Monday, June 30, 2008

This is a Dangeous Place

Mrs. Smith, in good health in her early seventies, was working in her garden at home when she was bitten in the arm by a rattlesnake. She used her shovel to chop it up into several pieces and brought it with her to the hospital. Someone it the ER identified it as a diamondback rattlesnake and an urgent call for anti-venom was sent out. Diamondbacks are extremely rare in this area, and the needed doses of anti-venom had to come from several different places. To administer the anti-venom a subclavian central line was inserted. This is a large IV that is inserted into the subclavian vein which runs beneath the clavicles towards the heart. As soon as central access was obtained, the anti-venom was started. Mrs. Smith immediately developed respiratory distress and was intubated (placed on mechanical ventilation) to protect her airway. She was then sent to the Medicine ICU, where I received her, for management of a suspected anaphylactic reaction to the anti-venom.

I had never cared for snakebite before and did not know what to expect. There did not seem to be much to be concerned about. Mrs. Smith’s arm was a little red and not particularly swollen. Although she was not able to speak with the breathing tube in her throat, she was clearly very awake and aware of her surroundings. She nodded appropriately in answer to questions and her eyes expressed calmness and understanding.

A chest X-ray had been taken shortly after Mrs. Smith’s arrival and within an hour or two the resident read it and came to her room to tell me that she had a pneumothorax. During the placement of the central line, the doctor had accidentally punctured her lung with the insertion needle. Her left lung had collapsed like a punctured balloon. Mrs. Smith now needed a chest-tube. Perhaps she had not had a reaction to the anti-venom at all.

The thoracic surgeon who came to insert the chest tube was calm and unhurried. It is a simple, low risk procedure and Mrs. Smith was quite stable and already on the vent. I stayed in the room to observe and assist. After administering lidocaine to numb the area, the surgeon began with an incision in her left flank. “Okay sweetie, this is gong to be the worst part,” she said as she made a hole, widened it and inserted the flexible plastic tube. Mrs. Smith winced. “Okay, this will be the worst part,” said the surgeon as she advanced the tube further into Mrs. Smith’s chest. Mrs. Smith winced again. “Okay, this is going to be the worst part,” said the surgeon, authoritatively, as she gave the tube one final push into Mrs. Smith’s lung cavity. A look of distress came to Mrs. Smith’s face, as if her breath had just been taken away. The surgeon reassured her, “I know that feels very strange sweetie, but that is the feeling of your lung re-inflating. It is a good thing. The surgeon finished up with a stitch or two. I attached the other end of the tube to a drain and attached the drain to a wall suction unit with a clear plastic hose.

The next day during physician rounds one of the residents was suspicious. He had done is internship in Texas and had seen diamondback bites before. Mrs. Smith’s arm should have been extremely swollen. She should have been much sicker. The story about the snake seemed wrong also. Diamondback’s tend to give warning before they strike and this snake had bitten without giving warning. The resident found pictures of timber rattlesnakes, much less poisonous and much more common in our area, and showed them to Mrs. Smith and to her family. They could not remember the snake very well, but seemed to confirm the resident’s suspicions. The body of the snake had been disposed of at the other hospital.

The doctors discussed what to do. Since they did not have the body of the snake and could not make a conclusive identification, and since Mrs. Smith was not being harmed by the diamondback anti-venom, the doctors decided to give the remaining two doses and leave it at that. If everything went well for Mrs. Smith and she did not develop a pneumonia or get an infection, it would take her a week or so to get off of the ventilator and get the chest tube out.

Poor Mrs. Smith - if she has stayed home all she would have had to deal with would have been a sore arm. She came to the hospital and we punctured her lung, gave her the wrong medicine, and put her on mechanical ventilation – all without so much as an ‘excuse me.’ I am sure she was grateful for the excellent care she received. I hope her insurance paid the bill. It must have been over a hundred thousand dollars. Oh yes, hospitals are dangerous places.

1 comment:

Devadeva Mirel said...

damned if you don't...even more damned if you do!!!