Practical wisdom from Christina Shenvi, MD and Nikki Waller, MD. Want the docs to address a particular question? Write in to lplaster@epmonthly.online.
I took care of a morbidly obese man in his 50s who came in with pneumonia and florid septic shock. I prepared to intubate him with video laryngoscopy, with a bougie available, and did everything I could to optimize positioning. I tried ketamine alone at first, but he clenched his jaw so I had to paralyze him. I tried everything I could but couldn’t intubate him. And then, of course, we couldn’t ventilate him either. Our trauma surgeon happened to be in the department, and I had a nurse call her over to help do a cric. The patient desatted to the teens, and started to brady down. The trauma surgeon got the airway just in time, but it was a long few minutes of watching the sats drop. Now I feel incredibly anxious about airways. Also I’m waking up at night worrying about it, feeling like I should have been able to intubate him, and worrying that he could have a hypoxic brain injury because of my delay. What can I do to get over this?
Our job is a hard one – it takes a high toll on us emotionally and physically. You brought up one of the toughest situations we face. We are the crashing airway experts in the hospital. So how do we feel when we can’t get a crashing airway? Like crap. As you’ve found out, it haunts us day and night, and can affect our mood when we’re seeing patients for weeks as well as our confidence level when dealing with future difficult airways. How can we get out of the airway nightmare PTSD? There is no magic trick. But here are some things that have helped me. First off, talk through the case with another emergency physician who wasn’t involved. This could be a colleague at your institution or another, a friend from residency, or even your old program director. It’s helpful if it is an ER doc. It’s likely your non-medical friends or significant other won’t understand the stress involved, and certainly won’t be able to think through your medication and instrument choices. It sounds like you were well prepared and had thought through the potential difficulties with backup plans at the ready. Having another ER doctor listen to your story and validate you can go a long way towards alleviating your airway anxiety.
Another thing that may help is talking it through with someone who was involved, someone who was there experiencing a lot of the same things you were. This might be the trauma surgeon who stepped in, if you have a good working relationship with her. They may even have some insight or validation as to how the case went from their point of view that could help you move on.
Most of all, though, these cases take time to get over and to regain our confidence. If you find you are particularly anxious about airways, taking one of the national difficult airway courses may help you gain even more expertise and confidence so that you feel more prepared to handle whatever rolls in the door your next shift.
I recently posted a patient picture on a Facebook group, and someone reported it to my institution. Now I’m getting investigated by our HIPAA compliance office. The picture I posted was before and after shots of an impressive arm laceration I repaired. I didn’t post any patient identifiers or any facial features. Since it was not identifiable, I didn’t ask for the patient’s consent. What gives? I thought HIPAA only matters if it’s protected health information. Why would someone report this?
Online Facebook forums such as EM Docs and Physician Moms Group have become major virtual doctors’ lounges to discuss cases, get advice, and vent about frustrations. However, they are essentially public forums, since anything online can be copied and sent, as you have found, to your department chair or your security/privacy office. HIPAA violations are one of the things that can get you fired faster than almost anything else. The rules are there for obvious reasons: protecting patients. However, the devil is in the details when it comes to what can and cannot be posted. A 2013 study of State Medical Boards found that 73% would investigate a physician for posts depicting intoxication and 40% would investigate posts involving alcohol without signs of intoxication (Greysen 2013)! All that to say, what is posted online is not private, and if reported will frequently lead to an investigation.
As a reminder of the actual HIPAA guidelines, according to 45 C.F.R. 164.502(d)(2), de-identified information is not subject to HIPAA regulations. To really understand what is deemed de-identified, familiarize yourself with rules under § 164.514(a) and (b) and read about the regulations on www.hhs.gov.
There are a couple points to keep in mind: First, just because you are being investigated does not mean anything will come of it. If you stayed within the HIPAA rules and your institution’s social media or privacy rules, then you should be ok. The office likely has to investigate anything and everything that is submitted to make sure there wasn’t a violation. Second, the individual who reported you likely thinks they are doing the right thing. One of the stipulations of HIPAA is that you have to not only refrain from violating the rules, but you are required to report any breaches of privacy that you are aware of! So while it’s possible the person who reported you has a personal vendetta and is out to get you fired, it’s more likely they thought they were fulfilling their duty.
Moving forward, be sure to learn about what your institution permits. Most large hospitals or academic centers will have social media offices and policies. Find out what is allowed under that and under HIPAA so that you don’t have to worry about future posts.
3 Comments
Morbidly obese male in his 50’s. Difficult to intubate! You did the best anyone can do! Finally resorted to surgical airway. Doesn’t the patient have to take some responsibility for making his medical care impossible to deliver?
We are responsible for the last 30 minutes of a human’s life, after they have wrecked their life for the last 30 years.
Only advice I can give, being that I have been in this scenario way too many times, always carry a number 10 scalpel with you.
Arriving alive and talking, but then trying to die in the ER because the MD cannot perform the needed procedure is the scenario. Yes, it can shatter confidence in one’s abilities. I would refer you to Literature Update 2015, Part 1 by Edward Panacek, M.D., regarding a alternate pathways before doing a surgical airway that has difficult landmarks and presents a operator expertise problem as well. LMA, King Combitube, and digital intubation on a airway that is not “juicy” are options that buy time on these patients. Sometimes.
Reference audiodigest.org Emergency Medicine Volume 32, issue 17, September 7, 2015. Also referred to as “topics that will change your practice, part 1.”