Airway Management on 600lb in ER

[anesthesia11230]

Come in the other day and resident shows me a picture of an intubated lady (600lbs) and proudly says he intubated her lastnight in the ER since she has some respiratory distress ( h/o asthma and was on BiPAP)

asks which attending helped you out...states he called no one as backup
(his rationale: didnt want the airway exerience to be taken away from him by a freaked out attending...no neccasarily stated that way)

Question that crosses my mind for the rest of you
How many residents out there would have gone on to secure an airway without informing an attending in this manner (assuming the patient is not "crashing" and maintaining her saturation with BiPAP although you forsee her tiring out soon)

his initial attempt was with lil droperidol 2.5mg (which is a drop in the ocean for this lady)...as he experienced her trying to bite his fingers off

next trial he gives some ketamine IV along with glyco...i agree good choice
maintains spontaneous ventilation with added bronchodilation
(no harm done so far)

he goes in with the glidescope but still doesnt see cords but daring ("lucky") enough to slip the ETT passed cords in which he didnt see

so my main concern/fear is supposing he didnt get lucky in passing the ETT
and now somehow there is some bleeding or extra secretions (i know glyco was given) but assuming something triggers her off into laryngospasm or further respiratory distress

no way in hell you can ventilate her
never visualized the cords

and bottom line: downward spiral

question is: how many would have attempted to secure an airway alone (or in this case with a CA-1 with little experience and prob not much support) without some attending supervision

afterall i dont think any skill was accomplished in airway management since no cords were visualised and was equivacal to just blindly jamming a tube down

(interesting side note was patient self extubated herself in the SICU and required her to have an emergent airway (cricothyroidotomy) and later the next day for a formal trach (this time nearly 5 attendings standby)

your thoughts
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[anesthesia11230]

another quick side question:

are residents getting the same training with fiberoptic bronchoscopes (FOB)nowadays as they once did before or is the glidescope preventing the development of this skill

my personal experience is...i hardly ever touch the FOB

hopefully after my thoracic rotation i feel i have this skill (FOB) in my bag of tricks

thanks

 

[coprolalia]

If he'd pulled that crap in my institution, he would've been fired in spite of his success. No "ifs, ands, or butts". He's not ultimately responsible for the patient's outcome. It was the attending on call supervising him who was. And, if something bad had truly happened, he would've just f***ed someone royally... and I'm not just talking about the patient.

-copro

 

[anesthesia11230]

agree 100%

when he told me the story i was impressed intially having thoughts in back of my mind thinking i would have been floored and have called the attending right off the back...not becuase of fear of airways (although i think anyone even the most experienced would be highly vigilant in this situation- as i saw the next day with the formal trach--nearly 5 attendings in the room)

was thinking to myself later on how lucky he was and how bad the situation would have been...ironically the guy is the "brightest" in our batch and 99% nationwide on the in service exam

go figure

 

[Jeff05]

although ketamine preserves spont respiration, it can, at times cause upper airway obstruction, especially in the morbidly obese. this is a situation in which one should have a second pair of HELPFUL hands (ok, if you're in the boonies by yourself, AS AN ATTENDING, do what needs to be done).

plan 1:
glyco 0.3 mg. wait a good 20 min.
have her gargle 4% visc lido. spray some 4% lido with an atomizer down into pharynx. trans tracheal block. awake fiberoptic intubation.

plan 2 - not boards friendly
build a ramp - positioning is 90% of this
preoxygenate patient for a GOOD 5 min.
prop 150/succ 60
glidescope, or DL

 

[Jeff05]

also exam scores and good common sense clinical practice sometimes do not go hand in hand.

 

[anesthesia11230]

PLAN A: sounds good (although i need much better training in FOB)
PLAN B: requires HUGE "Bolls"

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[huktonfonix]

awake FOI if possible without a doubt. however if this patient was non cooperative or crashing, you may not neccesarily have time to do this. In that case the question is can I get an LMA in her and ventilate. If so then I can FOI down the LMA. Either way I would have either a cricothyroidotomy kit, jet vent, or a surgeon standing by (as well as my attending ).

 

[Calilove]

As a CA-3, I can understand the feeling of wanting to do things by yourself sometimes... This leads to residents doing very risky and unsafe (inducing a 600 lb. pt) things unsupervised. However, most attendings in anesthesia are often freaked out in difficult situations to the point of making everyone else (including their residents) uncomfortable and anxious to the point of being unable to perform optimally. I've noticed that this fact is most true in attendings that are the LEAST competent.
For example, one of my attendings tried that yelling crap the other day after our pt was desaturating to 80s just after intubation. He was yelling to do this/do that. I politely ignored his a@@ and listened to the bilateral breath sounds, viewed my normal capnograph, continued on 100 FiO2, closed the APL a little, and bagged the pt while watching the O2 sat rise exponentially to 100% in under 30 seconds. Problem solved... no public demonstations to let everyone know how scared/anxious you are. Just get the job done.

One of the things I HATE about residency are attendings that dramatize everything. They always get the sick patients, always get the difficult intubations, always get the worst calls... When working with these attendings, everything is a NATIONAL EMERGENCY. I can understand anxiety. But, I've never seen a situation that got BETTER because you were yelling the loudest in the room. I've been in some crappy situations/cases/intubations, but I just can't see myself publicly wigging out on everyone everytime SHTF. This is our daily life as anesthesiologists, and I plan on living a long time, not reacting poorly to the daily stressors which our job entails. I've learned that a CALM yet confident demeanor and normal speech tone are key when keeping nurses and other medical staff at ease but still actively involved in difficult patient situations. I wished attendings across the board would just realize how ridiculous they look when they run around like little chickens with their heads cut off during stress. This is not only true for anesthesiologists. Even if you do get the difficult airway secured, the medical staff can still sense an insecure physician.

However, I hope that resident understands that his actions were not standard of care and would not stand up in any court of law. He/she would be in big trouble/fired/sued as an attending if that "lucky" intubation had not occurred.
Luckily, we perform fiberoptic intubations alot at my program so it wouldn't have been an issue to go the "awake" route. The patient was huge, so no sedation, only glycopyrrolate. Usually we're being called after the ER has already administered Propofol plus Muscle relaxant to intubate the now bloodied and traumatized airway they've created in the 600 lb patient.

 

[Anesthesia1979]

awake fiber is the way to go... agree with glyco and lido up the wazzu.
Have LMA, surgeons, glidescope; Miller 3; and whatever other little toys you want and a decided plan on what to do and when.

But the one other thing that I would add is this... don't do this in the ER... if patient is doing well with BiPap and has impending failure.... go to the OR. less people in your way and you're on your home turf.

Other thing to remember that while Ketamine is a bronchodilator; it also sensatizes the upper airway reflexes... this is not a person you want to have secretions touching the cords or passing an ett blindly; touching cords, but not entering trachea and inducing laryngospasm.

 

[nociceptor]

Lady in question.

Picture in question

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[urge]

his initial attempt was with lil droperidol 2.5mg (which is a drop in the ocean for this lady)...as he experienced her trying to bite his fingers off

Are they still inducing with droperidol at your program? He must have learned this from someone, a mummy anesthesiologist. Very odd to be using droperidol for this nowadays. Anyway, 2.5mg won't cut it in a pt this big. Maybe 10mg or 15mg will do it.

 

[Fastrach]

Lady in question.

Picture in question

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...except that this lady, while seemingly harboring a colony of leprechauns or posse of circus midgets in her rump, would actually likely be a grade I view.

 

[coprolalia]

Calilove,

I agree with your post...

But, I've never seen a situation that got BETTER because you were yelling the loudest in the room. ... I've learned that a CALM yet confident demeanor and normal speech tone are key when keeping nurses and other medical staff at ease but still actively involved in difficult patient situations.

... but, I just want tell you a different side to this. The problem with being "calm" all the time is that sometimes, when you are overly calm, the ancillary staff doesn't realize how bad the **** is hitting the fan. This happened to me about a month ago. I had a patient in the OR who I thought, based on prior anesthetic record, was going to be an easy airway. Well, after not being able to get anything better than one poorly running tiny 22g in her arm in the holding area, we started the case. You can guess what happened... IV infiltrated immediately after induction.

Now, when my stress level gets really high, I tend to get quiet and focused. To boot, she was a Grade IV view and we couldn't get the tube in. I'm with my attending, blood is starting to trickle out of this lady's mouth, and he's asking me to reach for the Eschmann. We're relaxed, focused on what we're doing, not screaming and yelling for help. What does the scrub tech do? Walks over to the speakers, plugs in her iPod, and starts blaring country music at a way-too-loud level. The surgical staff starts moving the patient's legs and getting the Foley ready. We haven't even secured the airway yet and the patient's Sats are in the 80's.

The point is, sometimes you have to have a "panicky" demeanor, if nothing more for show, to demonstrate to the other team members how serious the situation is. It's all about effective communication, and sometimes that effective communication is letting people know you're knee-deep in the ****. Clearly, both I and my attending failed in this instance.

Long story short, things turned out well and I told that scrub tech never to do that again until one of us said it was okay.

-copro

 

[Apollyon]

The point is, sometimes you have to have a "panicky" demeanor, if nothing more for show, to demonstrate to the other team members how serious the situation is. It's all about effective communication, and sometimes that effective communication is letting people know you're knee-deep in the ****. Clearly, both I and my attending failed in this instance.

I have to disagree with you, here, Copro - we're in the same boat in our different departments, so think of it this way - you're the knot on the end of the rope. You get untied or frayed, and everyone slides off into the abyss.

When they get to know you, then they see that you are cool under stress, and that keeps everyone else cool. It took me all 3 years in residency (and even had a nurse - in the second half of my 3rd year of EM - tell me "I don't listen to you") to get people to realize I don't spaz, and, as an attending now, it took a good 6-8 months. I never yell, I never throw things, and I say what's going on all the time. I've been criticized for that - that my thinking out loud makes me sound indecisive, but I disagree - it keeps everyone on the same page. Being in the OR is the same way - there were a few truly implacable gas attendings when I was at Duke that never blinked (including one who was there with a surgeon who was the epitome of the ones you hate), and this fellow (um, just a word) would just say things like, "this airway is more difficult than anticipated. Please stop what you are doing and let us get this tube in first and foremost".

I had a challenge like that last summer, when I was at an outside hospital when a dude that had been stabbed was just dumped at the door to the ED. I tubed the guy (and had to tell respiratory to secure the tube and to drop an NG in, as the RTs x2 just - literally - stood there doing nothing), put in a subclavian TLC (because I didn't have a Cordis there, which drove me nuts), and the biggest thing - clamped off the femoral artery, which I had to dig out, and had people standing there like deer in headlights. (I had staff hold direct pressure on the leg while I tubed the patient - ABC's all the way - then controlled the bleeding.) The charge nurse told me the next week that my stock had gone up with the staff because of how I handled that one case.

 

[Arch Guillotti]

IMHO I think the answer lies somewhere in the middle. I don't think as anesthesiologists we should ever be "panicky". We should always be as calm, cool and collected as humanly possible. I have had an unanticipated airway struggle during induction as well. Most of the time inductions go so smoothly that others in the OR just assume it is business as usual for us, when the reality is that we are having a struggle that could potentially be disastrous. No one seems to know this but us. Somewhere along the line some joker invariably cranks up the ipod or the nurses are screeching about what diet they are gonna do to get rid of that final 150 lbs. that is on the backside. What you need to do is to gain IMMEDIATE control of the situation by forcefully expressing yourself. No yelling, no panicking. Clear, loud directions. For example, once during an induction gone wrong the usual background chatter and stuff was so loud we couldn't even hear our own monitors. My attending calmly and forcefully said (without being an ***) "MUSIC OFF, QUIET PLEASE". You never see this attending get panicky and by the tone of his voice everyone in the room immediately knew that they needed to shutup, can the music and pay rapt attention to anything that we needed. You could have heard a pin drop were it not for the pulse ox which sounded like a foghorn in the background. USE THE FORCE.

 

[mytirf]

IMHO I think the answer lies somewhere in the middle. I don't think as anesthesiologists we should ever be "panicky". We should always be as calm, cool and collected as humanly possible. I have had an unanticipated airway struggle during induction as well. Most of the time inductions go so smoothly that others in the OR just assume it is business as usual for us, when the reality is that we are having a struggle that could potentially be disastrous. No one seems to know this but us. Somewhere along the line some joker invariably cranks up the ipod or the nurses are screeching about what diet they are gonna do to get rid of that final 150 lbs. that is on the backside. What you need to do is to gain IMMEDIATE control of the situation by forcefully expressing yourself. No yelling, no panicking. Clear, loud directions. For example, once during an induction gone wrong the usual background chatter and stuff was so loud we couldn't even hear our own monitors. My attending calmly and forcefully said (without being an ***) "MUSIC OFF, QUIET PLEASE". You never see this attending get panicky and by the tone of his voice everyone in the room immediately knew that they needed to shutup, can the music and pay rapt attention to anything that we needed. You could have heard a pin drop were it not for the pulse ox which sounded like a foghorn in the background. USE THE FORCE.

I completely agree...just simple direct and clear communication is all that is needed to identify the severity of the situation and what is needed to remedy it.

-MT

 

[jetproppilot]

Lady in question.

Picture in question

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Please, please tell me that pic is not real....

 

[Planktonmd]

Lady in question.

Picture in question

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OH DEAR GOD!
This must be one of the most impressive lymphedema cases.
The airway doesn't look bad though.

 

[urge]

OH DEAR GOD!
This must be one of the most impressive lymphedema cases.
The airway doesn't look bad though.

I don't think that's lymphedema. I think she is just fat.


Who is willing to do a fem/sciatic block on her?

 

[epidural man]

Lady in question.

Picture in question

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I'm really impressed with that chair she is sitting on. Who would have thought that it could be that strong. I wonder what brand it is. They should use this picture as advertisement.