Vent mismanagement

Submitted by an emergency physician

I had a classic case last night. I work at a level 2 trauma center and busy county hospital, and admitted an intubated COPD patient to the ICU. Her ventilator was at a rate of 9, because anything higher would cause her to start breath stacking with plateau pressures in the high 30s. PCO2 was about 60, which, looking at her bicarb that’s probably right about where she lives. SpO2 was in the high 90s on 40% FiO2 so there were no issues really with oxygenation. This NP, who apparently is part of the ICU team, comes down and unbeknownst to me, has the respiratory therapist adjust the ventilator to a rate of 15 (!) because the patient had “elevated CO2” despite the pH being normal. Twenty minutes later, the patient starts coding from a tension pneumothorax. I did a quick finger thoracostomy, got her back, put a chest tube in, and fixed to the vent settings. Next pH came back at 7.6 of course but the CO2 was “fixed”. This ICU NP actively tried to kill my patient while she was still in the ER without talking to me even once. Medicine is doomed.