too old ...

 

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…