G is for Grrr

On a trip and I can't connect to wifi and my personal hotspot on my phone won't work either.  Going to be in a hotel tomorrow so I should have a real post then...

Until then, enjoy this oldie from today's date in 2008 while I was still in residency:
And technically I talk about Guillain-Barre so there's a G involved...

My Guillain Barre patient took a breath today. Just a small one. Well, maybe half of one, but it's a big thing! Even she was surprised. So excited she tried another breath and was able to do it. It all started this morning when I noted that she was able to flex her fingers, ever so slightly.

We decided to do a "nif" (negative inspiratory flow) test. It tests how much pressure a patient can create when inhaling. You and I, normal lungs, we can generate a high pressure, greater than 40 or 50. My patient inhaled to an 8 or 9. But this is HUGE considering that she has been on a ventilator for over a week, not able to move anything below her neck during this time.

She finished her last session of plasmapheresis and was being transferred back to Children's Hospital as I was leaving this afternoon. Of note, her primary caretakers since her admission have been my fellow Emergency Medicine residents. One of my colleagues evaluated her in the Emergency Department. He then sent her to the Pediatric Intensive Care Unit (PICU) where a 2nd year EM resident intubated her and took care of her. When she was transferred to BGH, another of my colleagues admitted her to the ICU and then transferred her care to me when I started. We're hoping the 2nd year EM resident on service in the PICU tomorrow will be able to take care of her... kinda like keeping it in the family.

Other than that, the most I can comment on is other patients in the unit. My fluffy white cloud is following me around, and as I left this afternoon my second patient was being transferred out. I picked up no patients during the day, and tomorrow I will round on one of the other intern's patients as she will be taking the day off. We'll see if I get any patients after rounds tomorrow from the overnight service.

So, these are some of the other patients in the unit:

- a schizophrenic patient intubated with pneumonia. They are literally "crazy" and won't be easy to extubate. We'll have to see how they do.

- a patient with severe aortic stenosis (heart valve that is blocked) who is not eligible for surgery and who needs to remain on the ventilator to keep their lungs from filling with fluid. The attending is trying to talk to the family about placing a tracheostomy versus extubating the patient and "letting nature take its course."

- a patient that pulled their own endotrachial tube out and actually seems to be doing ok despite the fact that they were near death about 3 days ago. Still touch and go, but holding their own right now.

- a patient with lung cancer who has multiple complications and abscesses. They are end-stage, so for the most part we're doing palliative care. They were too sick to be in the cancer institute so we are trying to get them stable enough to be transferred back.

- a patient who developed severe sepsis, almost died and needed to be intubated within a few minutes of arriving in the ICU, who is unable to clot their blood and who had the misfortune of having a venous line placed into a non-compressible artery. They were headed for a procedure to try to safely remove the line when I was leaving.

- a patient who ate something bad (not sure if at a restaurant or some old hamburger meat) and was infected with e.coli 0157:h7 which causes a severe bloody diarrhea. Unfortunately, this patient developed sepsis and is now in multi-organ system failure. I will have to see if they are still alive when I go back in the morning.

finally, the GI bleeder with a "spurting" artery at the base of a massive stomach ulcer. I placed an NG (nasogastric - nose to stomach) into him when he came back from the endoscopy suite, and he was being wheeled to interventional radiology/surgery when I was leaving.

Funny, I keep saying, "as I was leaving" but that's how my day went. Everything happened in the afternoon, as I was leaving. That's what's been interesting about this rotation, not knowing what I am going to find when I step in the door in the morning...

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... !"