Just another saturday night on call

[VentdependenT]

On call at Childrens hospital. Did some cases during the day and got the hospital wide page to Trauma bay at 9pm.

7 year old with some sort of congenital anomaly undergoing chest compressions and bag mask ventilation. Blood pouring from mouth and nose.

First thing I hear from the doc running the code is "this child is a known difficult airway."

No neck, huge head, massive lower jaw. Kid is in PEA. Resident holding mask and resp tech bagging. No oral airway.

What is it with folks not putting in an oral airway?

Anyways I pop one in. She is a difficult ventilation even with me holding jaw thrust and the resp tech (who actually was very good) bagging. The team was extremely helpful in getting me a 5.0 cuff tube and Mac 2 blade and otherwise getting what everyone needed. Well run code. Thank God for the ER (a little different from prior posts eh?).

I couldn't see jack. I mean JACK. Suction. More blood. "Where the f'uk is this all comming from?!!" GI tract? Lungs?

Agonal breaths. Chest compressions. I had no idea if we were moving any air. The lungs were stiff as hell as well as the chest wall. Adrenalin is going. I'm getting slathered in blood. Christ...

After the second try (first with mac2, second with mil2) I told the doc running the code to call for trach on standby. Gonna give it one more shot.

Luckily on the 3rd try I saw bubbles comming up through the pool of blood and saw what may have been posterior aspect of arytenoids. 4.0 cuffed with stylette hockey sticked.

Got it in. How the hell did I do that? Dunno?

Thank God that night is over.

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[toughlife]

On call at Childrens hospital. Did some cases during the day and got the hospital wide page to Trauma bay at 9pm.

7 year old with some sort of congenital anomaly undergoing chest compressions and bag mask ventilation. Blood pouring from mouth and nose.

First thing I hear from the doc running the code is "this child is a known difficult airway."

No neck, huge head, massive lower jaw. Kid is in PEA. Resident holding mask and resp tech bagging. No oral airway.

What is it with folks not putting in an oral airway?

Anyways I pop one in. She is a difficult ventilation even with me holding jaw thrust and the resp tech (who actually was very good) bagging. The team was extremely helpful in getting me a 5.0 cuff tube and Mac 2 blade and otherwise getting what everyone needed. Well run code. Thank God for the ER (a little different from prior posts eh?).

I couldn't see jack. I mean JACK. Suction. More blood. "Where the f'uk is this all comming from?!!" GI tract? Lungs?

Agonal breaths. Chest compressions. I had no idea if we were moving any air. The lungs were stiff as hell as well as the chest wall. Adrenalin is going. I'm getting slathered in blood. Christ...

After the second try (first with mac2, second with mil2) I told the doc running the code to call for trach on standby. Gonna give it one more shot.

Luckily on the 3rd try I saw bubbles comming up through the pool of blood and saw what may have been posterior aspect of arytenoids. 4.0 cuffed with stylette hockey sticked.

Got it in. How the hell did I do that? Dunno?

Thank God that night is over.

And what are you so proud of? Remember intubating is a monkey skill. (just quoting MMD)

 

[goodoc]

Possibly keeping himself collected forming a backup plan and all under a very stressful situation. Kudos.

 

[toughlife]

Possibly keeping himself collected forming a backup plan and all under a very stressful situation. Kudos.

it was meant a joke since MMD says intubating is a monkey skill.

 

[coprolalia]

Well, to further "channel" MilMD, he would say that this is a "no lose" situation. You arive. The kid is in extremis. If you can't get the tube in, no one will blame you. If you do, you look like a complete stud.

Then again, we already know you are a complete stud.

-copro

 

[VentdependenT]

Well, to further "channel" MilMD, he would say that this is a "no lose" situation. You arive. The kid is in extremis. If you can't get the tube in, no one will blame you. If you do, you look like a complete stud.

Then again, we already know you are a complete stud.

-copro

Is it a no lose situation?

Whose gonna "cric" this kid? Me? The doc who has limited emergency airway experience? The ENT who is 15 minutes from the scene? The GS resident who is doing his childrens rotation and has limited, if any, airway experience?

Hrmm....guess who gets the russian roulette bullet? The most experienced airway dude....me. SUcks.

You guys (myself included) may have an IDEA how to do a cricothryotomy on an adult. But what about a kid with no neck?

WHat do you do? Do you back out? Do you do nothing and try and find an LMA? What about all that G*d damn blood?

THats the wall I was up against. ANd it SUCKS. What would I have done?

Gimme a 20g needle and a syringe. Stick the neck. Aspirate. Get air on maybe 2nd or 8th friggen try? Great. Wipe the sweat off my face. Take a deep breath. "scalpel please." Stick horizontal and vertical stab below where I got the aspirate. Shove a cuffed tube in there. Pray to whatever the hell you want to pray to that it works.

Never-the-less, I've enjoyed a few beers today. I got lucky folks. LUCKY.

Vent

 

[militarymd]

You guys have me "down" pretty good.

I never said NOT to take pride in being VERY good at manual skills.....Lap Chole's in 10 minutes....just another monkey skill.


I just like to point out that it doesn't take a "MD" behind your name to have good monkey skills.


I take EXTREME pride in my advanced airway skills, regional skills, etc.....however, I know that these skills has NOTHING to do with being a physician...and what I REALLY bring to the table.

 

[sevoat8]

so what happened to the child? did she make it to the PICU?

 

[VentdependenT]

so what happened to the child? did she make it to the PICU?

I wrote my note after hanging out for 10 minutes after the tube was secured and bilateral breath sounds were re-affirmed. Sats holding. In these situations I hang a while longer to see if anyone needs an extra hand. Pulse came back. Sats 88-91. Sinus? Who the hell knows what that was. It wasn't fast and it wasnt slow and it wasnt normal looking.

After my note I popped my head back in. As they were ventilating I noticed a serosanguinous fluid column rising and falling with each breath. Massive pulmonary edema/hemorrhage. Didn't matter how much of the stuff they let out/suctioned....it kept coming. I took off after seeing that. Doomsday.

Team still thumping away at chest compressions n' hanging product.

 

[coprolalia]

Is it a no lose situation?

Kid is abnormal and in extremis. I'd say that's pretty much "no lose".

-copro

 

[goodoc]

Tough you missed the point intubation is a monkey skill, the ability to act effectivley under pressure and plan is not. One they can teach anyone the other they cannot. These skills are the ones that seperate the purley average from the truly exceptional. The MD can just give you a bigger toolbox to draw from but if you panic and cannot think you will not get a single tool from that box.

 

[MX health]

...

 

[jetproppilot]

Yuk, Venty.

Thats all I can say about that.

Youre a stud. Nice job.

 

[Anesthesia1979]

reminds me of a case I had about 3 weeks ago (not to hijack)...
16 y/o with 6-7 GSW to chest... comes to ER with blood coming out mouth/nose with each breath EMS dudes give and each chest compression...thrown on gurney...

stuck the yankhauer down mouth as far as I could... sucked out 200ml while ventilationg over the yankhauer... as the rate slowed down, I DL'ed and saw more blood but saw some bubbles....

Lssson learned.... tube goes to bubbles when you can't see the cords.

Oh year that kid was dead when he got to the ER, and was dead when he left. But at least the surgery resident got the chance to practice a thoracotomy on someone who never had a pulse or an indication for a thoracotomy.

 

[Planktonmd]

reminds me of a case I had about 3 weeks ago (not to hijack)...
16 y/o with 6-7 GSW to chest... comes to ER with blood coming out mouth/nose with each breath EMS dudes give and each chest compression...thrown on gurney...

stuck the yankhauer down mouth as far as I could... sucked out 200ml while ventilationg over the yankhauer... as the rate slowed down, I DL'ed and saw more blood but saw some bubbles....

Lssson learned.... tube goes to bubbles when you can't see the cords.

Oh year that kid was dead when he got to the ER, and was dead when he left. But at least the surgery resident got the chance to practice a thoracotomy on someone who never had a pulse or an indication for a thoracotomy.

Why not?
Do you think a dead man would object to a thoracotomy if asked his opinion?

 

[toughlife]

Tough you missed the point intubation is a monkey skill, the ability to act effectivley under pressure and plan is not. One they can teach anyone the other they cannot. These skills are the ones that seperate the purley average from the truly exceptional. The MD can just give you a bigger toolbox to draw from but if you panic and cannot think you will not get a single tool from that box.

I was trying to poke some fun at vent and hopefully trying to beat MMD to a sarcastic comment. If YOU didn't get my joke, then you don't know MMD.

 

[goodoc]

just emphasizing the point that these procedures while essential are not really what separate us from a mid-level, our greater education and clinical knowledge are the thing that matters not our "skills" these can be taught to anyone. Nothing personal like I said just emphasizing a point.

 

[toughlife]

just emphasizing the point that these procedures while essential are not really what separate us from a mid-level, our greater education and clinical knowledge are the thing that matters not our "skills" these can be taught to anyone. Nothing personal like I said just emphasizing a point.

Point well taken.

 

[Anesthesia1979]

Why not?
Do you think a dead man would object to a thoracotomy if asked his opinion?

I don't think his parents would have wanted it.... or the extra $2000 they're going to get charged for it....

While they were at it, they could have done a lap appy on him, too... try to get their times down from 2 1/2 hours.