Resuscitation in paradise
With limited resources, you must adapt and overcome
By Robert Donovan
"U.S. Coast Guard! U.S. Coast Guard!" came the urgent call off the coast of a Bahamian island. A 55-year-old woman had run into trouble snorkeling in shallow water and had been dragged, limp and not breathing, onto shore by her best friend.
Sixty miles away in Florida, the Coast Guard was unable to respond rapidly enough, but a nearby boat captain remembered there was an emergency physician on duty on a neighboring private island. He called directly to the Chief of Security on the small Bahamian island just minutes away.
On call at the nearby island, my radio crackled to life: "Island Doctor! Island Doctor!"
I responded immediately and the next thing I knew I was in a speedboat, on my way to the patient with some airway equipment, some epinephrine and an AED in hand. Reports were sketchy: a woman was receiving CPR.
I've always had great respect for those of you in the field, but I was about to be suddenly thrust into your world, emerging on the other side with a heightened appreciation for your ability to deliver expedient medical care in the midst of an uncontrolled environment.
The most terrifying boat ride of my life
It was a slightly breezy and rainy day, and the water was choppy. With our speed up to 45 mph, the bumpy ride took only a few minutes in the capable hands of its captain, and soon I was jumping into waist deep water with my equipment held high.
It would be more correct to say that, observing "scene safety," I jumped carefully, so as to avoid a large and curious stingray that might have wondered what I was doing there. (This is where I would say that I fought off a few sharks too, but that would be an embellishment – although the stingray was real!) I looked to the shore and saw a woman receiving CPR and mouth-to-mouth resuscitation. I feared a dismal outcome for this patient.
Resuscitation and scene management
She turned out to have a faint pulse, so I asked for CPR to be stopped. She was cyanotic. Her breathing was very labored and noisy – she had clearly aspirated salt water and sand. I brushed sand away from her mouth and nose and inserted an LMA. Once it was placed, I applied the BVM and oxygen, working to improve her status enough to transport her back to my clinic.
A few minutes later she began to move her arms, extubating herself in the process. Without an IV or paralytics, I could not re-intubate her, so I applied high flow oxygen per mask and began to organize the volunteers to move her into the boat for transport. With no gurney or backboard on hand, we found a flotation device rimmed with wire that would suit our purpose.
It's wonderful to have so many volunteers in these situations, but with all the excitement and adrenalin flowing, the scene was quite chaotic. I had to slow everyone down enough to safely move the patient. The move from the beach into the speedboat was going to be tricky with a 75 kg, minimally responsive woman, and we would lose style points if we accidentally drop a patient or bang her head on the side of a boat! This was a critical patient and we certainly didn't need to add to her troubles.
There are so many things happening at once, and getting the situation under control is as much a part of our job as administering the correct medical care. I knew I had to get her back to the clinic without delay, stabilize her and arrange for her transport to a Florida trauma center. Minutes counted. That being said, I had to slow the boat captain down on the return trip as I didn't want the patient to get hurt as we bumped and bounced over choppy water.
Improvise, adapt, overcome
Back on the island, activity had been taking place since I had radioed for a few things to be ready at the dock. Fortunately, there were plenty of volunteers there as well. My wife, a registered nurse, knew what I would need and had been busy getting things organized at the clinic.
At the dock, we moved efficiently to get the patient onto a backboard and loaded into a van, the only car on an island where golf carts are the main transportation. All the seats had been removed from the back. We transported her quickly to the clinic. My wife had notified the Island Manager that I would most likely be transporting the patient off the island once she was stabilized, and he got busy arranging for the Coast Guard to pick up the patient via helicopter. It was 4:30 pm – only a few hours until dark. Transports off the island after dark are tricky, because the Bahamians don't allow air traffic after dark in order to prevent drug smuggling.
Caring for the patient
I'm sure you can all speak to how time distorts and moves so slowly, and so quickly, in these critical situations. Here's the clinical picture:
- Labored noisy breathing
- Auscultation revealed diffuse wheezing, prolonged expiration, wet noisy lungs
- Initial O2 saturation 70% on high flow oxygen
- Skin cyanotic, wet and cool to touch
- Tachycardic with adequate pulses
- Minimally responsive to stimuli initially, but improving
In pretty short order we treated her as follows:
- High flow O2 non-rebreather mask
- IV with normal saline
- Albuterol inhaler, multiple doses; no nebulizer available so I gave 5 doses every 10 minutes with inhalation
- Drying and warming measures (using my own heating pad – improvising!)
- Monitoring oxygen saturation levels, which progressively improved
- EKG showed no ischemic changes
- Bedside ultrasound showed good cardiac wall motion
- BP checks: 130/74
Within a 2-hour period, while communicating to various hospitals back in Florida and awaiting the Coast Guard arrival for transport, her clinical picture improved greatly. Her SpO2 level was up to 90%. Her skin color became pink, warm and dry, and her breathing was much easier. Her heart rate came down and her mentation improved – she began to respond appropriately to questions and conversations.
Although she was more alert, she was becoming agitated because she had to urinate. We had no Foley available, so a quick in-and-out cath solved that problem and she was resting comfortably afterward. Since she was improving, I was cautiously optimistic but didn't want to get overly confident.
The Coast Guard helicopter was to arrive at 6:45 pm and was to be a hot load. I was concerned about blankets or sheets being pulled up into the rotors, so as I was thinking out loud, I commented, “If we can't secure the sheets, then I guess she can just be naked.”
To my surprise, she responded by saying, "I don't want to be naked. I'm too fat right now."
That's when my wife looked at me and winked, smiling as she said, "I think she's going to be OK! That's higher reasoning for a woman." So we figured out how to cover her up and still maintain safety.
On a follow-up phone call the next day, I was able to speak with her husband. He said that a CT scan was normal, as were all of the cardiac tests (most likely ultrasound and enzymes). Her lungs were improving, although I suspected she was going to need a bronchoscopy to remove any debris she might have aspirated into her airway.
Drownings are one of the most preventable tragedies of our time. Thousands of people – from infants to adults – die each year, and many who survive the initial event may later die due to the delayed injuries to their lungs, or suffer neurological insults from the hypoxia they encountered. My patient was one of the lucky ones.
One of the things I love about emergency medicine is the surprises and the challenge to stretch us ever further. This experience has given me an all-new appreciation of what you in the field face each day, and my hat is off to you with humble gratitude for making a difference in those first minutes of contact with our mutual patients. Bravo!