A night like tonight

I’m not really sure how you describe it. I intubated 2 people. While I was upstairs, my partner downstairs intubated someone. AFter he left the night doc coded someone who died. I had a woman arrive from a nursing home that wanted no intervention and she died (why did she get sent?) None of this bothers me at all in an emotional way, it is what it is, and it’s a lot of fun (sometimes). So what made this night strange is the cluster of trying to intubate someone on the floor.

Before I tell you about it, I have a confession to make, you can call me conceited if you like. When I played soccer as a young one (from 5 to 18, competitively), I was pretty good. I had good ball skills. I knew the game. I could make space. I could cover players. I knew how to use my body to push people around without getting called. I could play with the boys or with the girls. I could score goals, I could play goalkeeper. My favorite memory was gettingg pulled out of goal to take a penalty kick, scoring and running back to goal. I would get extremely frustrated when our team did poorly and i used to wonder, even at 10 years old, how good the team would be if there were eleven of me and I played every position. I admit it, it sounds pretty stuck up. But that’s what I used to think. I felt that way tonight, in the midst of what should be highly trained medical professionals I had to be everybody…resident, attending, nurse and respiratory therapist.

On the floor in the ICU, I arrived to intubate a patient. By the time I arrive on the floor, the decision that the patient probably needs intubation has been made five to ten minutes prior by the residents working in the units. There has been some patient assessment, lab tests or catastrophe that leads them to the decision. They call a “code”, the operator overheads the code to the whole hospital. ON weekends and nights, the ED attending leaves the ED (even if there are 30 people in the waiting room) and goes to the floor, via the elevator, sometimes (if you’re me) getting lost on the way. SO, it’s not unreasonable to expect that by the time I get there, some basic preparation has been done. There are two intubation bags on each unit with tubes, stylets, handles, blades, etc, etc.

When I arrived at this particular bedside, the resident waited anxiously at the head of the bed for his chance to intubate. Suction was ready, but that was it. No bag valve mask, no tubes, no handles, no blades, no meds. The intubation bag wasn’t even there.

I handed over my “travel meds”, succs, roc and etomidate, to the nurse and requested that she draw up the etomidate and succs. A few minutes later (minutes are centuries during a code) she says, “we’ve already got versed drawn up, can we use that?” I’ll spare trying to describe my internal thoughts at this point. (If any of you have performed rapid sequence intubation, you’ll be rolling your eyes at this point as well. )

Me: “No, I prefer etomidate.”

ICU Nurse: “I’ve never heard of etomidate, do we have it?”

Me: “Yes, but I also brought some up with me, it’s in the box I brought.”

ICU Nurse: “Where is it, I don’t see it”

Me: “It’s in the bottle labeled E-T-O-M-I-D-A-T-E”

ICU Nurse: “Is this it?” -holding up bottle labeled E-T-O-M-I-D-A-T-E

Sigh. Meds are finally drawn up and given, I let the resident look and he TELLS me that he can see the cords, that he saw the tube go through the cords. I listen first over the epigastrum and immediately tell him to take the tube out. It was “in the goose”. SO now his O2 sat is dropping. I try to get him to help me bag mask ventilate be he keeps dropping, and finally had the respiratory therapist step in. We get him up to 100% and I look, and without any trouble, slide the 8.0 tube right through the vocal cords. I told the resident he just needed more practice, which is 100% true.

But really. It’s one thing to admit you can’t see any anatomy that you recognize. But to THINK that you’ve just put a tube between a set of vocal cords and instead put it into the stomach, well, that could kill a person. That’s why I’m there. I saved a life tonight.

The second code in the ICU that I also had to leave the ED for, was even more of a cluster. Fortunately, I let the hospitalist intubate and he did a great job on attempt number one. But the (young) nurse on this case also had trouble with the etomidate. She drew up 2mls of it, 4mg. Hmm. 4mg might be enough to put a newborn infant to sleep, but probably not. I asked her 3 times if what she was holding was the correct dose. Three times she answered yes and finally said the concentration out loud. Another nurse picked up the bottle and read the concentration and nurse #1 realized her mistake. In the end, I drew up the drug myself and we pushed it.
The respiratory therapist in this code was so excited that she was bagging about 60 times per minute. I had to ask her 3 times to slow down.

There were a variety of other head scratching things that happened in each code, but those were the major things that simply boggled me. If I wasn’t there, both of those people would probably be dead. You’d think that would make me feel elated, or that all those years of school were worthwhile, but really I just get annoyed at staff that seem inadequately prepared for their responsibilities. I put in the time to learn…why haven’t they? Sigh.

I ate about 3 chocolate chip cookies and a glass of wine when I got home. Somehow a bowl of quinoi with light soy doesn’t quite hit the spot after a night like tonight.

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