Chapter 271

Episode 271. Drowning (2)

“Patient from a drowning incident is coming. For now, let's set up according to that.”

As I informed them of the characteristics of the patient who would soon enter and ordered the setup, the Ambulance crew, Nurse, and Interns busily Started coming into motion.

'They said the Patient's ROSC (*Return of Spontaneous Circulation) was achieved once.'

In the case of a typical cardiac arrest patient, there is sufficient residual oxygen in the blood immediately after collapsing. Therefore, rather than securing the Airway on-scene or in the early stages at the Emergency Room, it is more advantageous to strongly maintain chest compressions focused on resuscitation to make the stopped Heart beat again. That is why the general public is not taught artificial respiration these days.

However, in a drowning Patient, severe asphyxial hypoxia caused by water filling the lungs is the most fundamental Cause and preceding mechanism that stopped the Heart. Therefore, the Airway must be secured early as the highest priority.

“For now, please pull out the endotracheal intubation kit.”

At my Words, a Nurse who was organizing something in the corner hurriedly raised her Head and answered.

“Ah, Yes! Understood!”

“Since we might have to do RSI (*Rapid Sequence Intubation), please check the medication in advance too.”

“Yes~!”

I turned on the window in the Void.

[Dead Medic Gallery]

Hell Slave ER Return

Author: Korean Slave 1 (Male)

For now, it's a drowning patient.

Yeah.

[Comments]

Mes of the God (Male): Simple drowning?

ㄴ Korean Slave 1 (Male): Probably so

ㄴ Mes of the God (Male): If so, there's nothing to help with.

ㅇㅇ (121.131): ? Since he has to do an intubation, shouldn't we help Hell Slave, who is a living doctor? The intubation could be difficult.

ㄴ Latte is Mine: You newbie….

ㄴ Cardiology Ghost: You newbie….

ㄴ Rheumatology Old Woman: You newly arrived quack….

'Hmm, looks like another newbie came.'

Since I am treated among the Gallery members as just about "living doctor 1 who is good at airway," that gallery member who doesn't know my few strengths is highly likely to be a newbie. For now, putting that aside.

Latte is Mine: Hell Slave, you know that for a drowning patient, you have to smash through resuscitation for even a few hours, right?

'There's no way I don't know that.'

ㄴ Korean Slave 1 (Male): Yeah

For a typical cardiac arrest patient, if there is no response to CPR for more than 30 to 40 minutes, a declaration of death is made on-scene or in the Emergency Room. However, if it's a drowning Patient in a state of cardiac arrest accompanied by severe hypothermia….

'It doesn't matter if you perform resuscitation for a longer time.'

Because the cold body temperature drastically lowers the metabolic Demand of brain cells, producing a protective effect on the brain. In other words, it's a similar feeling to a kind of TTM (*Targeted Temperature Management), though the cause-and-effect relationship is different.

According to the principle that a patient is not medically dead until their core body temperature becomes warm, a hasty declaration of death must never be made until the core body temperature is restored to at least 30 to 32 degrees. Well, even if it means running an extracorporeal circulator, resuscitation must be done, so it consumes a lot of resources, but….

'Even so, it's better if we can just increase the probability of saving them.'

It was at that Moment.

Aeeeeeeng-

From far Outside the Emergency Room automatic doors, the loud sound of a Siren Started to be heard.

“Looks like they're here.”

Leaving the Intern with a tense Face behind me, I stepped toward the entrance of the Resusc in advance and held the Automatic Door open.

Ziiing-

“Patient incoming!”

“Yes, to Resusc Room 1!”

At my guidance, the paramedics Started pushing the Stretcher carrying the patient straight into Resusc Room 1.

Drrrrck-

“Moving the patient, one, two, three!”

Swwish-

“BP 90 over 60, pulse 55, and respiratory rate is 12. We came while squeezing oxygen with a bag-valve mask. Temperature is 32.5 degrees!”

“Yes, good work!”

The Patient was now completely moved to the Hospital. Since the 119 paramedics Safely made the Heart that had once stopped beat again and brought them here, sending them out alive is now our responsibility.

Ding-

Ding-

“Han-ssi!”

“Why?”

At Baek Eunseo (Female)'s Shout, I raised my Head.

“Oxygen saturation is showing 82!”

I turned my Head just like that and looked at the Vital Signs Monitor.

[SpO2: 82%]

The oxygen saturation of a normal adult is 95 to 99. Definitely an abnormal figure. The Patient is in a coma with almost no Consciousness, and is not receiving oxygen properly.

“Showing signs of irreversible oxygenation failure, so we will perform RSI (*Rapid Sequence Intubation).”

At my intubation declaration, the nurses Started moving to gather the medications and the endotracheal intubation kit.

“Give Etomidate 20 and Rocuronium 80.”

“Yes!”

At my verbal order, the Nurse injected the medications she had hurriedly prepared.

After 1 Minute passed like that. At the point when all the patient's muscles would be relaxed. I Started the endotracheal intubation.

“Give me the Laryngoscope.”

“Yes, yes!”

'The blade….'

I insert the Laryngoscope's Macintosh No. 4 blade deeply into the Mouth. And….

'Epiglottis….'

The epiglottis is lifted, and the vocal cords are exposed.

'Right now… Okay.'

Found it.

“Give me the Tube. 7.5 millimeters.”

“Yes.”

The 7.5mm endotracheal tube is accurately inserted into the Airway, inflating the balloon to completely isolate the Airway.

“Intubation is done. Auscultation check….”

Suddenly, through the opening of the Patient's endotracheal tube that had just been inserted, pink, sticky foam like shampoo bubbles continuously Started to push up to the Outside.

“Uh, Teacher!”

An Intern called me with a panicked Expression.

“Th-that, we need to suction….”

“No, no. Give me that gauze instead.”

I stopped him and took the gauze from the Nurse. If the medical staff here gets obsessed only with repeatedly inserting and removing a plastic suction tip deep into the bronchi to pull all this foam out and clear it cleanly, what happens? A variable occurs where the actual mechanical ventilation Time to blow oxygen into the lungs is critically delayed. Then, the effort spent wiping that foam or whatever becomes completely useless.

'So, I have to ignore this kind of variable as much as possible.'

The foam rising from the lungs is not foreign matter from the Stomach, but a pathophysiological product made by destroyed surfactant and plasma proteins mixing with water. Therefore, wasting precious resuscitation Time to suction this kind of stuff? Then they die.

“Yes, give me some more gauze.”

I lightly wiped away only the large foreign matter around the Tube once and then connected the ventilator.

“Hmm… For now, just a moment.”

I turned on the blue window in the Void.

Korean Slave 1 (Male): Asking a question about vent (*ventilator) setup.

ㄴ Latte is Mine: What do you need?

ㄴ Hippocrates' Descendant: The settings of a ventilator can be said to be considerably important, living doctor!

'Old man Hippo is saying obvious things again.'

ㄴ Korean Slave 1 (Male): I'm thinking of giving a strong PEEP (*Positive End-Expiratory Pressure) of around 10 to 15, is that okay? Is this right?

What I am thinking of is this. In the ventilator settings, the positive end-expiratory pressure value is intentionally set very high, around 10 to 15 cmH2O, to leave strong pressure in the lungs even when exhaling. Then, those numerous bubbles will be pushed back by physical Air pressure. That way, it will help force open the collapsed alveoli to maintain the surface area where oxygen can pass into the blood. So, I wanted to get confirmation from the ghosts.

First, without waiting for the ghosts' answers, I adjusted the rest of the ventilator settings.

“Set it to V-AC mode.”

Since the Patient has no spontaneous breathing effort, for now, we let the Machine do the breathing.

“Tidal volume is… Hmm, let's go with around 420.”

Keep the ventilation volume as low as possible. The lungs, which have decreased in volume due to being filled with water, must not suffer pressure damage from tearing under high pressure.

Just then, an Intern kicked open the door to the Resusc and ran in.

“ABGA (*Arterial Blood Gas Analysis) results are out!”

ABGA. It's essential to Check what state a cardiac arrest patient is in.

“Give it here.”

Slap-

I took the paper just like that. Before I knew it, Baek Eunseo (Female) had come to my Side, poking her Head out and checking the paper.

“Eunseo.”

“Ah, Yes.”

“Nasogastric tube, please.”

At my Words, Baek Eunseo (Female) wore an expression of realization and hurriedly returned to her previous spot to start issuing orders.

“Please prepare an L-tube (*nasogastric tube) with a 16 French. Let's, for now, drain the water first.”

If they were floundering and drowning, a swallowing reflex would have occurred unconsciously. A large amount of water would have accumulated in the Stomach. Trying to pull that out.

I turned my Head and focused back on the ABGA result sheet.

“Hmm… For now, there's academia, respiratory acidosis. It even reached metabolic acidosis.”

“Temperature is 32.5 degrees!”

A Nurse shouted hurriedly. Still 32.5 degrees.

'This isn't good.'

Moderate hypothermia, where the probability of ventricular fibrillation—a type of arrhythmia—occurring is extremely high. If the Heart stops again here, there is no answer.

“Let's rewarm.”

Before I knew it, the Patient's Clothes had been cut off and replaced with a patient gown.

“…That was fast.”

“I did it.”

As expected of the chief veteran, Nurse Jung. I swallowed those thoughts inwardly and opened my Mouth.

“Turn on the Bear Hugger (*forced-air warming blanket). And cover with the pads….”

The warm 38-degree Air generated by the equipment travels along the Patient's entire body, raising the temperature. And….

“Catch a C-line and let's use a warmer to give warm saline.”

Warm up the IV fluids administered through the veins to raise the internal body temperature as well. Let's just get them warm first.

…

After about 15 minutes passed.

[ BP 100/60 mmHg ]

[ HR 68/min ]

[ SpO2 92% ]

“The vitals are quite decent.”

“The core temperature has also risen by 1 degree to 33.5 degrees.”

I called Baek Eunseo (Female) to ask about Hospitalization.

“Eunseo?”

Baek Eunseo (Female), who had just put down the call phone, came running over.

“Yes.”

“What did Internal Medicine say?”

“For now, they said to move the patient quickly to the MICU. But there are no beds, so….”

“We have to play Tetris.”

Tetris. Because there are no beds, a patient in relatively better condition is sent to a general ward a Day earlier, and the more critical patient is moved up.

“Yes… probably so.”

“Let's wait for a bit first.”

…

…

Ding-

Ding-

Beep-

Exactly 15 minutes after judging that the condition had improved.

“Ah, shit….”

The Patient's condition, which seemed to temporarily stabilize in response to initial resuscitation and mechanical ventilation, Started to rapidly collapse.

Thanks to the warming therapy implemented earlier, the core temperature quickly rose to 33.8 degrees. That part was all well and good…. But as it rose rapidly and the systemic peripheral blood vessels expanded, vasoplegic rewarming Shock occurred, where the central Blood flow rapidly drained to the periphery.

[ BP 75/40mmHg ]

[ HR 45/min ]

[ SpO2 77% ]

“Norepin is going in correctly, right?”

To defend against hemodynamic instability, we gave norepinephrine, a vasopressor. However….

“The BP isn't rising.”

Whether due to the damaged myocardium or the dilated peripheral blood vessels, the blood pressure response was minimal. I scratched my Head. Damn it. What do I do?

'…Ha, that way, there's no other choice.'

I soon made up my mind firmly and opened my Mouth.

“…Let's put them on ECMO. Call Thoracic Surgery.”

“Ah… Yes, understood.”

Hearing my Words, Baek Eunseo (Female) grabbed the call phone again and Started to place a call to Thoracic Surgery. Refractory hypoxia that completely exceeded the limits of a ventilator, and an impending secondary cardiac arrest. To block this, ECMO is the only way….

“The ECMO team went to the ICU, and they say Thoracic Surgery currently only has a 1st-year on-duty doctor!”

Freeze. At those Words, I momentarily stopped what I was doing and slowly turned back toward Baek Eunseo (Female).

“…Uh?”