Nightmare at Bowen

Hello all,

Well I had another doozy of a clinical coordination shift the other night.  As I previously mentioned, part of my job here is coordinate the transport/treatment of patients throughout the whole of north Queensland and it can get a bit tricky from time to time. 

The evening began with a call from a doc on Thursday Island  (TI) located at the Northeastern most tip of Australia.  There was a 18-year-old schizophrenic on Badu Island who had recently returned home from the hospital who decided to forgo his medications and self medicate with large amounts of marijuana.  Needless to say he had become acutely psychotic and was roaming his remote tropical island with a machete “looking for the aliens”.  The doc I was speaking with had been in communication with the only health care provider on the island, a nurse, and had suggested using antipsychotic medications to control the situation.  When that didn’t work, and the patient became increasing agitated, the nurse had called for help. 

So here is what I had to coordinate.   First I needed to speak to the helicopter pilot to make sure he had enough time/fuel to get to Badu.  Next I had to find and anesthesiologist who would be wiling to fly to the island, forcefully intubate (put a breathing tube in) the patient with the help of the police and bring the patient back to TI and care for the patient until we could send a plane (3.5 hours) from Cairns. Of note, it is policy that many psych patients must be intubated in order to fly on the helicopter.  It sounds extreme until you imagine an acutely psychotic patient thrashing around at a few thousand feet.  Then I had to speak to the team in Cairns about the retrieval.  If everything went according to plan, the retrieval team would arrive at about 12:30.  The caveat to this was that if the Cairns retrieval team got a call about a more acute situation (trauma/acute cardiac event), the intubated psych patient would get bumped and then be stuck in TI, where they only have one ED respirator and no ICU, until sometime the next day.  That's not good.

As that plan was being coordinated, I got my next call.  Bowen is a small town 2 hours south of Townsville and they have a VERY basic emergency department and hospital.  I picked up the phone and heard the quite panicked voice of the Bowen doc who explained that they had a patient with known COAD (COPD) who was unresponsive and they needed help.  I began by getting a bit of the history, vitals and finding out what interventions had been done since the patient arrived.  Most of the basics had been initiated, and the patient was on Bipap (a mask that helps people breathe).  When I asked for the patients GCS (measure of mental status, can be between 3 and 15), I was told 7.  At that point I quickly went into the back room where we have the ability to  video connect via satellite with a select group of smaller EDs.  This  “telehealth” system provides the coordination doc the ability to see the patient (from 2 different camera angles) and communicate with the staff.  When the screen finally came up there was an obese elderly guy with a bipap mask on his face.  He was grey, diaphoretic, and obtunded.  I focused the other camera on the monitor and started asking some questions.  This guy had been in the ED for over one hour.  He arrived with GCS 12-13, was given nebs, steroids and started on bipap.  His first gas showed a pH of 7.1 and a pC02 of 125 (VERY BAD).  One hour later his repeat gas showed a pH of 7.0 and a pCo2 of 150 (VERY VERY BAD).  Remembering that not all docs out in “the bush” have the same training, I asked if there was anyone in the hospital who could intubate.  The doc in the room quickly informed me that she could.  This was music to my ears.  This patient was clearly failing bipap and was so altered his airway was in jeopardy.  But no worries, I had someone who could intubate.  It was when I asked this doc what meds she was going to use that I began to realize that maybe I should rethink my plan.  Her reply was “I don’t know.  I was hoping you could remind me.  I’ve done 6 or 7 but they were all with different consultants (attendings)”.  My heart sunk.  I asked her of the 7 she had done, how many had been successful.  “At least half of them,” she said.  To give you an idea of what that means, I've done at least 150.

Now I have worked with Shellenberger, so I know fear, but this was something else.  One look at this guy and you could tell he would not be an easy intubation, and the only person there with any skills has intubated “at least half” of 7 total intubations.  I asked the doc and staff to hold for a minute and I ran in the other room.  I called to the helicopter coordinator and asked how long it would take to fly to Bowen with an experienced doc for an emergent intubation.   I was told it would take only 25 minutes.  I got excited again; this patient would make it yet.  The coordinator then continued.  “25 minutes on a normal day, but the helos are grounded due to the dust storms.”  My heart sunk again. 

Note:  In case you did not read it in the news, there were massive dust storms that moved across Australia recently decreasing visibility to less than 10  feet in some places.

I ran back into the telehealth room and let everyone there know that there would be no cavalry tonight.  At that point I had a decision to make.  Let the very inexperienced doc try to intubate (which I was about 95% sure would not be successful) or try something more conservative.  First do no harm. 

So I asked what the bipap settings were at… I was told 6 and 3.  I honestly didn’t even know it went down that low.  So I decided to try the conservative route and I asked the bipap to be turned up to 10/5 and repeat a gas in 20 minutes.  That’s right I made the decision to increase the bipap on the patient with the GCS of 7-8.    I ran back in the other room to take a few more calls, but had the telehealth on in the background.  20 minutes later I got a call.  The gas was now pH 7.2 and the pCo2 was 120.  THINGS WERE IMPROVING!  I told them to put it to 12/6 and call back in 30 with another gas.

The next call was from a dive boat stationed on Norman reef 4 hours off the coast in the middle of the Great Barrier Reef.  A 29-year-old novice diver had panicked at 40 feet during a night dive and removed her respirator.  No one was too sure how much seawater she had aspirated or how quickly she had shot to the surface, but she was now on deck coughing and complaining of chest pain.  I was talking to the skipper of the boat and I let him know that just based on the story alone, she would need to be brought back to shore for evaluation.  He was reluctant to move the boat considering he had 50 other divers on the boat and he asked about using a helo to winch the patient off the boat.  No can do at night I told him, too dangerous.  We contacted the Australian coast guard who agreed to head out to sea and meet the dive boat half way and take over care of the patient from there.

Just about then I got a call from Bowen.  pH 7.3, pCo2 105 and GCS 13 (MUCH MUCH BETTER).   An hour later the patient was able to give the thumbs up.

Note:  The TI patient was intubated on Badu and brought back.  Cairns never made it up that night. 

These were just the most exciting cases of the night.  In addition I had a pediatric trauma from Palm Island, a snake bite from the Whitsundays, a roo-strike from Charters Towers and a rigid abdomen from Mt. Isa.