Текст книги "Dude, Where's my Stethoscope?"
Автор книги: Donovan Gray
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Текущая страница: 5 (всего у книги 14 страниц)
“Is this table okay?” she asked.
“How about somewhere a little more, uh, private?” I replied, sotto voce.
She moved us to a more suitable spot, gave us our menus and departed.
Five minutes later she returned to take our drink orders. Jan requested something a friend had told her the restaurant stocked – Heisenberg on tap. The waitress apologetically informed her that it was no longer available because the owner had moved the draft tank to his other restaurant. Shucks. Jan settled for a Blue Light. I ordered a Sling. Yes, you read that right – a Sling. I love girly drinks, especially the ones with those colourful little umbrellas in them. What can I say?
Our waitress returned with Jan’s beer, but no Sling. Turning to me she asked: “Is a Sling the same thing as a Singapore Sling?”
“Yes, it is.”
She pulled one of those red bartender drink-mixing books out of her hip pocket, rifled through it and said, “According to this, Singapore Slings are usually made with two ounces of lemon juice.” I nodded sagely. “My book also mentions an alternative recipe that calls for two ounces of lime juice instead of lemon juice,” she continued. “Which would you prefer?”
“Lemon juice, please,” I replied.
She skittered off.
Before long she was back with two tall, yellow drinks on her tray. Neither looked even remotely like any Sling I had ever seen before.
“I made one with lemon juice and the other with lime juice,” she beamed. “Check and see which you like best.”
I took a sip from the first one. It was incredibly sour.
“I don’t think you added enough grenadine,” I theorized.
“Grenadine? Darn it! Are these things supposed to have grenadine in them?” She consulted her little red bible. “You’re right; they are supposed to have grenadine! Hang on, I’ll be right back!”
She zipped away.
Seconds later she returned with a bottle of grenadine.
“Okay,” said our teenybopper waitress. “I’ll pour, and you tell me when to quit.”
I glanced at Jan. She grinned and took a swig of her Blue Light.
“Go for it,” I said.
After a couple of glubs I held up my hand and she stopped pouring. We all stared at the one-inch layer of grenadine congealing at the bottom of the glass. My drink was beginning to look like a science experiment gone bad. Our waitress picked up my soup spoon and used it to stir the dubious concoction.
“How does it taste now?” she asked eagerly.
I took a sip. Yecch!
“Wonderful!” I said. “Thank you very much.”
She heaved a sigh of relief, gathered up her stuff and left.
“Our special this evening is liver and onions.”
Liver and onions? Yecch!
“Do you have any fish dishes?” I asked.
“We have some really awesome pickerel, sir.”
“Is it bony?”
“I don’t think so.”
“Okay, I’ll give it a try, then.”
Jan deliberated for a minute before selecting Weiner schnitzel and noodles with a side order of fresh vegetables. As we waited for our food, she drained the last of her Blue Light. I stirred my vile Sling morosely.
Our food arrived. Jan was disappointed to find her “fresh vegetables” were in fact canned peas. To add insult to injury, when she began eating she discovered the noodles tasted like those lumps that used to form in Cream of Wheat.
“I didn’t mind the lumps in Cream of Wheat, but they’re not supposed to masquerade as German noodles!” she complained. I snickered. Revenge is so sweet.
“Should have ordered the pickerel,” I said smugly. “Brain food, you know.”
I cut off a piece and bit into it.
“Ack!”
“What’s wrong?” asked Jan.
“Bones!” I gasped. A dense cluster of bones trying its damnedest to assassinate me, to be precise. I gingerly extracted the razor-like spicules one by one. Subsequent mouthfuls weren’t any better. After several attempts I gave up and turned my attention to the accompanying rice and broccoli. Both were insipid.
At the end of the meal, our food was virtually untouched. When our waitress returned she looked worried.
“Was everything okay?” she asked.
“Splendid. Do you have any decaf?”
“All we have is Sanka,” she said.
The only thing worse than no coffee is Sanka. I’d sooner drink bilge water.
“Um, maybe we’ll just take the check now,” I replied.
We left her a big tip. I’m guessing she used it to purchase the new Backstreet Boys album. Or perhaps a couple of tubes of Clearasil. Small town living. There’s no life like it!
“ I swear, he wasn’t breathing!”
The other day I was working in the ER when suddenly the overhead PA system crackled to life: “Code Blue in the Special Care Unit, Code Blue!”
I abandoned my patient in mid-sentence and belted out of the department. As I passed the operating room I was joined by both our surgeon and our anaesthetist.
At the entrance to unit 4 we nearly collided with four ambulance attendants on their way to assist at the code. The seven of us thundered down the hall like a herd of stampeding rhinos.
We came crashing into the room only to find that two other doctors, a medical student, a respiratory therapist and at least half a dozen nurses had already beaten us to the punch. It was standing room only.
I wormed my way to the bedside to see how the resuscitation was progressing. To my surprise, the patient was sitting bolt upright in his bed. His eyes were as wide as saucers. He was looking fearfully at the medical student, who happened to be brandishing the defibrillator paddles. There was a nursing student with Ferrari-red cheeks at the foot of the bed.
“I swear, he wasn’t breathing!” she was telling anyone who’d listen. After a fair bit of grumbling the mob slowly began to disperse.
As we left the room I heard the anaesthetist mutter, “Code Blue? More like a Code Blue Light!”
Rollover Rob (The Adamantium Man)
Last Wednesday night the ER was flat-out ridiculous. Think TARFU. No, scratch that. More like DEFCON 1. I didn’t get home until well after two in the morning. I shed my clothing and fell asleep within seconds. Five minutes later the phone rang. It’s uncanny how often that happens.
“A-roo?” I groaned into the receiver. Wait a minute, that’s not English. “Hello?”
“Hi Dr. Gray. Sorry to wake you, but I’ve got an intoxicated 24-year-old man who was just in a rollover. He has a swollen left elbow, some contusions and several superficial lacerations.”
“Coupla minutes.”
As I fumbled around in the dark in search of my discarded scrubs I recited my well-worn motivational mantra: I love my job, I love my job, I love my job… .
When I got to the hospital I hung up my jacket and went to the ER. I must have looked even more pathetic than usual because the nurse supervisor apologized again for waking me up.
“It’s okay,” I said. “Where is he?”
She pointed to room F.
A tattoo-laden critter in a Kid Rock T-shirt, muddy black jeans and roach-killer cowboy boots was sprawled on the stretcher. He stank of booze. When he saw me he grinned widely and yelled, “HEY, BUDDY!”
“I’m not your buddy,” I growled. He looked surprised. I guess back on his home planet everyone’s cheerful at 2:45 a.m. “What’s your name?”
“Rob.”
“Okay Rob, take off everything except your underwear.”
Just then a teenage girl wearing more makeup than your average circus clown barged in and addressed my new patient.
“Hey, baby, your lighter’s not working,” she said. “Got any matches?”
“Who are you?” I asked.
“Rob’s girlfriend.”
“Were you in the accident?”
“Nope.”
I jerked my thumb towards the door.
“Out.”
Bozette hightailed it out of the room. While I shut the door, Rob stripped down to his Fruit of the Looms.
As I examined him I got more of a history. The saga went something like this: Rob and his merry band of cretins had been drinking heavily all night. Sometime around 1:30 he managed to convince his sidekicks Little Klutz and Friar Schmuck to drive him to a neighbouring town so he could look up his ex-girlfriend and three-month-old son. They were doing an estimated 150 kilometres per hour when their car parted company with the highway. Not surprisingly he didn’t recollect too much about the crash itself, but he did remember kicking out the remnants of the rear windshield and crawling away from the smouldering wreckage. In order to avoid the police with all their pesky questions and breathalyzers, the gormless trio fled the scene. When Rob got back to his apartment his current girlfriend took one look at him and dragged him to the ER to get checked out.
Aside from an abundance of minor scrapes and bruises, Rob appeared to be all right. Even his nipple rings were intact. The only thing of concern was his left elbow – it was moderately swollen and he wasn’t moving it well. I asked switchboard to call the x-ray tech in. I was feeling a little guilty about the way I had summarily kicked his girlfriend out earlier, so I asked the receptionist to allow her to return so they could sit together while he waited for his films. My conscience appeased, I hunkered down at the main desk in the ER and began my charting.
As soon as his girlfriend arrived they started talking:
“You okay, baby?”
“Yeah, I’m fine.”
“What’d the doctor say?”
“I just need a couple of x-rays, no big deal.”
“Will you need a cast?”
“Dunno.”
“What about one of those shots for, you know, that, like, lockjaw thingy?”
“Naw, I got one of those after I got my tats in jail a coupla years ago.”
“Oh, that’s good. You sure you’re okay, baby? How many times did you roll?”
“Six or seven times, max. Like I said, no big deal. I’ve been in lots of rollovers before. I just walk away from them.”
“Oooh, Robby,” she squealed, “you’re the best!”
Yep, that’s a really important trait to take into account when considering a potential mate – the ability to walk away from rollovers. You just never know when it might come in handy!
Drinking Problem
Several nights ago a 14-month-old boy with a cough was brought to our emergency department. While I obtained the history from his mother, the little fellow happily explored the room. After a couple of minutes he toddled back to her and reached for the half-full cup of Tim Hortons coffee she had been sipping from.
“Eh! Eh!” he grunted.
“Jack-Jack want coffee?” she asked.
“Eh! Eh!” he confirmed.
She handed him the cup. I watched in disbelief as he noisily slurped the rest of the java down. When he was finished he burped loudly, hucked the empty cup onto the floor and wobbled away.
“You let your 14-month-old son drink coffee?” I asked incredulously.
“Oh, Jack drinks whatever I drink,” was her reply.
Blood
At 8:30 this morning a trucker accidentally dropped a large hunting knife on his left foot. The blade pierced the skin and embedded itself deep in the bone. When he pulled it out, a miniature geyser of blood erupted. He tried to staunch the flow with some towels, but within a few seconds they were soaked. He drove his rig to our hospital and limped into the ER. The triage nurse applied a tight pressure dressing and had me paged.
By the time I arrived, the minor trauma room was saturated with the odour of blood. It washed over me in waves as I stitched up the wound. Traces of it clung to my clothes long after the patient departed.
Just as the ghostly scent of blood was beginning to fade from my memory, an industrial accident victim was brought in. He had crushed his right hand between two steel plates. Fortunately no bones were broken, but several of his fingernails had blood trapped underneath them. The nail bed hematomas were causing a lot of pain. To relieve his discomfort I drilled holes through the damaged nails with an 18-gauge needle. The smell of the draining blood gave me a weird feeling of déjà vu.
An hour later a drunken 25-year-old who had just put his fist through a plate-glass window staggered up to the receptionist’s desk. Arcs of blood sprayed from his jagged wrist laceration in perfect sync with his heartbeat. I hustled him into a treatment room and began suturing. After about a dozen stitches the bleeding reluctantly came under control.
My next patient asked me to look at a mole on her shoulder that had recently enlarged. It was multi-coloured, elevated and irregular. She didn’t have a family doctor, so I removed it for her. More molecules of blood escaped into the air.
After the mole excision I went to the dirty utility room to deposit my used scalpel blade and needles. One of my colleagues had just finished a busy lumps-and-bumps clinic, so the sharps disposal container was nearly full. When I opened it I was assaulted by the odour of fresh blood once again.
Our bedroom is bathed in moonlight.
The clock on the wall reads a quarter past midnight.
I’m lying in bed, waiting for the Sandman.
I can still smell blood.
Paralyzed
Tharn – a fictional word used in the Richard Adams novel Watership Down to describe rabbits frozen in terror at the sight of the headlights of an oncoming car.
One night I was working in the emergency department when the nursing supervisor advised me an ambulance had just been dispatched to pick up a teenager who had collapsed. A few minutes later EMS radioed to notify us they were coming in hot with an unstable cardiac patient.
They rolled in with a drowsy 15-year-old boy named Johnny. He had a pulse of 230 and a dangerously low blood pressure. We got him into a gown, administered oxygen and put him on the cardiac monitor.
He wasn’t my patient, but I vaguely remembered seeing him in the ER a few years prior for issues related to an irregular heartbeat. At the time a pediatric cardiologist had strongly recommended Johnny undergo a relatively minor procedure on the electrical pathways of the heart to eradicate the disorder.
“Did you ever get that heart procedure done?” I asked.
“No.”
“Why not?”
“I didn’t want it.”
“Does your heart beat too fast sometimes?”
“Yes.”
“What do you do when that happens?”
“I take these.” He pulled a bottle of heart pills out of his pocket. “I’m supposed to take one three times a day, but sometimes I forget. If my heart’s going too fast I take a few extra. I’ve been doing that a lot lately.”
“Where are your parents right now?”
“I just live with my mother. Why?”
“I’m going to need to speak to her.”
“About what?”
The pills he was on can sometimes trigger abnormal heart rhythms if not taken as prescribed. Using layman’s terms, I advised him that with the current combination of heart disease, unknown levels of cardiac medication in his bloodstream and unstable vital signs, the quickest and safest solution would be for us to provide intravenous sedation and then use special paddles to electrically convert his heart rhythm back to normal.
“You’re not doing that to me,” he declared.
I telephoned his mother and asked her to come to the ER right away. When she arrived I reviewed the situation with her and explained why it would be better for us to cardiovert her son now, before things got any worse.
“What does Johnny say?” she asked.
He doesn’t want to do it, but he’s too young and scared to make a rational decision.”
“If he doesn’t want it, he doesn’t have to have it.”
The best alternative to electrical cardioversion was a medication named procainamide, so I started him on an intravenous infusion of it.
Half an hour later his pulse had decreased to 180, but his blood pressure was still too low and he remained in an abnormal heart rhythm. I telephoned a cardiologist for advice. He agreed the optimal treatment was electrical cardioversion, but felt that given the circumstances we could give a second cardiac medication a try. Two doses of the alternate drug had no discernable effect on Johnny’s rapid heart rate, so I restarted the procainamide.
By midnight his pulse had declined to 150, but his blood pressure was fading and he was nearly comatose.
I told his mother if we waited any longer to perform the procedure, he would probably die. She consented resignedly. My colleague Serge sedated him and I performed a synchronized cardioversion at 50 joules. His rhythm remained unchanged. I increased the power to 100 joules and shocked him again.
Johnny’s heart stopped beating. Stone-cold asystole.
“No pulse!” the emerg nurse shouted.
Time stood perfectly still. The silence was deafening. My body locked up. My brain turned to mush. I couldn’t think. I could barely breathe. Serge and I stared at each other blankly. We hadn’t anticipated this outcome, and as a result we weren’t mentally prepared for it.
Serge’s lips twitched spasmodically as he tried to decide what to do next. Finally he said: “Electricity got him into this and it’ll get him out of it. Shock him again.”
I looked stupidly at the paddles in my hands. The urge to do something was overwhelming. From the deepest recesses of my frozen mind a thought struggled to rise. I waited for it. Finally it burst to the surface: You don’t shock asystole!
“No,” I said numbly.
“Okay,” he said. “Put the paddles down, then.”
I think I was making him nervous. I woodenly returned the paddles to their slots in the defibrillator and watched in a haze as Serge strained to think us through this mess. He was as rattled as I was, but at least he was fighting it.
Suddenly his eyes widened.
“Start CPR!” he yelled. The ambulance attendants sprang into action. “One milligram of epinephrine IV!” He had broken free of his mental gridlock. He grabbed an endotracheal tube and intubated Johnny. Now everyone was moving but me.
The events unfolding around me seemed to be occurring in a surreal, molasses-like slow motion. Although I was fully aware of the fact that I had skillfully dealt with cases worse than this in the past, for some reason I was completely paralyzed. I remained in a near-catatonic state; a fly in amber. I tried to focus on the asystole algorithm, but I simply could not stop thinking, “What did I just do? I’ve killed this boy.” It was awful.
Although my sang-froid completely deserted me, fortunately for Johnny my teammates kept their wits about them. They performed excellent chest compressions and lung ventilation. They administered the correct drugs at appropriate intervals. Six inconceivably long minutes later Johnny developed a recognizable rhythm on the cardiac monitor. Seconds later his femoral pulses returned and a blood pressure of 70 systolic was recorded.
By that time my miasma was clearing and I was semi-functional. I ordered a dopamine infusion and got on the phone to the closest ICU with an available bed. Within an hour he was airborne.
Johnny went on to a full recovery and had his cardiac electrical problem fixed a few months later. He has not had any further heart rhythm issues.
As for myself, that night taught me the danger of getting caught flat-footed. I now try to be a good Boy Scout and prepare myself for every eventuality, even though in my heart of hearts I know that there’s no way that you can be ready for everything all the time. ER workers are, after all, only human.
Rick’s Tears
When they told me Rick was coming in by ambulance, I knew right away something was very wrong. Rick never called EMS, no matter how sick he was. To him, coming in by ambulance was tantamount to admitting defeat. I went to the resuscitation room and started preparing my gear.
Rick was a 35-year-old man who had been waging an intense chess-like battle against cancer for the past five years. Although he wasn’t my patient, I knew him fairly well because I had treated him in the ER on several occasions. One thing that always impressed me about him was his relentlessly positive attitude. Rather than walk around in a blue funk bemoaning his fate, he focused his energy on getting better. He had more important things to do than die of cancer. He wanted to spend more time with his wife, Tammy. He planned to help his kids make the awkward transition from childhood to adolescence. He had a business to run and projects to complete. Most cancer victims hope they’ll survive. Rick intended to. Death simply wasn’t an option.
He demonstrated his indomitable will to live in many ways. When the initial staging tests revealed the cancer was much more widespread than originally expected, his response was, “Well, we’ll just have to work a bit harder to get rid of it, that’s all.” When his first chemotherapy cocktail failed miserably he moved on to the next line of treatment without so much as a backward glance. Plan B was followed by plans C, D, E… . One day the cancer disappeared. Extensive testing failed to show any trace of malignancy within his body. Rick was in remission. He was thrilled, but he wasn’t surprised – he had fully expected to conquer his foe.
A year later the cancer recurred. At first Rick was despondent, but before long his unflagging optimism returned. Conventional chemotherapy proved to be completely ineffective this time, so he signed up for oncology trials involving experimental drugs. If he was quoted a mere five percent chance of success for a given regimen he’d say, “That’s all right – I’m going to be in the lucky five percent.” When the drug proved to be a failure he’d shrug and say, “Let’s hope the information they got from studying me will help the next guy beat his cancer.”
Once in a while a treatment regimen would look promising in the early stages – Rick’s tumours would shrink, his blood counts would improve and he’d start to feel better. He would predict with unshakeable confidence that it wouldn’t be long before he was rid of his disease. Within a few months, though, the cancer would invariably regroup and resurge, stronger and more resilient than ever. Eventually it became apparent to everyone but Rick that he was not going to win the war.
The attendants hit the door running. “He was awake and talking the whole way here, but when we pulled into the ambulance bay he slumped over and became unresponsive!”
Rick looked sepulchral. He was propped up in the stretcher and leaning heavily to the left. His eyes were vacant and he was barely breathing. I put two fingers to his neck. His carotid pulse was weak. I cupped my hand to his ear and said, “Rick, can you hear me?” He didn’t respond. I put my hand in his. “Rick, squeeze my fingers.” His hand remained limp. I was reaching for the blood pressure cuff when I noticed his left eye glistening. I stood transfixed as a solitary tear broke free and tracked down his cheek. A tear from a dying man. Endgame. I felt someone walk over my grave. Turning to one of the attendants, I whispered, “What’s his code status?”
“I’m not sure, but you can ask his wife – she’s right next door in the triage room.”
Tammy was distraught. I explained that Rick was moribund and asked if he had ever given any indication as to whether he wanted aggressive interventions in the event his heart stopped beating. She said he had requested no heroic measures be undertaken. We went back to the treatment room together. His blood pressure was hovering around 60 systolic and he was nearly unconscious. It didn’t look as though he was going to last long. She held his hand and stroked his thinning hair. The rest of us stood by and waited.
Impossibly, several minutes later he opened his eyes and looked around. He was too weak to talk, but he seemed to recognize Tammy. He obviously wasn’t yet ready to relinquish his fragile hold on life. I sequestered his family in the triage room for an impromptu conference and asked if they were in favour of giving him a rapid infusion of intravenous fluids in an attempt to boost his blood pressure. I explained any improvement would likely only be temporary, but that it might give him a few more hours of consciousness. After deliberating for a short time they decided to give it a try.
Halfway through the third litre of saline he arose like Lazarus, asked for a drink of water, and held court with his family. When I asked him what his wishes were regarding end-of-life care, he confirmed he didn’t want CPR, defibrillation, intubation or mechanical ventilation. Intravenous fluids were fine, though; he was hoping to keep body and soul together long enough to participate in an exciting new chemo trial scheduled to commence in a couple of weeks.
“You do your job, and I’ll do mine,” he said to me with a mischievous twinkle in his eye.
Over the course of the next two hours Rick slipped in and out of consciousness. During lucid intervals he would reminisce with his family about happier times. Sometimes he spoke wistfully about up-and-coming treatments he had read about. Not once did he speak of death. Shortly after midnight he lapsed into a coma. I wrote admission orders and transferred him to the medical floor for palliative care. By 3:00 a.m. the emergency department’s waiting room was empty. I hung up my lab coat and drove home.
Three hours later my telephone rang. It was a nurse from the medical floor.
“Sorry to wake you, Dr. Gray, but Rick just died.”
“I’ll be there in a few minutes.”
I got out of bed, dressed and returned to the hospital.
Pronouncing someone dead is a strange ritual. It’s equal parts medicine, religion and magic. Like falling snowflakes, no two pronouncements are ever the same. Sometimes the body is alone in the room; shrouded in darkness, isolated and abandoned. Other times the room is well lit and packed with family members and friends. Sometimes the dominant mood is sadness. Other times it’s relief. No matter how many mourners are present, though, a palpable stillness descends when I enter the room. I become a shaman. My gift is closure.
On this occasion there were seven people clustered around the bed. When I walked in, they all turned towards me expectantly. My fingers gripped the stethoscope in my pocket. For a moment it felt like a string of rosary beads. I approached Tammy and squeezed her shoulder in sympathy.
“Thank you for looking after him earlier,” she said.
“You’re very welcome,” I replied. “I only wish we could have done more. Was he in any pain at the end?”
“No, he looked like he was comfortable.”
“Did he ever regain consciousness after he left the emergency department?”
“Yes, a few times. The last time was about half an hour ago. He opened his eyes and spoke to me. I think he must have realized he was about to die.”
“What did he say?”
“ The fire’s gone out.”
Rick was recumbent on the bed with his eyes closed. Although it was clear that his life-thread had finally been severed, I could sense his family needed me to confirm it. I lifted his cooling wrist and felt for a radial pulse. There was none. I assessed his carotids. Nothing. I placed the diaphragm of my stethoscope directly in front of his bluish lips and listened for breath sounds. Silence. I auscultated his chest for a heartbeat. Once again there was no sign of life. The last thing I usually do is check for a pupillary reflex. I put my right thumb on his left eyelid and gently opened his eye. A solitary tear broke free and tracked down his cheek.
Parenting 101
My next three patients are a young family with mild gastro symptoms. While I obtain a history from the parents their toddler Billy pokes around the room, happy as a clam. I examine the father. I examine the mother. Now it’s Billy’s turn.
I ask his parents to put him on the stretcher. When his mother leans over to pick him up, Billy goes bonkers. He windmills his arms and screeches, “No!” He then runs behind the stretcher and stares up at us defiantly.
“I don’t think he’s going to let you look at him,” his mother concludes.
“How old is Billy?” I ask.
“He just turned two.”
“I think we’re in charge here, don’t you? Please put him up on the stretcher so I can check him.”
She approaches Billy cautiously. He bares his teeth at her like he’s some kind of rabid ferret. When she lifts him up, he arches his back, kicks his feet and uncorks a blood-curdling, “No! No! No! NOOOOOO!!!!” Damned if she doesn’t put him back down.
“Billy doesn’t like doctors,” she reiterates.
I’m running out of patience.
“Look, this isn’t a democracy – his vote doesn’t count. It doesn’t really matter if he says no. Just put him on the stretcher anyway.”
At this juncture a tiny light bulb appears above her head. Aha! A brand new concept! This time she and her husband pick up Billy and deposit him on the stretcher like they mean business.
“Now you sit still, Billy,” she says firmly. After putting up a token show of resistance he settles down nicely. I begin my examination.
Adventures in Paralysis (The Ventilator Blues)
Every now and then we ER docs supplement our armamentarium with techniques borrowed from other specialties. Rapid sequence intubation (RSI) is one such purloined procedure. It involves using induction and paralytic agents to facilitate emergency endotracheal intubation. In plain English, this means we sometimes give patients who are struggling to breathe drugs that render them comatose and paralyzed. We then move their tongue out of the way with a device called a laryngoscope and quickly advance a hollow 12-inch plastic endotracheal tube (ET tube) past the back of the throat, through the vocal cords and into the trachea (windpipe). When the tube is in place we attach it to an Ambu bag. Squeezing the bag rhythmically results in 100 percent oxygen being delivered to the patient’s lungs. Depending on the situation, the ET tube can subsequently be attached to a ventilator.
As the name implies, RSI allows us to rapidly take control of a patient’s breathing. Anaesthetists have long used coma-inducing and paralyzing drugs in the OR, but it wasn’t until relatively recently that it was recognized there was a role for these medications in the ER as well. RSI is an invaluable adjunct, and it has bailed me out of a number of airway crises. Usually it goes off without a hitch, but once in a while things can get a little hairy. Here are three cases from my Yikes! file.
Are You Sure This Stuff Is Going to Help Me Relax?
Several years ago I was working in the ER when we got word an ambulance was on its way in with someone who had been trapped in the basement of a burning building. Before long the paramedics arrived with an uncooperative man in his early 20s. His clothing was badly charred and he was covered in soot. Inspection of his throat revealed a raw, beet-red palate, and his sputum was speckled with carbonaceous material. It was obvious he had suffered significant thermal damage to his upper airway. It is generally recommended that patients with this type of injury be intubated early. If you wait too long, late attempts at securing the airway may prove to be impossible due to massive soft tissue swelling in the throat. In situations where multiple intubation attempts have failed, oftentimes the only remaining airway management option is emergency cricothyroidotomy, i.e., cutting the front of the neck open to directly access the trachea. Rumour has it that incising the neck of a confused, combative burn victim isn’t much fun. Intubate early and save yourself a world of grief.
