Me, the Boy, His Ribs and the Forceps

Jenny Blair, M.D.
August 28, 2005

Ask not for whom the beeper beeps.

It beeped for me during the wee hours of a night shift. During my flight-doc months in the emergency room, I am on call for ambulance and helicopter transfers. This one, in bad weather, would be by ambulance.

We didn't have much information: 15 years old, asthma attack. Came in unresponsive, so sick that the ER doc at McCurry Hospital intubated him to take over the work of breathing. One of his stiff lungs sprang a leak when he was attached to a ventilator. The air lodged in the pleural sac, the normally empty space between his lung and the chest wall. This is called a pneumothorax and it can be deadly even in healthy people. The ER doc was now placing a tube under his armpit to try to evacuate that air. The boy needed an intensive-care unit and we would be bringing him to ours.

I pondered these things on the half-hour drive through the night. Mina, the seasoned flight nurse, curled up on the bench in the back of the ambulance, trying to get some sleep before we arrived, while I sat with my back to the driver, shining a penlight over my pocket critical-care book. Asthma. Oxygen, albuterol, epinephrine, magnesium. Check the blood oxygen saturation. Intubated? I went over the settings one would need to dial in the mechanical ventilator to accommodate the stiff lungs of an asthmatic. I thought my way through the steps of chest-tube placement, just in case the McCurry doc met with problems.

And I breathed: slowly, deliberately, as calmly as I could.

Breathing serves two purposes: It brings in oxygen and dumps carbon dioxide. Asthmatics can have trouble dumping carbon dioxide. Its buildup makes their blood acidic, which brings its own set of problems.

Mina and I and the pilot rolled our litter into the McCurry ER. My patient lay unconscious, sedated, a mercy since down his throat was a breathing tube and between his ribs was a chest tube. A nurse was "bagging" him - pumping air into his lungs by hand.

I took stock. He had scant breath sounds on the side of his pneumothorax. X-rays confirmed the air collection was still present, though smaller than before the chest tube was placed. He'd gotten the usual treatments. His oxygen saturation was 92 percent, not so good. His blood pH was 6.99, no better, the ER doc told me, than when he'd first arrived. His carbon dioxide level was 110. The body normally keeps that level between 35 and 45. Near-fatal asthma occurs over 50.

Normal blood pH is 7.4. 7.2 makes me nervous and 7.0 means something had better be done right now. Below 7, in my limited experience - well, that was unheard-of. And this was after he'd gotten treatment. Evidently, we were running to stand still.

Yet, there were things that could be done. I ordered magnesium, a very effective asthma drug. I added an antibiotic. I asked the nurses to place an orogastric tube, since his stomach was distended by the air that had been blown into his mouth. As per routine, I phoned medical control - the attending physician at home base - and apprised him of the situation. I talked to the doctor in the pediatric intensive-care unit, too, who suggested that, since he still had a pneumothorax, a second chest tube was something to consider. I ordered another pH, hoping to see an improvement.

pH: 6.78. CO2: 130.

Unthinkable. No-man's land. At that pH, in a few minutes, the even heart tracing would flutter to berserk. Formerly steady beeps would become shrill alarms. I couldn't put him on the ambulance. It would happen before we made it out of the parking lot. This kid was about to die.

The nurses looked at me. The boy's mother stood there, waiting. I switched off my hesitation and told them the plan. Chest tube it was.

"I need size 61/2 gloves. Betadyne. I need a 20-French chest tube and a kit. Scalpel. Vaseline gauze?" Bit by bit, the equipment arrived, piled onto a tray. Though part of me, through long habit, waited for a prompt, nobody prompted me. When it was time to start, we started.

I scrubbed the boy's armpit with iodine. I draped him with sterile towels and the flight nurse and I gloved up. At her request, I let her begin the procedure. She'd trained to do this, but had never done it before. "Go ahead and make your incision," I told her after we'd located the right spot. She hesitated, as would anyone before doing something as audacious as slicing into a living human being. "Go ahead," I urged her, "don't be shy. You won't hit anything vital here." She made the incision and carefully burrowed through the chest wall to the ribs. Then I took over.

My job now was to use blunt forceps to force my way between the ribs and into the pleura with its contained air that prevented lung expansion. The heart lay under my forceps as well. It would be disastrous to lose control while pushing. But I'd done enough of these that I trusted myself not to let that happen.

Time stopped. The entire world consisted of me, the boy's ribs and the forceps. I pushed and prodded. The room was silent.

Finally I popped through. My finger touched his pleural sac. Mina handed me the chest tube. With some difficulty I threaded it past my finger into the pleural space, then pushed it in.

A rush of air and a little blood sputtered out the other end of the tube. This was it, or so I hoped. Hastily I called for sutures. My hands shook; I bent needle after needle, but eventually the tube was fixed in place. We connected it to a vacuum apparatus.

"Let's get another blood gas," I said. A few minutes later: the miracle. pH 6.99, CO2 112.

I could hardly believe my eyes. I asked the staff to load him onto the litter and called medical control to give them the good news. Even better, I learned we'd be in the PICU in minutes: The weather had improved and the helicopter was on its way. In no time, we were airborne. I rhythmically squeezed the bag that delivered air to his lungs, ignoring the lurching of the aircraft and the city dawn, forgetting my usual nervousness at being airborne.

Soon we arrived, Mina and I and our charge, with his IV, bladder catheter, endotracheal tube, orogastric tube and two chest tubes. And - through some combination of predisposition, everyone's skills and good luck - his life. The PICU fellow spotted us as we rolled off the elevator. "Corner pocket," she said cheerfully, indicating his room.

A few days and phone calls later, I went up to see him. He could breathe on his own now, so he'd been extubated the day before and they'd pulled out the chest tubes he no longer needed.

His mother hailed me. She told him who I was.

He was small, built like a prize fighter. He sat on the edge of his bed, legs dangling, connected only by IV and heart-monitor stickers to the equipment around him. He had dark, curly hair and an intense gaze.

What do you say? "How are you doing?" "You gave me quite a scare." "I'm glad to see you looking so much better." I said them.

John kept it simple and merely thanked me. His mother chatted with us for a minute. As I left, I thanked him back, which probably confused both of us. I'd wanted to learn what he was like, what kind of person he was, because all I knew about him was his pH and the look of his epiglottis and the way his lung felt under my finger. I knew him better than he knew himself, but I didn't know him at all. Somehow there was no way to ask.

"You should definitely take the opportunity to get to know him. It's a unique connection the two of you share," a friend wrote me in an e-mail. Yet, though I'm

curious about John, I don't agree. He's 15. This episode should not take on disproportionate importance in his life. I don't want to remind him of his own

vulnerability.

I'm the one who can never forget him or what he gave me: the knowledge that I can be effective, that I'm not just a harmless presence in the world at best and a drain on its resources at worst.

After growing up with every privilege, I'd yearned for another kind altogether, that of being useful. I worshipped know-how and clear thinking. I have always wanted to enter a bad situation and turn it around. Meeting him was a kind of culmination. This, at last, was why I went to medical school. That is why I thanked John. I don't think I'm smug about doing what I did. It's just that I can't believe I got to.

Copyright 2005, Hartford Courant