Great quotes from the emergency dept

[QuikClot]

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Very true. I never once tubed anyone during my medicine residency and now I just started a job that requires intubation. I've watched videos and practiced on dummies, but boy is that first intubation going to suck. They are trying to get me into the OR for practice but it doesn't look like that will happen soon. Any advice? I'm nervous about this.
And wayyy off topic.

Speaking from my lofty peak of a couple of dozen tubes [/sarcasm], my suggestions:

1. Just breath. If the patient is properly pre-oxygenated, you have oceans of time. If you need more, just reoxygenate. Don't panic.

2. Visualize success. You're first tube doesn't have to suck. It may be easy. Intubation is not a hard proceedure -- just high-stakes.

3. Make sure you're getting good crich pressure on your anterior airways. Makes all the difference.

4. When you first try to intubate, you're going to have trouble fitting the blade between the teeth. When that happened to me, I felt stupid -- as if I couldn't even find the ballpark, let alone get on base. But I discovered that everyone struggles with space in the mouth. Go carefully, avoid the teeth, don't worry that you are the first person to have trouble getting the blade in that little space.

 

[RuralMedicine]

Our medicine and pediatric residents get absolutey no experience in intubations. They never intubate patients in the hospital (anesthesia does it; they are even part of the code teams). They never intubate patients in the ED either because all intubations must be done by EM residents who have attended and been certified on our airway course.

Given that I understand why they aren't allowed to intubate (and shouldn't be). However, given that I think your program is failing them (and their potential patients).

Adult ED intubations were probably about 60-70% EM residents (and attendings) and the remainder done by IM/ Gen Surg with the majority of those being IM. IM residents intubate in the ED in the context of their EM rotations (categorical IM does 1 month each year Med Peds somehow ends up with an extra month on top of that exactly how that works we aren't sure) or when patients slated for admission to medicine deteriorate in the department. Also when things get busy at our county ED it's not uncommon to have the patient handed off early to medicine. [ie "I started him on BiPAP 20 minutes ago I think he looks better. RT is doing another gas in 30 minutes either he'll fly or you'll be intubating later"] In other settings I imagine the EP follows a little longer and either "fixes" him or intubates. It worked where I trained because there was a culture of mutual respect and strong communication.

 

[DropkickMurphy]

There are only two kinds of funny stories; ones about our own ignorance, and ones about somebody else's.

DKM's dog-humping analogy for an asthmatic's "breathing" is funny and absolutely dead accurate. As such, it is both a funny story and a good teaching story. You will remember that about asthmatics -- that their breathing often becomes ethusiastic but ineffectual.

It can be read as mean to the resident, but it all depends on tone. If you imagine it in a sarcastic, aren't-you-supposed-to-be-a-doctor voice, it does have a paragod sound to it. If you imagine it in a gentler, let-me-show-you-something-I-had-to-learn-too voice, it doesn't sound mean at all. Insufficient evidence for conclusion. So why don't we suspend the rush to judgement and get back to the stories.

Granted, it was said in a sarcastic, albeit half-joking manner. Trust me, I was taught the same way by the ED docs I work with. They expect us to be on our toes and to call it as we see it and they do the same to us. I've had my fair share of screwups and will openly admit them. Now, back to the stories.

 

[southerndoc]

Given that I understand why they aren't allowed to intubate (and shouldn't be). However, given that I think your program is failing them (and their potential patients).

Adult ED intubations were probably about 60-70% EM residents (and attendings) and the remainder done by IM/ Gen Surg with the majority of those being IM. IM residents intubate in the ED in the context of their EM rotations (categorical IM does 1 month each year Med Peds somehow ends up with an extra month on top of that exactly how that works we aren't sure) or when patients slated for admission to medicine deteriorate in the department. Also when things get busy at our county ED it's not uncommon to have the patient handed off early to medicine. [ie "I started him on BiPAP 20 minutes ago I think he looks better. RT is doing another gas in 30 minutes either he'll fly or you'll be intubating later"] In other settings I imagine the EP follows a little longer and either "fixes" him or intubates. It worked where I trained because there was a culture of mutual respect and strong communication.

I agree that there are educational concerns for medicine residents, even if we do have a >95% fellowship rate in our categorical medicine program. However, policy is policy. I shouldn't argue with it -- it gives us a TON of intubations (at their expense)! It certainly would NOT hurt our residents one bit to give up a few intubations to the medicine residents.

 

[RuralMedicine]

I agree that there are educational concerns for medicine residents, even if we do have a >95% fellowship rate in our categorical medicine program. However, policy is policy. I shouldn't argue with it -- it gives us a TON of intubations (at their expense)! It certainly would NOT hurt our residents one bit to give up a few intubations to the medicine residents.

I'm not sure my first approach to solving the problem would be to use the ED as the opportunity for the IM residents to intubate. If the program I trained in had implemented a "no one except for EM may intubate in the ED" policy I would have still had plenty of opportunities to become competent.

I think it would make more sense to consider endotracheal intubation a procedure a competent internist should be comfortable with. (ABIM takes this stance) Perhaps the OR is the ideal place to learn to intubate (where I trained we did have a required anesthesia month at some point during the intern year) as it's often a more controlled situation. The approach is a little different (one of our Pulm fellows made the point that we intubate people they would never clear for surgery which is sometimes true) but I think you can definitely take valuble tools and skills from the month. Ideally your IM residents would then be able to intubate their patients when it was indicated.

As far as the fellowship arguement I'm not sure that excuses them completely. Obviously if they intend to do Pulm or CC then intubation is a very expected procedure but even in Cardiology and GI it could come in handy.

 

[signomi]

I think it would make more sense to consider endotracheal intubation a procedure a competent internist should be comfortable with. (ABIM takes this stance)

I agree! Here I am working as a hospitalist and medical officer of the day and I am the first call for intubations...and I have had zero training. It is not required by the ABIM though. They have even started waving the thoracentesis "requirement" because a lot of hospitals are moving toward only CT-guided thoracentesis by IR. The only way to get intubation experience was to use your 1-2 elective months on anesthesia, which a lot of fellowship-bound people are disinclined to do.

 

[inked_caduceus]

Not a terribly in-depth story, but I love the fact that my first experience in an ER as a med student was helping to take a history on a guy who had managed to shoot himself in the ass.

Gotta love Detroit Receiving on a Friday night. 🙂

 

[RuralMedicine]

I agree! Here I am working as a hospitalist and medical officer of the day and I am the first call for intubations...and I have had zero training. It is not required by the ABIM though. They have even started waving the thoracentesis "requirement" because a lot of hospitals are moving toward only CT-guided thoracentesis by IR. The only way to get intubation experience was to use your 1-2 elective months on anesthesia, which a lot of fellowship-bound people are disinclined to do.

Interesting. The ABIM procedure logs we were given list intubation as a procedure perhaps that has changed since I started. I do know that the minimum number to be credentialled in our residency for pretty much any procedure was more than the minimum number to sit for ABIM. (Our program directors actually verify we've completed everything rather than a blanket sign off that some program directors do.) I also wasn't aware of the thoracentesis requirement being waivable and it certainly wasn't publicized in our program as I had a few friends scrambling for them in June so they could graduate. Our institution does do a fair amount of radiology guided thoracenteses the problems we had were when it was more urgent/ emergent at nights and on the weekends when IR wasn't readily available. I did a few in that context after being "credentialed". Also our pulmonology / CC attendings would usually do their own (ie supervise the resident or fellow to do) unless they had real safety concerns so the trend was more to think of doing them yourself. Now in practice I have the same situation with IR not being readily available even moreso than in residency. Additionally our radiologist will not touch anyone with an INR over 1.3 (While I agree that one needs to consider the increased risk in these scenarios if it truly needs to be done it would make sense to take the safest approach to doing it. This has not yet been a thoracentesis issue but I've done a few paracenteses here I would have probably handed off to IR as a resident. Fortunately everything went alright but I thought a second and third time about if it really needed to be done and had a very detailed (and well documented) informed consent conversation with the families).

 

[roja]

Key things for improving FIRST LOOK intubation: (remember, in the oR you have tons of time, etc. If you are intubating on the floor/ED you are doing an airway on a sick patient with little reserve. ) Your goal should be to GET THE TUBE THE FIRST TIME.
But realize, with good technique this can be done.

1. Position the patient.... you want the ears lined up with the shoulder. There have been great studies showing this increases your view significantly (and thus your success rate). It usually involves putting a towel or two under the SHOULDER BLADES.
2. Position yourself. Don't bend over, hunched and get your ear on the patients face....
3. SWEEP with your blade. Get your fingers out of the patients mouth *(that wierd thing anesthesia does is a remnant from before paralytics and patients used to bite down. it also keeps you from putting your blade in appropriately. ) Stick the blade in R cheek (away from the tongue) and sweep it in. This gaurantees the tongue isn't in the way. i have seen grade 4's go to a grade 1 with the right technique
4. Keep the elbow off the bed. Lift out with your blade arm.
5. Do your own chric pressure. You are driving, you are seeing. Move the damn thing aroudn tand then hold it there for someone to change hands. If it moves, stick your hand on thiers and move it till you see.
6. Do NOT take your eyes off the chords. ever. Period. trust someone will slap the tube into your hand wihtout you looking. they can see your hand. You need to see the cords.


good luck!

 

[emtp6811]

2. Position yourself. Don't bend over, hunched and get your ear on the patients face....

All of this is great advice, but I especially like #2! I see so many medics hunching over the patient like smelling their dead breath will help, but I am just the opposite. Ever since I learned the spinal precautions position for intubation I have used it every chance I get because I can lean back for a better view, and the more I lean back the better leverage I have to lift the jaw. Granted I am sitting on a floor with their head in my crotch to do this, but the mechanics are the same when you're standing with a patient at waist level. Position your legs one in front of the other like you're about to do a lunge, bend your knees alittle and kind of "sit into" your view, and use it as leverage to lift the jaw and give you more room. [I hope this makes sense, otherwise were both going to look a little freaky... 😳 ]

Also, remember this golden rule: if I can do it, anybody can do it -- and that includes you!

 

[Jeff698]

Not a terribly in-depth story, but I love the fact that my first experience in an ER as a med student was helping to take a history on a guy who had managed to shoot himself in the ass.

If you're willing to take that figuratively, it would describe a large majority of ER patients. 🙂

Take care,
Jeff

 

[DropkickMurphy]

Not a terribly in-depth story, but I love the fact that my first experience in an ER as a med student was helping to take a history on a guy who had managed to shoot himself in the ass.

Gotta love Detroit Receiving on a Friday night. 🙂

Sweet....that's a classic.

 

[signomi]

Just wanted to say that last night was my first night on the job and of course there was a code. 🙄 I was fortunate that he had his dentures out and with the advice of remaining calm and taking my time I got it in on the first attempt. I have no illusions that they will all be easy, but it was good to build confidence. Thanks for the advice.

 

[Doula-2-OB]

More stories, less tangent! 😉

 

[blotto geltaco]

I don't think I have to tell you what part of my anatomy you can very firmly plant both of your lips upon. Oh, wait.....you're obviously not that sharp judging by the fact that you don't realize those are in fact the same condition , so I'll just come out and say it: KISS MY ASS. 👎 Have a nice day.


(Sorry to everyone else for the interruption to the thread. Now back to our regularly scheduled discussion.... )

Nice reply.

 

[DropkickMurphy]

Nice reply.

Why thank you. 😀

 

[mward04]

Okay...I've got two:

"I'm as dry as a popcorn fart"

in reference to her vag d/c...
"I don't get it, my vagina has been really happy for the last month"

 

[deleted6669]

overheard in the ed last week...
ed attending talking to urologist describing urethral trauma/hemorrhage:
"you need to come see this guy, he's bleeding like stink...this guy has PENISTAXIS"

 

[DropkickMurphy]

overheard in the ed last week...
ed attending talking to urologist describing urethral trauma/hemorrhage:
"you need to come see this guy, he's bleeding like stink...this guy has PENISTAXIS"

Ouch.....ouch......did I mention "ouch"?

 

[Febrifuge]

Me, the other day: "So, I need to ask just one more time. Unless you tell me not to, I am throwing away this guy's finger."

3rd-Year resident: "Yep. Oh wait, let me see it."

[we step into the hallway]

Me: "Here ya go."

G3: (Looks at it) "Cool."

Me: "It looks... sad."

G3: "What do we do with it, anyway?"

Me: "Red bag. It gets incinerated."

G3: "Aww. That is sad."

 

[ER-ER-Oh]

Me reading the cheif complaint on the chart: "My **** be hurtin'"
Me looking at patient's penis: "Oh God!"
Me asking patient about the white-green discharge and the many vesicles on his joint: "Where you been puttin' that thing my friend?"
Patient replies: "I been puttin' it everywhere doc, just got out of prison three months ago"

 

[Dr.Evil1]

A student presented this one to me:

CC: Unresponsive

PT is a 54 yo male who was brought in after his girlfriend called an ambulance. Apparently she was talking and he didn't seem to respond to her so she called 911. When I asked the patient he said that he feels fine and just got bored listening to his girlfriend drone on and on so he turned her out.

I just cracked up laughing and discharged the patient ASAP

 

[deleted109597]

3 great CC, as written by the triage nurse. Different people.

"My mouth is not right. I can't even watch TV it is so uncomfortable."

"I have Hep B & Hep C. My liver has been more swollen lately."

"Pt pulled out J tube and then replaced it himself."

 

[docB]

Two great quotes this week:

Guy with blood alcohol of 537 wakes up and says his excessive drinking happened because "I was partying with some homeless guys last night." The homeless party? Who knew.

Charge nurse to novice nurse who is discharging drunk, homeless patient, "Cut off the ID band. Discharging a drunk with an ID band is like pi--ing into the wind. It's comin' back and you won't like it."

 

[Lola713]

How about...

29 YOM presented after attempting to chase his ex-boss down in Wal-mart parking lot....

CC: "I keep seeing Chucky sitting on my chest telling me to hurt myself"

One of the few patients ever that actually left psych resident speechless.

 

[leviathan]

Has anyone ever felt the sudden need to burst out in intense laughter after a patient says something really stupid, but somehow you manage to not even crack the tiniest smirk? I've yet to break my composure, but I know it will probably happen one day. Has anyone laughed in a patient's face, and what did they do/say to break you?

 

[docB]

Has anyone ever felt the sudden need to burst out in intense laughter after a patient says something really stupid, but somehow you manage to not even crack the tiniest smirk? I've yet to break my composure, but I know it will probably happen one day. Has anyone laughed in a patient's face, and what did they do/say to break you?

The last time I laughed out loud at a patient the conversation went like this:
Me: Why are you here in the ER?
Patient: I got real bad pains. I know it ain't nuthing dangerous or nuthin' so I won't get no blood tests or nuthin' but I need some medicine real bad. The only thing that works for me is Demerol and I need 5 times the reglar dose right now or I might die from the pains. Affer that you can just give me some Demerol to go so the pains won't come back.
Me:
The guy just looked down at the floor when I busted up. I think he'd been trying to come up with that for a while and he realized it wouldn't fly.

 

[deuist]

I had a patient with no pain tolerance that I was changing a bandage on. When I was removing the gauze he kept groaning and whimpering, "Please, be careful." After I removed the last of the gauze, he took a deep breath and yelled, "****!" at the top of his lungs. There was a few seconds of silence until I burst out laughing. The patient had a good laugh, too.

 

[docB]

Wasn't said in an ED but the best pop culture quote applicable to EM:

We're just two lost souls swimming in a fish bowl
Year after year
Running over the same old ground.
What have you found? The same old fears.
Wish you were here.

- Pink Floyd, Wish You Were Here

 

[deleted109597]

Me: What brings you here?
Pt: Well, doc, I gots to tell you. Lately I've been, you know, farting out my dick. Seriously. And man do they smell.
Me: [stoneface]I see
EP who consulted: Hey, did I describe the dickfart well enough for you?
Me:[/stoneface]Pretty much to a T

*dreaded colovesical fistula

 

[EM2BE]

Me: What brings you here?
Pt: Well, doc, I gots to tell you. Lately I've been, you know, farting out my dick. Seriously. And man do they smell.
Me: [stoneface]I see
EP who consulted: Hey, did I describe the dickfart well enough for you?
Me:[/stoneface]Pretty much to a T

*dreaded colovesical fistula

One thing I did not know until now. Good to hear now instead of later.

 

[da8s0859q]

Two great quotes this week:

Guy with blood alcohol of 537 wakes up and says his excessive drinking happened because "I was partying with some homeless guys last night." The homeless party? Who knew.

Charge nurse to novice nurse who is discharging drunk, homeless patient, "Cut off the ID band. Discharging a drunk with an ID band is like pi--ing into the wind. It's comin' back and you won't like it."

Thanks for the thread resurrection; this is fantastic.

 

[tastytreat]

40ish gentleman was bird hunting with his brother. brother's gun gets somehow snagged on on a branch and discharges into brother's leg (yes, there were many dick cheney jokes). on xray 27 pellet fragments are found scattered between his ankle and thigh. ortho gets consulted and says there's nothing they can do. i ask my attending if he'd consider a therapeutic mri. he didn't think it was as funny as i did 🙁

 

[ditch doctor]

Drunk driver MVA that would not consent to blood alcohol test. He was a big dude and it took me, another resident, 3 security guards and the 2 cops that brought him in to hold this guy down while the nurse tried to get blood. The whole time he's spitting, kicking and screaming over and over, "F%$ YOU!!" He then thinks for a moment and screams, "I REFUSE TO GIVE BLOOD!!! YOU F__KING BUNCH OF [african american racial expletive]'s AND [hispanic racial expletive]'s!!!! MOTHER F__KERS!!!!"

Then we told him not to curse because there was a lady in the room. He then completely calms down and says in a very quiet voice, "that's not fair bringing a woman in here so I can't curse and cut up. I hate you bunch [string of 3 or 4 hispanic racial expletives].... stealing my job"

We all looked around and noticed everyone in the room white with blonde hair and blue eyes.

 

[iamcatwoman]

Whilst a surgical intern in the UK, was injecting some hemorrhoids in male patient in ED under supervision of entire male team (I was the only female) ...

me: ok, just a little prick.
patient: ooh, a little prick in my ass - now that's a first.

 

[BADMD]

Drunk driver MVA that would not consent to blood alcohol test. He was a big dude and it took me, another resident, 3 security guards and the 2 cops that brought him in to hold this guy down while the nurse tried to get blood. The whole time he's spitting, kicking and screaming over and over, "F%$ YOU!!" He then thinks for a moment and screams, "I REFUSE TO GIVE BLOOD!!! YOU F__KING BUNCH OF [african american racial expletive]'s AND [hispanic racial expletive]'s!!!! MOTHER F__KERS!!!!" .

You held down a guy who was actively refusing to have his blood drawn in order to have it drawn for legal purposes? Did the cops have a warrant? Did you call legal first? That is not a good situation and can definitely blow up on you.

 

[ditch doctor]

You held down a guy who was actively refusing to have his blood drawn in order to have it drawn for legal purposes? Did the cops have a warrant? Did you call legal first? That is not a good situation and can definitely blow up on you.

Don't need a warrant.

Schmerber v. California, 384 U.S. 757 (1966)

 

[DireWolf]

Only 1 in 1000 intubations result in a can't tube, can't ventilate situation where you're forced to do a surgical cric or find alternative means of airway control.

The evidence is clear: paralytics facilitate intubations. You can either paralyze, and take that 1 in 1,000 chance, or you can not paralyze, and fight to get the tube in. Some studies have reported as high as 30% failure rates when using sedation alone.

Interesting. Anesthesiology resident here. We carry the code pager for airway emergencies 24/7. I'd say out of 60 residents, maybe 5 would ever use paralytics to intubate someone in a code situation.

First of all it's not necessary. Second of all code situations are rarely in a controlled environment like the OR. Third of all you just burned a very big bridge - if you can't ventilate the patient then it's game over.

It's personal preference, but for code intubations, I never use paralytics.

 

[BADMD]

Don't need a warrant.

Schmerber v. California, 384 U.S. 757 (1966)

The Schmerber case says that the blood can be entered into evidence. It does not protect you from a battery complaint for holding the guy down while he gets his blood drawn.

Around here, the cops can get a warrant fast enough that they always produce one

 

[ditch doctor]

The Schmerber case says that the blood can be entered into evidence. It does not protect you from a battery complaint for holding the guy down while he gets his blood drawn.

Around here, the cops can get a warrant fast enough that they always produce one

In view of the time required to bring petitioner to a hospital, the consequences of delay in making a blood test for alcohol, and the time needed to investigate the accident scene, there was no time to secure a warrant, and the clear indication that, in fact, evidence of intoxication would be found rendered the search an appropriate incident of petitioner's arrest. P P. 770-771.

 

[BADMD]

In view of the time required to bring petitioner to a hospital, the consequences of delay in making a blood test for alcohol, and the time needed to investigate the accident scene, there was no time to secure a warrant, and the clear indication that, in fact, evidence of intoxication would be found rendered the search an appropriate incident of petitioner's arrest. P P. 770-771.

Yes. Quite right. Schmerber is a case dealing with the exclusionary rule and the fourth amendment. It does not protect you, the physician holding the patient down, from a battery complaint.

Our local laws must vary, as the cops here do get warrants.

 

[The White Coat Investor]

Interesting. Anesthesiology resident here. We carry the code pager for airway emergencies 24/7. I'd say out of 60 residents, maybe 5 would ever use paralytics to intubate someone in a code situation.

First of all it's not necessary. Second of all code situations are rarely in a controlled environment like the OR. Third of all you just burned a very big bridge - if you can't ventilate the patient then it's game over.

It's personal preference, but for code intubations, I never use paralytics.

I agree with you that paralytics are rarely necessary in a code. The recently dead never seemed to have much "airway tone" to fight. Now, let's talk about your comment about the bridge because it's kind of dumb. So we got this dead guy here, some fool paralyzes him and for whatever reason can't intubate him afterward. You say he burned a bridge. I say the bridge never existed. I mean, what exactly are you going to do, let him breathe on his own? If he was breathing on his own (AKA not dead), why the hell are you intubating him?

In EM we don't intubate electively. If we need to "get back over the bridge" we crich the patient. Your approach works for the difficult, urgent airway when you have time to breathe them down a little, muck around with the fiberoptic etc etc, but for the crash airway....either I get it, I don't get it but can bag the patient while screwing around with difficult airway devices/get another set of hands (perhaps even an anesthesiologist), or the patient gets a hole in his neck. Can't intubate, can't ventilate=crich.

The really scary ones are the ones you can't crich either (imagine a nasty Ludwig's angina.) Hopefully you can get these to the OR with an ENT/gen surgeon and an anesthesiologist before it becomes a crash airway situation.

 

[Jeff698]

From a teenage patient's PCP note:

"The patient has dysmorphic features and developmental delay, both of which appear to be familial".

I know he likely was serious, but when read in the context of a 3am ED visit for a runny nose (and when I was getting a wee bit giddy), it seemed there just might have been a different meaning applied to those words.

Take care,
Jeff

 

[deleted6669]

overheard earlier today:
ed attending evaling pt faking aloc-
"if you keep playing possum on me I WILL INTUBATE YOU!"

 

[Annette]

A foley threat works even better!

 

[Faze2]

"You can talk TO me b*tch you ain't gotta talk AT me like that. I ain't a mothaf*ckin child. I got 6 mothaf*ckin kids b*tch and 4 f*ckin grandchildren, I ain't a f*ckin child."

BTW, pt was 38 years old. Can we just please drop condoms out of airplanes over all the entire country?

This rant occured after she asked (yelled "at") the fast track medic, "Why the **** I ain't goin back b*tch I been here for 3 hours and I can't mothaf*cking breath."

Poor kids/grandkids. They really have absolutely no shot at all do they?

 

[neuroprotector]

I saw this on observations once:

PT: I need to see a male doc.
Doc: Okay, let's take a look. *Takes a look* Wow, that's some pretty banged up, uh, machinery.
PT: Yeah, it really hurts.
Doc: What happened?
PT: Well, I was working in my garage, and I sort of leaned over my shop-vac...
Doc: Wait, you were naked in your garage?
PT: Um, yes.

 

[Chronic Student]

Are you implying that you do routine activities fully clothed?

 

[DocFrog]

Pt comes in c/o of "swollen penis"...on exam it is concerning for Fournier's gangrene so we call a urology consult, but the resident/fellow does not want to come down. I'm trying to explain to the resident why we really need him and my attending is beside me shouting, "Tell him it's really swollen...it looks like a sausage...like a Kielbasa!"

Oddly enough, when I repeated, "His penis looks like a Kielbasa" the urology resident agreed to come down...no one else seemed to have as hard of a time as I did keeping a straight face, however.