Ubuntu #3 The Michelin Man: The case of a ruptured bulla
Author: Dr Kylen Swartzberg | Editor: Dr Kat Evans
The Case: Presented in real time
Friday Night, Ubuntu Emergency Department.
21:15 – 53 year old male patient rushed into triage in a wheelchair by his panic stricken wife. She shouts to the triage nurse that her husband’s lips & face started swelling up 10 minutes ago whilst at a braai & states he is allergic to Penicillin.
Two ED doctors happen to be walking past during the exchange & notice the swollen face & air-hungry patient. They grab the wheel chair & rush into the resus bay activating the resus alarm.
21:16 – Whilst one doctor & nurse move the 100Kg looking patient onto the bed & start face mask O2, the other doctor administers 0.5mg adrenaline IM in the right thigh. The next dose is drawn up & kept aside.
21:17 – Further colleagues have arrived & lines are prepared. The patient is only able to speak 2 words per breath. The first line is up in the right cubital fossa & hydrocortisone & promethazine are given IV.
21:18 – Monitors are being connected & whilst the 2nd IV line is being inserted, one of the doctors exclaims that there is a lot of crepitus in the arm & hand. The doctor speaking to the patient & adjusting the face mask also notices that there is diffuse crepitus of the entire face & scalp.
21:19 – The senior doctor asks the patient if he smokes? With a deep breath & a raspy voice he says ‘yes’. The senior excitedly proclaims that she knows what this is & that she has seen this once before…..
21:20 – Whilst the BP cuff is inflating the seconds of suspense feel like a TV game show taking an ad break. “It’s a ruptured bulla!” There is a brief sigh of relief as anaphylaxis is shifted off the working diagnosis. The vitals monitor beeps in 200/110. (Due to the IM adrenalin & subcutaneous emphysema) Saturation on non-rebreather mask is 92%.
21:21 – The senior directs preparation for a definitive airway due to extensive upper airway & neck subcutaneous oedema as well as bilateral IC drains. (Xrays will take too long & due to diffuse subcutaneous emphysema, from scalp to inguinal ligaments, ultrasound lung evaluation is not currently of use).
21:23 – The patient reports worsening difficulty in breathing. Induction agent & muscle relaxant given.
21:24 – A difficult airway is anticipated. The most senior doctor is ready with laryngoscope in hand. Video laryngoscopy is at the bed side as backup. ET tube goes in, in seconds. The team member who assisted with external laryngeal manipulation keeps his finger on carotid pulse.
21:25 – No pulse is felt. A wide eyed medical student begins chest compressions. Bilateral finger thorocostomies are done simultaneously by a doctor on each side. Air gushes out of the right thorocostomy incision. The first paddle check is done after about 15 seconds of compressions & completion of thorocostomies. An organized rhythm & a palpable central pulse.
21:26 – The now haemodynamically stable patient is seated at 45 degrees. X-rays are on the way, the medical team is notified to prepare an ICU bed. Excitement & team high fives all around.
21:45 – The patient looks 20Kg lighter & his face looks like he is a different person as the subcutaneous emphysema rapidly begins to decompress. “He is beginning to deflate” are the words used on the handover round by the doctor who affectionately dubs this patient ‘The Michelin Man’.
The patient is extubated in ICU during the early hours of the morning & found later that day to be eating a meal. He is only identifiable as he is the only patient in the general medical ward with bilateral chest drains. His face looks entirely different as he has now fully ‘deflated’. He reports feeling great except for having a very painful chest.
Discussion & Learning points:
Bullous lung disease is a spectrum of disease with multiple causes, most commonly smoking 1,2
Patients with bullous emphysema, especially large bullae are at higher risk for pneumothorax 1,3
There are numerous case reports in the literature of ruptured bullous lung disease. So this is definitely a topic to keep in mind when patients with a smoking history or emphysema present with shortness of breath & chest pain.
In this case it was a very different presentation to which normally is the case & given the very brief history of known allergy & facial swelling & breathing difficultly, the possibility of this being anaphylaxis was real & it was a good move to start treatment for it. Besides the increased BP, no obvious harm was done in the process. Possibly an earlier history could have been gained from the wife regarding other conditions & habits.
Always touch your patient. How important was this in this case? The doctor verbalizing to the team what he was feeling was key to triggering the memory of the senior who had just walked in & had not yet had the opportunity to touch the patient.
This leads on to the need for good & clear communication between team members & team leader during a resuscitation. One doctor can not be doing, feeling & seeing everything at once so good communication is vital.
The case also highlights that there are no shortcuts to experience. In other disciplines there can be a monotony of cases but this is obviously not the case in emergency medicine. This forms a major component of why many of us love EM. It may take years to see or experience a specific condition & when that happens, take stock of it, read up about it, take it in & store it. You never know when your single experience will save the life of the next patient or help others learn. There is a dictum that I always rely on: “no effort is wasted”. Even if there are at present no obvious results or rewards, the time will come when the effort pays off.
This case also demonstrates how absolutely crucial it is for the entire team to be engaged. Every one doing their part to make the whole come together. All aspects of the resus were happening in parallel. Oxygen, lines, drug prep, IC drain prep. As well as anticipating the course of disease/events. The anticipation of the possibility of airway compromise, the possibility of the airway being difficult, the anticipation that when PPV was started IC drains were not yet ready, so staff at the ready to perform finger thoracostomies.
Things can escalate rapidly here in the ED of the Ubuntu hospital and when working as a team, lives are saved on a daily basis.
Edited by: Dr Kat Evans
Author: Dr Kylen Swartzberg
Emergency Medicine Registrar – Johannesburg, South Africa
Passion for all things emergency medicine, teaching & sharing of knowledge.
A love for the outdoors and scuba diving.