Again, the words “we need a doctor in here” clattered out through ED like a stack of bedpans falling from a gurney. The attending with monaural hearing loss was preoccupied with the off service intern making sure he didn’t get behind, while our third year resident was discharging a patient in the bay next door. I sat behind my stack of dictations more than 2 hours beyond the end of my shift, being the only person with an MD behind my name who heard the call for help. As I have learned, when you hear the call, you’d better come running because there’s trouble in there!
The patient was white as a sheet, cold as a rock, wet as a seal and blue as a…well…as an ugly bruise from his neck to his ears. He had oxygen mask running at full throttle and although his stomach heaved up and down, no air was being pulled in to his lungs. “He was tubed last time he was here” the medics informed us. I rubbed his sternum…his eyes were open but no response. His lungs bubbled and frothed like a murky aquarium. All I needed was the spark to set me into action. Let’s tube him now, the attending said who had finally strolled in. a nurse brought the intubation box while I sent the intern to the head of the bed. “Do we want meds?” asked a nurse. I hesitated just long enough to confirm the doses in my mind. “Thirty of etomidate, one-fifty of succs,” I called back. I pulled out the 8.0 intubation tube knowing that this man would need as much help as possible getting air into his lungs. I checked the balloon, inserted the stylus, checked the #3 Mac blade and light and handed it to the intern who deftly inserted the blade and … missed the trachea…
Secret joy welled up inside of me. I stepped in as he stepped aside, inserted the blade, lifted up and away with my left arm pulling his head off the bed enough to clearly see the vertical black space between his vocal cords. The tube went in, the balloon went up and the CO2 detector turned “yay for yellow”. I was in.
What do you notice about this post that’s different than say, my first trauma resuscitation for example?
No italic text!!
No panic, no thinking, just reflexive action! Yes! This is it, my first true “Resident guided intubation with direction of Rapid Sequence Intubation.” No third year looking over my shoulder whispering the doses. No attending guiding my actions. No doubting the order or sequence of drugs and actions. No referencing my pocket card while no one is looking. This is it, I think.
I’ve finally arrived.