Thread by @IM_Crit_

COVID stories: Elderly pt, C19+, extubated after 2 wks on MV and did well on 8 l NC until next morning, when I came on service. O2sat ⬇️ to 70% 😩with good waveform in the monitor. I had never seen him before; I put my PPE + grabbed the US hoping to make a fancy dx (PTX? PE?) 👇

Bilateral lung US with lung sliding (-> no PTX), thickened/irregular pleurae (-> I guess due to COVID) and multiple B-lines (ddx: COVID, pulm edema) 👇

Echo: LV with good contractility at the base, apex rather hypokinetic, RV OK, no pericardial effusion 👇

It turns out that patient had a working diagnosis of Takotsubo's a few days earlier, so my echo findings were not new. I actually found the cause of his desaturation as soon as I entered the room and without using echo 👇

Just by looking at his face, it was clear that he had vomited and obviously aspirated too ...🤦‍♂️The nasogastric tube had been pulled during extubation the previous night and was never replaced. Do you want to learn what happened next?👇

Per his family's wishes, he was DN-R-I (do-not-re-intubate). We tried for a couple of hours NIV/HFNC with sat in the 70s; he was breathing 50/min. He received a small ketamine dose and a nasogastric tube was re-inserted; it gave back 150 cc of dark fluid on manual+wall suction👇

Several hours later, his O2 sat had improved to high 80s. Then, his nurse reported that when she gave the afternoon pills through the NGT with a bit of water, she felt resistance and the pills just came back from the NGT. A CXR was ordered. What do you suspect we found?👇

The nasogastric tube had been unintentionally placed in the right lung. Was it harmful for the patient?

I think it was not harmful. My theory is that actually the unintended NGT placement in the right lung helped us to suction out much of the gastric fluid that the patient had aspirated in that side! After our discovery, the NGT was replaced and advanced to the stomach this time 👇

The patient gradually improved and after a few days he left the ICU. Against all odds considering how he looked for several hours post aspiration, he actually made it out of the hospital... 👇

Messages:
1. Just by looking at the patient's face can sometimes lead to the correct diagnosis; ultrasound is not always necessary
2. Patients' hospital courses can evolve in mysterious ways