Description of Event or Problem · 0
DURING INTUBATION OF PT, AIR LEAK IN ET TUBES. CODE WAS CALLED AND PT EXPIRED. DATE OF SERVICE: (B)(6) 2022. WAS A PATIENT WHO HAS BEEN IN OUR FACILITY SINCE (B)(6) 2022 WITH COVID-19. THE PATIENT HAD BEEN ON OUR TYPICAL REGIMEN FOR THIS, INCLUDING STEROIDS, OLUMIANT, AND VEKLURY. THE PATIENT HAD FINISHED A COURSE OF VEKLURY AND WAS CONTINUING TO GET STEROIDS. THE PATIENT HAD WORSENING RESPIRATORY STATUS OVER THE LAST TWO DAYS. I SPOKE TO THE PATIENT ON (B)(6) 2022. THE PATIENT DECLINED TO BE INTUBATED AT THAT TIME. HE STATED THAT HE FELT LIKE HE COULD KEEP HIS SATURATIONS AND HE UNDERSTOOD THE RISKS OF WAITING. THROUGHOUT THE NIGHT LAST NIGHT, UP INTO THE MORNING OF (B)(6) 2022, THE PATIENT HAD SOME TIMES WHERE HIS SATURATIONS DROPPED TO THE UPPER 80'S. AT THE TIME I SPOKE TO HIM, THE PATIENT WAS SATURATING BETWEEN 88%-90%. HE STATED THAT HE DID FEEL SOME BETTER BUT THAT IF THINGS WORSENED THEN HE WOULD UP FOR INTUBATION. APPROXIMATELY 2-3 HOURS AFTER I HAD SEEN HIM, HE DEVELOPED INCREASING WORK OF BREATHING AND ASKED THE NURSE TO CALL ME AND TELL ME THAT HE WAS WILLING TO BE INTUBATED. THE PATIENT WAS TRANSFERRED TO THE INTENSIVE CARE UNIT. THE PATIENT WAS NOTICEABLY MORE SHORT OF BREATH THAN HE HAD BEEN THAT MORNING. WHEN SITTING ON THE SIDE OF THE BED, HE STATED THAT HE WAS HAVING SIGNIFICANT DIFFICULTY BREATHING, WHICH HE DID NOT HAVE THE MORNING I SAW HIM ON THE 14TH. ONCE THE PATIENT WAS SET UP IN THE BED, AS OPPOSED TO ON THE SIDE OF THE BED, HE BEGAN STATING THAT HE WAS HAVING MORE ISSUES AND THAT WE BETTER HURRY UP. THE PATIENT WAS GIVEN A BOLUS OF PROPOFOL FOR SEDATION. AFTER ADEQUATE SEDATION AND BAG/MASK VENTILATION, THE PATIENT WAS GIVEN SUCCINYLCHOLINE BOLUS FOR PARALYTIC TO AID IN INTUBATION. THE PATIENT RECEIVED BAG/MASK VENTILATION UNTIL IT WAS FELT THAT THE PATIENT'S PARALYTIC HAD TIME TO BE EFFECTIVE. THE PATIENT HAD TWO UNSUCCESSFUL ATTEMPTS AT INTUBATION THAT WERE IMMEDIATELY RECOGNIZED, THE FIRST OF WHICH WAS WITH A 7.5 ET TUBE AND 4- MAC DISPOSABLE BLADE. THE PATIENT WAS NOTED TO HAVE A VERY SMALL AIRWAY THAT WAS SWOLLEN. THE CORDS COULD BE VISUALIZED PARTIALLY. I COULD NOT GET A REAL GOOD LOOK AT THE CORDS. A CO2 ADAPTER WAS USED AND NOTED TO NOT HAVE COLOR CHANGE. THE TUBE WAS TAKEN BACK OUT AND WE WENT BACK TO BAG/MAS VENTILATION. THE PATIENT HAD A SECOND ATTEMPT WITH A #4 MILLER BLADE. I STILL COULD NOT VISUALIZE CORDS. THIS ATTEMPT WAS NOTED TO NOT BE IN THE RIGHT SPOT AGAIN AND WAS REMOVED. WE WENT BACK TO BAG/MASK VENTILATION. THE NEXT ATTEMPT WAS MADE WITH A #4-MAC BLADE WITH A BOUGIE. I DID HAVE NURSING LIFT THE PATIENT'S HEAD, WHICH DID BRING HIS CORDS MORE POSTERIOR AND ALLOWED ME TO INSERT A BOUGIE. FOLLOWING THAT, I PLACED A #7.5 ET TUBE ACROSS THIS BOUGIE WITH GOOD CHANGE ON HIS COLORIMETER. THE PATIENT RECEIVED BAG/MASK VENTILATION WITH INCREASING SATURATIONS. THE PATIENT DID HAVE PRECIPITOUS DROP IN HIS SATURATIONS WHEN HE WAS TAKEN FROM 100% 11% NONEBREATHER AND HIGH FLOW JUST OVER TO BAG/ VENTILATION. THE PATIENT THEN WAS BAGGED UNTIL HIS SATURATIONS WERE INTO THE 80'S. WE ATTEMPTED TO PLACE THE PATIENT OVER ONTO THE VENTILATOR. HOWEVER, WE HAD LOSS OF TIDAL VOLUME, ESSENTIALLY REGISTERING ZERO. THERE WAS AN AIR LEAK NOTED AROUND THAT. WE TRIED FILLING UP THE BALLOON AT THE END OF HIS ET TUBE WITHOUT BEING ABLE TO MAINTAIN THAT PRESSURE AS IT WOULD CONTINUOUSLY LEAK OFF. I FELT AT THAT TIME THAT THIS WAS A SITUATION WHERE THE ET TUBE WAS MALFUNCTIONING DESPITE HAVING BEEN TESTED BEFORE PLACEMENT. I INSERTED THE BOUGIE THROUGH THE TUBE AND CHANGED OUT TO A #8-0 ET TUBE, AFTER A REPAIR KIT DID NOT CORRECT THAT. AFTER THE #8-0 ET TUBE WAS PLACED, THE PATIENT HAD GOOD END TIDAL CO2 BASED ON THE MONITOR. WE WOULD GET INTERMITTENT SATURATIONS IN THE 80'S BUT WAS HAVING DIFFICULTY WITH PERFUSION. INITIALLY, THE PATIENT HAD FAIR BLOOD PRESSURE BUT THEN THIS DROPPED QUICKLY. THE PATIENT WAS PLACED ON THE VENTILATOR AND ESSENTIALLY HAD NO VOLUMES. WE WENT BACK TO BAG/MASK VENTILATION AND WAS ABLE TO GET GOOD END TIDAL OF CO2. SATURATIONS THAT WERE MAINTAINING, DEPENDING ON HOW WELL IT WAS PICKING UP OFF AND ON. THE PATIENT DEVELOPED AN EPISODE OF BRADYCARDIA AND HYPOTENSION THAT EVENTUALLY LED TO A CODE 300. THE PATIENT HAD A PROLONGED CODE 300 INITIALLY WITH COMPRESSIONS, IV EPINEPHRINE AND THEN EVENTUALLY AN EPINEPHRINE DRIP. THE PATIENT HAD REGAINED HIS PULSE BUT HAD SIGNIFICANT ACTIVE ECTOPY WITH ST SEGMENT ELEVATION NOTED ON THE MONITOR. AN EKG DONE DURING THAT TIME SHOWED SIGNIFICANT ST SEGMENT ELEVATIONS IN ANTERIOR LEADS, AS WELL AS SIGNIFICANT ST DEPRESSION IN INFERIOR LEADS. THE PATIENT THEN LOST HIS PULSE AGAIN. WE STARTED BACK WITH STANDARD ACLS PROTOCOL. WE LOST HIS PULSE DESPITE BEING ON AN EPINEPHRINE DRIP AT CODE LEVEL. THE PATIENT WAS ALSO PLACED ON DOPAMINE SECONDARY TO HYPOTENSION. EFFORTS TO RESTART THE PATIENT'S PULSE WERE UNSUCCESSFUL WITH SECOND CODE 300. THE PATIENT'S FAMILY WERE MAINTAINED ON THE PHONE WITH NURSING. I SPOKE TO THEM TWICE, ONCE AFTER THE FIRST CODE AND THEN AFTER THE PATIENT HAD EXPIRED. THE PATIENT'S FAMILY WERE THANKFUL FOR CARE BUT UNDERSTANDABLY VERY SAD. I EXPLAINED TO THEM THAT THEY ARE WELCOME TO COME TO THE HOSPITAL TO BE WITH HIM AND THEY ARE DECIDING ON THAT AND THE WILL LET THE CHARGE NURSE IN THE INTENSIVE CARE UNIT KNOW.