I'll March My Band Out...

So, sometimes you have to toot your own horn.



There's a lot of little victories we win from day to day.  They can be as simple as making it out of bed in the morning, to not losing it when the coffee girl gets it wrong again, to saving a life and being the hero.  Of course, in Emergency Medicine, you save a life and then go on to the cough, runny nose, year long history of headache suddenly worse tonight... there's no fanfare, no applause, no big Broadway number. And, we're ok with that.

But, sometimes... just sometimes you want to yell from the rooftops, "Hey! World! Look at what I did today!" So that's what I'm doing with two stories from the E.D. No congratulatory applause needed, but statues in my honor will be accepted.

Just a note, this is going to run a little longer than my usual posts so you might want to grab a cool beverage.  Champagne toast in my honor... aww... now you're making me blush...

You know I dread Mondays;  in general, the busiest days in the E.D.  So I was mentally preparing myself and starting the day off with the usual cafeteria fare and a coffee.  It was just before the start of shift, and I ran into the Nursing Supervisor who gave me the head's up that a patient in the ICU was not doing well and might need to be intubated (put on a ventilator). He said he would let me know as sometimes the anesthesiologists handled the intubations, and there should be someone free.

I went back to the E.D. and made sure I had the GlideScope at the ready since typically ICU patients are harder to intubate, and I wanted to make sure I had all my tools ready.  Sure enough, about 10 minutes later I was called to the ICU.  It was explained to me that the patient was very sick from a simple infection gone horribly bad and not only needed to be put on the ventilator but also needed a central line.

The patient was on a CPAP machine that was helping their breathing but was quickly tiring and needed to be put on the ventilator.  A central line is like an IV except it is much bigger and can deliver fluids and medications rapidly.  It's usually placed in one of the larger veins of the neck or just under the collar bone.  Sometimes it's put into the femoral vein in the groin.  We have been putting them into the neck vein using ultrasound so we can visualize the needle going in which is much safer.

So, anyway, the patient is on the CPAP doing ok for the time being, so I decided to do the central line first.  I got all of my equipment in order and the last thing we did was lay the patient flat so it would be easy to put in the central line.  I was dressed in a sterile gown and was just about to insert the needle when the nurse noticed that the patient's oxygen status was dropping.  So we tossed everything off the patient, and I got into intubation mode.

Intubation involves timing medications to relax and paralyze the patient and then using a laryngoscope to lift the jaw and see the vocal cords.  Only when I took my first look there was nothing to see.  I adjusted the scope and looked again, still nothing.  Understand that while this is going on the patient is not getting oxygen to their lungs and this patient had no reserve and starting dropping their saturations again.  I pulled out and we "bagged" the patient to get their oxygen saturation back up again, and I grabbed the GlideScope which I had brought with me, thankfully, from the E.D.

I got back into position and took a look with the GlideScope... nothing... Everyone's eyes were glued to the small screen.  I made a few adjustments and suddenly there were the vocal cords!  I think we had all been holding our collective breaths about that time, but suddenly it was the like that cave scene in "Raiders of the Lost Ark" where all the walls start to collapse around you.  I quickly put the endotracheal tube in and watched in almost horror as the tube pushed the vocal cords further and further away.  I had the EMT standing next to me grab the stylet supporting the tube, and I pushed harder.  We all watched the screen as the balloon on the tube slid through the vocal cords, then we let out a breath and got to the business of securing the tube.

Not even catching my own breath, I re-gloved and gowned and quickly put in the central line that I had been working on.  We got the patient's oxygen saturations back up to an acceptable level.  The primary physician ordered antibiotics and fluids now that we had the central line to be able to manage all the different fluids, and I ordered a STAT chest x-ray so that we could confirm placement of the breathing tube.  I grabbed the GlideScope and headed back to the E.D.  An hour had passed, and I would be seeing my first patient... back pain, really?  I think I can handle it.

My second story will be much quicker...  I had just finished intubating a young man involved in a roll-over car crash (who ended up having a brain injury and would be later transferred to a neurosurgeon) when we got the call that three victims of another roll-over car crash were on their way in with one patient also having a head injury.  I quickly reviewed the labs and films on the first victim when the second victim was at the back door.  We got him into the other trauma room, and I repeated all the instructions to my respiratory tech who was getting very familiar with the routine.

Two trauma intubations within 45 minutes of each other.  Two more car crash victims to add to the already full Emergency Department.  Yup, got it.

"I'm gonna live and live NOW!
Get what I want, I know how!
One roll for the whole shebang!
One throw that bell will go clang,
Eye on the target and wham,
One shot, one gun shot and bam!
Listen here, World, here I am... !"