chicken in esophagus

[Gas you down]

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so you have a big hunk of chicken/beef/whatever stuck in esophagus.

intubate?

if you consider topicalization/mac how confident are you that the GI doc can just push the food through easily? or watch him stuggle for over an hour, pulling it out piece by piece?

but they do it all the time in the ER, with just mild sedation. is this wise?

i decided to intubate, the gi doc said he hadn't seen it in 30 yrs.

how are you going to defend yourself from a lawyer, when you are asked to explain why is there a piece of chicken in the bronchus? (keep in mind you may be supervising)

//first time poster

 

[pgg]

One of my more aggressive residency attendings told me that if these patients were capable of regurgitating or actively coughing or retching up enough to be an aspiration risk, then the chunk of dinner wouldn't be stuck in the esophagus in the first place.

Well, I can sort of see that logic, and maybe he's right, but I intubate these people. They obviously don't meet NPO guidelines, and what we're doing isn't conscious sedation. On a simply practical note, the last one I did was a fish bone that took about 45 minutes to retrieve. Who wants to MAC that and share an unsecured airway?


Why does the GI doc care? If it really does turn out to be a 2 minute procedure as they usually promise (but rarely deliver), the patient's going to be awake and extubated in 5 anyway. I don't see the big deal. I do see some anesthesia providers making their lives harder than necessary doing PITA or ill-advised MACs because misguided surgeons think they're easier or safer.

 

[Idiopathic]

if they do them in the ER, great

if they bring them to you, then you decide...i would lean towards intubation for most of these, based on previous experience with things that are only supposed to "last 2 minutes"

 

[urge]

pent sux tube

When they invite you to the party, they have to understand you are bringing a guest: 8.0 tube.

End of story.

 

[IlDestriero]

pent sux tube

When they invite you to the party, they have to understand you are bringing a guest: 8.0 tube.

End of story.

👍
I really dislike GI.
Struggle, struggle, "I got some of it", (patting himself on the back),
"Where did it go?"
Cough, cough.
"F***".

Not in 30 years my ass. If they have enough sedation to tolerate the snake, I doubt they're protecting their airway.

 

[IN2B8R]

Trying to see the logic of this statement and I, honestly, do not see it: they can still actively cough, retch and aspirate all GASTRIC/pre-pyloric contents once the stuck solid piece has been removed! Your prior attending must have trusted that the suction on a gastroscope never stops sucking! 🙄 The good thing is that you chose to ignore what that particular attending was teaching....😀

One of my more aggressive residency attendings told me that if these patients were capable of regurgitating or actively coughing or retching up enough to be an aspiration risk, then the chunk of dinner wouldn't be stuck in the esophagus in the first place.

Well, I can sort of see that logic, and maybe he's right, but I intubate these people. They obviously don't meet NPO guidelines, and what we're doing isn't conscious sedation. On a simply practical note, the last one I did was a fish bone that took about 45 minutes to retrieve. Who wants to MAC that and share an unsecured airway?


Why does the GI doc care? If it really does turn out to be a 2 minute procedure as they usually promise (but rarely deliver), the patient's going to be awake and extubated in 5 anyway. I don't see the big deal. I do see some anesthesia providers making their lives harder than necessary doing PITA or ill-advised MACs because misguided surgeons think they're easier or safer.

 

[JLM]

About 3 months ago while on call, we got a crew member from 'diners, drive-ins and dives' while they were taping in new orleans. Dude had a HUGE chunk of chicken stuck in the distal esophagus. I know our food is good, but you should still chew it first.


He got a bedside EGD in the ER on propofol (which I tried to argue against) and when GI got done mucking around for an hour we brought him to the OR and did RSI because we considered him an aspiration risk.

Then GI (3 staff, 2 fellows) really went fishing.


4 hours of chicken plucking, piece by piece. It was torture.

Saw him in the quarter less than 24 hours later, booze in hand.

 

[pgg]

Your prior attending must have trusted that the suction on a gastroscope never stops sucking! 🙄

Actually that was exactly what he argued, that the GI guy could suction stuff after he "uncorked" it.

The good thing is that you chose to ignore what that particular attending was teaching....😀

I'm not very smart, but I can be taught ... sometimes by bad example. 🙂

 

[jetproppilot]

so you have a big hunk of chicken/beef/whatever stuck in esophagus.

intubate?

if you consider topicalization/mac how confident are you that the GI doc can just push the food through easily? or watch him stuggle for over an hour, pulling it out piece by piece?

but they do it all the time in the ER, with just mild sedation. is this wise?

i decided to intubate, the gi doc said he hadn't seen it in 30 yrs.

how are you going to defend yourself from a lawyer, when you are asked to explain why is there a piece of chicken in the bronchus? (keep in mind you may be supervising)

//first time poster

I would've intubated the dude.

F u ck your GI colleague.

Nice job. 👍

 

[Ronin2258]

👍
I really dislike GI.
Struggle, struggle, "I got some of it", (patting himself on the back),
"Where did it go?"
Cough, cough.
"F***".

Not in 30 years my ass. If they have enough sedation to tolerate the snake, I doubt they're protecting their airway.

I can see the side of caution. Definitely want the tube myself.

GI are, well...frustrating, to put mildly. At least in my experience.

 

[Arch Guillotti]

pent, sux, tube.

 

[Hamhock]

I can't see "we" (EM) do this all the time, but I can't speak for all of EM...just my experience in a handful of EDs.

First: We don't even SEE this "all the time".

Second: When we do see it, only about half the time the case ends of with EGD. We usually let them sit for a bit with reglan then glucagon vs. CCB vs. nitro...then sit a bit more.

Third: If GI is coming in and asking for us to do the procedural sedation for their EGD (which they don't always do!; both of the hospitals I currently work at let GI docs order sedation meds [benzos and fentanyl max; but they want propofol] and go at it in the ED without EM or anesthesiology - but that's another post about something I am clearly not a fan of at all), I bet most of us would reach for RSI meds and an ETT...ESPECIALLY if glucagon was given - these folks puke like a high-schooler free from parents for the first time (which is something we do see all the time).

I'd actually like to hear what other EM folks would do...I'll try to ask in the EM forum without breaking SDN rules (cross-posting or something).

HH

 

[canjosh]

I can't see "we" (EM) do this all the time, but I can't speak for all of EM...just my experience in a handful of EDs.

First: We don't even SEE this "all the time".

Second: When we do see it, only about half the time the case ends of with EGD. We usually let them sit for a bit with reglan then glucagon vs. CCB vs. nitro...then sit a bit more.

Third: If GI is coming in and asking for us to do the procedural sedation for their EGD (which they don't always do!; both of the hospitals I currently work at let GI docs order sedation meds [benzos and fentanyl max; but they want propofol] and go at it in the ED without EM or anesthesiology - but that's another post about something I am clearly not a fan of at all), I bet most of us would reach for RSI meds and an ETT...ESPECIALLY if glucagon was given - these folks puke like a high-schooler free from parents for the first time (which is something we do see all the time).

I'd actually like to hear what other EM folks would do...I'll try to ask in the EM forum without breaking SDN rules (cross-posting or something).

HH

Similar to my experience in a couple of community EDs. When GI comes they order benzos, tie up as many ED nurses/techs as possible to hold down the actively wretching patient, and go to town. Usually tried to push the bolus into the stomach, and if that didn't work they'd do a basket retrieval of the proteinaceous chunk. Plan C was to actually take the patient to the endoscopy suite...imagine that.

Just like Hamhock's experience, the EM folks were hands-off and out of sight once GI showed up to ramrod the pt.

 

[Oggg]

I did one of these a while ago. Patient had a normal bite of chicken and it got stuck for ~18hrs. Lots of drooling. I didn't even think twice and the patient got some narcs and propofol for a quick MAC. The GI doc just pushed the chicken into the stomach and we were done in <2min.

 

[sevoflurane]

Assuming a normal AW... what is the big frigg'n deal with intubing the patient?

It's like a 5 minute procedure... right around when your sux is wearing off.

I don't understand why people have to make things so complicated.

Just make sure to keep a nice set of Magill forceps handy during laryngoscopy... I love stealing the show (2 times in my short career).

 

[sevoflurane]

👍
I really dislike GI.
Struggle, struggle, "I got some of it", (patting himself on the back),
"Where did it go?"
Cough, cough.
"F***".

Not in 30 years my ass. If they have enough sedation to tolerate the snake, I doubt they're protecting their airway.

Agree 200%.

 

[periopdoc]

Anesthetic #1. Every time. No question.

If you could do it without then why did you call me?

Say hello to my little PVC friend.

- pod

 

[RT2MD]

Assuming a normal AW... what is the big frigg'n deal with intubing the patient?

It's like a 5 minute procedure... right around when your sux is wearing off.

I don't understand why people have to make things so complicated.

Just make sure to keep a nice set of Magill forceps handy during laryngoscopy... I love stealing the show (2 times in my short career).

hehehehe, good times! 😀 How do you bill for that? 😎