There is a post in my archives in wich I ran my first code as a resident without any outside assistance from the attending. It was nerve-racking, and I’m sure I was up all night afterwards. I remember those days of the steep learning curve with a little bit of reverence for who I was back then. WOuld I put myself through that again? I’m not sure.
But I am sure of the fact that I’m a lot more confident than I used to be. It’s exactly because we put ourselves directly in the firing line of bad cases…bad hearts, bad lungs, guns, knives, bats and bricks that we learn to practice emergency medicine.
It’s days like the one I’m about tell you that leave me in awe of my responsibility as an ER physician. This time I was the attending in charge, with a medical student wide-eyed at the entrance to the patient’s room.
She was a frail older woman who had been found by her husband, cold and gray on her bed. He called 911 right way. They were unable to intubate her in the field. Failure to intubate by prehospital personel is a huge red flag for a “difficult airway”.
We didn’t know any of the history until the paramedics rolled her into the room, pounding on her chest, bloated stomach with a bag mask spraying bloody spit every time they tried to squeeze air into her lungs.
“She needs a tube,” the paramedic shouted. “Her vocal cords were too swollen, we couldn’t get anything in.”
Crap. Swollen vocal cords in a cyanotic patient in cardiac arrest. The thought crossed my mind, “It’s finally my turn to do a crichothyrotomy in the ER.” Rather than being fearful of the proceedure, I visualized it happening with minimal blood and simply slipping a 5.0 endotracheal tube through her neck into her lungs.
I began shouting orders as I opened the bedside intubation bag…”Page anesthesia, get the crich set ready, get her on our monitor and attache the defib paddles. Continue CPR with cricoid pressure…”
We didn’t need paralytics. I used a 4.0 Miller blade and slipped it into her throat. “Suction!” I shouted. The respiratory therapist thrust it into my hand and I evacuated a pool of bloody spit from her throat. I continued shouting orders… “Hand me the tube, stop CPR, give me some cricoid pressure…”
I could clearly see the false vocal cords and the arytenoid cartilage, two small bumps that sit above the vocal cords. But I couldn’t see the vocal cords themselves. As soon as CPR was stopped, the epiglottis fell down into my field of view. Crap.
I repositioned the blade, visualized where the cords SHOULD be, and slipped a tiny 6.0 tube into her lungs. Anesthesia had shown up at my side and helped secure the tube and check the placement. The airway was in place, but I still had to manage the rest of the code. I handed the tube over to the nurse anesthetist and respiratory therapist and continued managing the dozen or so people in the room.
“Resume CPR. Set the vent at 12 per minute, 400 cc, 100% O2, 5 of PEEP. Feel for a femoral pulse. Start a 2nd IV line and bolus a liter of Saline. Give an amp of calcium and bicarb. Give another round of Epi & atropine. ”
It wasn’t looking good. She wasn’t responding to anything, she had been down a long time and in asystole…no one would have faulted me for stopping right then and there. But we had to try and reverse any of the causes of asystole before giving up, so we pressed on.
“Stop CPR,” I said, and all eyes turned towards the monitor. Nothing. Flat line. “Resume CPR,” I said. I had to buy myself a little more time to look over my protocols and see if I was missing anything. Nope, we’d done it all with the exception of putting a needle in her heart and lungs…but there was no history indicating she had tamponade or pneumothorax.
I waited a minute. “Stop CPR”. All eyes watched the monitor. A rhythm. Sinus tach. “Feel for a pulse,” I shouted. “I can feel it,” said a tech. “Check a blood pressure.” “One twenty over eighty,” the nurse replied.
I was in disbelief. She came in dead and now she was “alive”. I reviewed the case in my mind… I had secured an airway. We continued circulating blood to her system and loaded her with meds to help stimulate the heartbeat and counteract deadly accumulations of potassium and acid in her blood. I had basically followed simply Advanced Cardiac Life Support protocols and it worked.
Was it a “save”? Well, she ended up dying anyway, but it at least gave her family some hope for a short period of time, and gave them time to gather at her bedside in the ICU to say their goodbyes.
I’ve come a long way since my intern year, and it’s hard to imagine how it is I’ve come to learn all this stuff. But it’s pretty cool that I have.
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