
oxygenation despite aggressive respiratory intervention. It was a Sunday and
only one ECMO was available at the southern part of the island. Yeap, the last
ECMO was in our setting.
The visiting cardiothoracic surgeon was available and he was summoned and patient was hooked on to the machine in no time.
We were lucky as only venovenous mode was needed as the patient did not had any cardiac failure condition.
The
patient’s renal function had deteriorated few days later after being hooked
onto the ECMO.
Our nephrologist was consulted and hemodialysis was planned and insertion of double lumen
catheter was warranted.
Tan who covered
the ICU had however gone back for a long trip in Penang and the ICU was
partially covered by a junior neurologist and boss.
It was a
difficulty decision to be made for the double lumen catheter insertion and Boss
had come to us for opinion. The ECMO VV was inserted via the right side and a
CVP was inserted over the left femoral vein leaving only the left internal jugular
vein to be available.
A double lumen
catheter from the left upper part was not a usual practice and the catheter would
need to squeeze with the ECMO catheter along the superior vena cava when being
passed through. Definitely not a good idea.
After some
exchange of idea, we had decided to switch the CVP into the double lumen catheter
with guide wire method and then a CVP would be inserted via the left internal
jugular. Not a good practice as the possibility of contamination and infection would
be high for doing so.
Boss had agreed
and asked us to proceed with the procedure as no other option was available. I
had to perform the procedure as my colleague had failed a pigtail recently and
I understood his mental condition.
I was lucky as I
had the senior surgical aide on shift that day. The changing was a smooth one
and no massive oozing from the insertion point was noted.
The central line catheterization
was however more difficult as I had to squeeze myself through a load of wire
and tubing to get to the top side of the bed. No margin of error and I had done
a scan prior to catheterization. The jugular vein was engorged and the neck was
short. A short neck was a good sign as there is not much consideration for the
point of insertion. No space was available to perform an ultrasound guided
insertion as I was surrounded with tube and machine. A quick look and marking
were all I could do.
I sighed upon completion of the procedure; I am a little too old for this kind of thrilling moment. I just couldn’t complaint about the judgement of my colleague about the catheter insertion; one tends to opt for the easiest path. The catheter was placed shallow than usual as I intended to avoid squeezing with the ECMO catheter. However at 14cm, there was still no flow noted and I had to retract it to 12cm and finally I got a slow but acceptable flow.
It had been 1 week
since the thrilling event and even though he was still hooked onto the ECMO but
yet his lung had much improvement judging from the xray.
I was still the
youngest among the senior physicians. Most of the senior physicians were almost
70 and yet they are still keen on their job. In the past, Ving had asked me
about retirement from time to time but recently we had acknowledged the facts,
income is always the key to a comfortable life and retirement might not be an
option for us in the near future…