Intern Nightmare Scenarios

[BobBarker]

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Will try to post some interesting experiences from I intern year for our MS4s to think about. These are all things that happened to me last year unless otherwise noted.

Scenario 1
4AM Bathtime
Paged to the ICU at 4am. A 500lb patient had received a trach around 18 hours prior. They had placed him in a trapeze to give him a much needed scrubbing. Usually, PTs try to die during baths, FYI. The trach had become somewhat partially dislodged when they paged me and he had rapidly desaturated. When I arrived at bedside, he was back in bed being ambubagged through the trach satting in the low 90s. His face and tongue were incredibly swollen. It is a a large amount of subcutaneous emphysema. This guy looks like something out of a cartoon his face is so distorted. How do you proceed?

 

[Libertas]

I'll stab...

Sounds like because the trach is partially dislodged you're ventilating in some plane that you shouldn't, causing the edema. Call for ent/surgery, page anesthesia, if they haven't already. The trach is fresh so I don't think you can just pull it all the way out and put it back in. I don't think it would be possible to pass a wire through the trach and try and re-position because who knows where the wire would thread.

Why did he get a trach in the first place? Is it safe/possible to bag from above in the mean time? Might have to re-cut.

 

[BobBarker]

Nice thoughts. I will wait for some more replies before going on further, however he got the trach for chronic respiratory failure directly related to being a fat toad.

 

[Libertas]

If he got the trach for respiratory failure and not airway surgery, oropharyngeal cancer, etc, then I'd definitely try ventilating from above.

 

[BobBarker]

I like that you are thinking ventilation. If the trach is in the airway with the cuff up, bagging from above will probably just make the sq emphysema worse and distend the stomach. You have paged the general surgeon who placed the trach and are awaiting his return call. You are the only physician in house with the exception of the ER. Pt is wide awake still satting in the low 90s with bagging through the trach.

 

[noodler]

You could also try lightly sedating the patient then manipulate the trach while someone else continues to bag ventilate. Ausculate the lungs with the manipulation to determine if air movement improves with re-positioning. Also, since the patient is not crashing yet I wonder if you could use US to determine the placement of the trach and then assess from there, possibly placing a small tube through the trach and then continuing to ventilate (maybe that is completely absurd?).

 

[docrower]

Maybe this is crazy, but if you're worried about exacerbating the subcutaneous emphysema, why not pull the trach and intubate from above? Cover trach site with sterile gauze. Normal anatomy, should increase your O2 sats, prevent further subcutaneous edema.

 

[Planktonmd]

Call for help: Anesthesiology + Surgeon
Do not sedate and encourage spontaneous ventilation.
Do not pull the tracheostomy out and tell them to ventilate with small tidal volumes until help arrives.
When an experienced person is present get a fiberoptic scope and go through the tracheostomy tube while someone is assisting ventilation with mask on top.
Try to get a view of the Carina and then advance the trach tube as much as you can.
If patient is desaturating fast or if you lost the tracheal hole and could not find it with the scope spray the mouth with some topical anesthesia and insert an LMA.
You might have to put pressure on the neck hole to prevent air escape.
In the mean time the surgeon should be ready to explore the neck wound and re-establish the tracheostomy.

 

[Apollyon]

Maybe this is crazy, but if you're worried about exacerbating the subcutaneous emphysema, why not pull the trach and intubate from above? Cover trach site with sterile gauze. Normal anatomy, should increase your O2 sats, prevent further subcutaneous edema.

This brother is 500lbs, and there's you - the intern, in March, and the attending in the ED (unless there are residents down there, too). You might want to leave the trach in, if you are going to try the laryngoscope. If sats are in the 90s, and you pull the trach, and can't even elevate the blade, you've just jumped feet first into the fire. You don't pull the trach until the ET tube is bumping into it.

 

[scudrunner]

Why were they ambubagging him as opposed to putting him back on the vent, especially considering they got him back in bed? This guy needs more O2 than room air supplies. Obviously there is something wrong with the trach, or his airway, since he has sub-q air, but he's still ventilating so it would seem you have some time.

 

[ssmallz]

Sats in the low 90s are airway urgent, not emergent. Currently you are ventilating, not optimally but ventilating none the less. This pt is stable and that's the most important thing. First rule of medicine - do no harm. Don't sedate the pt, don't pull the trach, just keep ventilating and wait for help to arrive.

 

[TrustMe]

Call surgeon and anesthesia. In the meantime, get a fiberoptic scope and difficult airway stuff (should be a box/cart for this in the ICU, if not, it should now be your mission to get this established in said ICU). Stick the fiberoptic scope through the trach. If you see something that looks like trachea/carina, great. Advance the trach. If you just see tissue/blood, continue what ever is currently being done to keep the sats in the 90's and wait for help. When help arrives, excuse yourself to go change your pants and then return to see what the problem was.

 

[BobBarker]

The attendings are giving some sage advice. If you sedate him at all, or try to go from above you have just scheduled your first M&M. Google image angioedema and multiply the most swollen person by 5 and you have this guy.

So you get attending surgeon on the phone.

"Sir, this situation is critical. The trach has become partially dislodged and the patient has extensive sq emphysema. He is satting in the low 90s but is stable."

-"Oh yeah... He probably just needs a long trach. Get a 6.0 shiley XLT. Slip a swizzle stick down the trach. Hold onto the stay sutures, remove the trach and slide the new one in. It's real easy."

"Sir, I do not feel comfortable at all doing that. I have never even scrubbed in on a trach"

"it's real easy..."

The house supervisor has summoned an ER attending for your assistance.

 

[urge]

I wonder if you could use US to determine the placement of the trach and then assess from there,

Ultrasound?..... What would you be looking for?

 

[BobBarker]

Why were they ambubagging him as opposed to putting him back on the vent, especially considering they got him back in bed? This guy needs more O2 than room air supplies. Obviously there is something wrong with the trach, or his airway, since he has sub-q air, but he's still ventilating so it would seem you have some time.

The ambubag is hooked up to 100% oxygen.

 

[urge]

-"Oh yeah... He probably just needs a long trach.."

Did you reply " and you didn't put it in the OR because....."?

Watch out for attendings like this. I'm sure he would throw you under the bus if your trach expedition didn't go as planned.

 

[Libertas]

I'm guessing you mean looked similar to angioedema, but I don't think angioedema would be associated with subq emphysema.... so I'm sticking with the trach is in the wrong place or something else is wrong with airway. I'd be very hesitant to apply positive pressure using the ambu bag to the trach.

Get him out of the sling thing, and sit him up as much as possible. I'd try to convince the surgeon to come asap or get the ED attending to help with a surgical airway at bedside if the situation deteriorates.

The attendings are giving some sage advice. If you sedate him at all, or try to go from above you have just scheduled your first M&M. Google image angioedema and multiply the most swollen person by 5 and you have this guy.

So you get attending surgeon on the phone.

"Sir, this situation is critical. The trach has become partially dislodged and the patient has extensive sq emphysema. He is satting in the low 90s but is stable."

-"Oh yeah... He probably just needs a long trach. Get a 6.0 shiley XLT. Slip a swizzle stick down the trach. Hold onto the stay sutures, remove the trach and slide the new one in. It's real easy."

"Sir, I do not feel comfortable at all doing that. I have never even scrubbed in on a trach"

"it's real easy..."

The house supervisor has summoned an ER attending for your assistance.

 

[BobBarker]

Looks similar to angioedema. I'm not trying to make these tricky. He is in the bed as already stated. Your are close to killing the patient.

 

[Josh1]

As a med student: I love the interesting cases on here, gets me thinking about practical things before I'll actually be in the storm of this. It's also interesting to get a dialogue about cases and see peoples reasoning behind decisions which sometimes you don't get the whole story on the floor because people don't have time to spell it out. Keep it up!

 

[dhb]

You could try some to pass some king of stylet/bougie down the trach and see if you can pass smoothly/ feel tracheal rings then push the trach back over the guide or exchange the trach over the bougie (but not before you get backup).

4am bath?? then people wonder why you get icu psychosis...

 

[cincincyreds]

Well, with that trach in, it sounds like you can ventilate the patient, but you are also causing subcutaneous emphysema which is making this case into a disaster. Since it seems like someone is able to ventilate from above, after calling for all the help you can, pull out the trach, put your finger in the hole, and ventilate from above. Even use an LMA if you have one to make ventilation from above easier. Hopefully, ENT and Anesthesia will arrive with some useful tools to help you out before you need to find a lawyer.

 

[BobBarker]

Convince the surgeon to come in. Hear garage going up, luxury automobile firing up. He is actually en route now. Pt still wide awake, still in the low 90s, sq emphysema about the same. Pt being assisted with bag through trach. ER attending arrives and calls surgeon. Conversation about long trach takes place again. ER attending orders 2mg of Ativan and calls for bougie and long trach. Surgeon still en route, pt status unchanged. We gather our tools and prepare to to try to switch out the trachs.

 

[BLADEMDA]

Convince the surgeon to come in. Hear garage going up, luxury automobile firing up. He is actually en route now. Pt still wide awake, still in the low 90s, sq emphysema about the same. Pt being assisted with bag through trach. ER attending arrives and calls surgeon. Conversation about long trach takes place again. ER attending orders 2mg of Ativan and calls for bougie and long trach. Surgeon still en route, pt status unchanged. We gather our tools and prepare to to try to switch out the trachs.

Good post. However, your future luxury car may look more like this:

 

[Planktonmd]

Convince the surgeon to come in. Hear garage going up, luxury automobile firing up. He is actually en route now. Pt still wide awake, still in the low 90s, sq emphysema about the same. Pt being assisted with bag through trach. ER attending arrives and calls surgeon. Conversation about long trach takes place again. ER attending orders 2mg of Ativan and calls for bougie and long trach. Surgeon still en route, pt status unchanged. We gather our tools and prepare to to try to switch out the trachs.

Here is the rest of your story:
ER attending gives Ativan, patient is now less combative because of: Ativan + Hypoxia + Hypercarbia.
ER attending inserts bougie in hole and feels almost confident that his bougie did go down the trachea, in mean time the patient saturation is now 80% and turning blue.
Stud ER attending pulls the trach out and tries to insert new one in over the bougie... a few tense moments pass, saturation is 50% and heart rate is slowing down... trach is facing resistance and does not want to go in... they can not ventilate from on top because of the severe swelling... ER stud sweating and barking orders to nurses to give atropine... get crash cart.... monitor goes beeeeeeep...
Surgeon still en route!

 

[Arch Guillotti]

I also think this scenario is a distinct possibility. This is a tough situation to be put in as an intern. Looking back on some of the scenarios I was involved in as an intern, I wonder how some of the patients survived.

My guess is that it was sort of uncomfortable talking to the surgeon - but he needs to take responsibility for the patient since he did the procedure after all. You did the right thing in getting him to come in, even if it means telling him that you are in over your head and need help.

I would not give sedation either. ED docs are known to be reckless cowboys😀 so the ativan is to be expected. The good thing for you is that the ED doc now has the ultimate responsibility for the patient.

Since the patient is quasi stable I would wait for the surgeon to arrive and in the meanwhile take the same steps everyone else has outlined - fiberscope, LMA ready etc.

If the ED doc flubs the exchange remember you still have the stay sutures, pull them up and out and try to get the long trach or an ett in the right hole.

Here is the rest of your story:
ER attending gives Ativan, patient is now less combative because of: Ativan + Hypoxia + Hypercarbia.
ER attending inserts bougie in hole and feels almost confident that his bougie did go down the trachea, in mean time the patient saturation is now 80% and turning blue.
Stud ER attending pulls the trach out and tries to insert new one in over the bougie... a few tense moments pass, saturation is 50% and heart rate is slowing down... trach is facing resistance and does not want to go in... they can not ventilate from on top because of the severe swelling... ER stud sweating and barking orders to nurses to give atropine... get crash cart.... monitor goes beeeeeeep...
Surgeon still en route!

 

[BobBarker]

ER doc inserts bougie, feels comfortable he is in the airway. Trach is removed. Multiple attempts at passing trach are made. Sats dropping 60s, I call for a 6.0 tube, 50s, I slide the ETT over bougie into airway, 40s, cuff up bagging ETT, sats rising, good chest rise, Sats up to 100. Surgical site is now a bloody mess but looks like we are in the clear.

 

[BobBarker]

I collect my thoughts thinking we are done and barely escaped. ER doc says that 6.0 went in easy, let's put in an 8.0. Bougie back down the 6.0, it's removed, 8.0 slid over the bougie but won't go in. He grabs a 7.5 and it as well won't go in. Pt now in the 70s and I put the 6.0 back down. Sats back up to 100 quickly. Surgeon and anesthesiologist at bedside 2 minutes later, thank the attending for his efforts and take the pt quickly to the OR. I retreat to the call room in silence.

 

[TrustMe]

I collect my thoughts thinking we are done and barely escaped. ER doc says that 6.0 went in easy, let's put in an 8.0. Bougie back down the 6.0, it's removed, 8.0 slid over the bougie but won't go in. He grabs a 7.5 and it as well won't go in. Pt now in the 70s and I put the 6.0 back down. Sats back up to 100 quickly. Surgeon and anesthesiologist at bedside 2 minutes later, thank the attending for his efforts and take the pt quickly to the OR. I retreat to the call room in silence.

The enemy of good is better. Bad call on the ER guy trying to make a now stable situation into something better. He did a nice job getting the 6.0 ETT in the hole. Now leave it there until surgeon gets there to revise the trach.

Don't retreat to the call room in shame at the situation (only to recover and change your pants). You knew you were in over your head. You called the right people and got the right equipment at the bedside to help improve however you could. ICU call as an intern is rough. It almost isn't fair to the intern or to the patient.

 

[MTGas2B]

A fresh trach (less than 3 days or so) is as good as no trach when it goes bad. Safest move is to secure the airway from above. The big ones can be scary, but not always.

1. Best move, pull the trach, tube from above

2. If the airway looks frightening, the situation is stable and surgical support is quickly available, gather the airway gear, get some help around, and sit tight.

3. You can try to pop an FOB in and drive it back. I'm not a fan of this approach. Big downer you might see big wall of tissue, won't be able to get the trach back in, and burn up your pre-oxygenation that you could have used to do option #1 safely or go from situation #2 to a code while you stir up more bleeding an ruin the partially functioning sub-optimal trach position.

4. Trying to railroad the tube back in with a bougie/yankour/finger is dicey. You might get back in the right place, but you can easily dilate a false tract. You won't know until your patient turns blue. I'd take as the option of last resort

 

[jetproppilot]

Call for help: Anesthesiology + Surgeon
Do not sedate and encourage spontaneous ventilation.
Do not pull the tracheostomy out and tell them to ventilate with small tidal volumes until help arrives.
When an experienced person is present get a fiberoptic scope and go through the tracheostomy tube while someone is assisting ventilation with mask on top.
Try to get a view of the Carina and then advance the trach tube as much as you can.
If patient is desaturating fast or if you lost the tracheal hole and could not find it with the scope spray the mouth with some topical anesthesia and insert an LMA.
You might have to put pressure on the neck hole to prevent air escape.
In the mean time the surgeon should be ready to explore the neck wound and re-establish the tracheostomy.

This Plank dude

KNOWS SOME S h It!👍

SPOT ON

except for the obvious question of

why in the ******* are they bathing a dude In the ICU with a plethora of problems at


4am?


Just sayin'

 

[Hamhock]

1. Best move, pull the trach, tube from above

4. Trying to railroad the tube back in with a bougie/yankour/finger is dicey. You might get back in the right place, but you can easily dilate a false tract. You won't know until your patient turns blue. I'd take as the option of last resort

Regarding #1: If the situation is semi-stable as the descriptions above (sats 90s, spontaneously ventilating), I don't think I would pull that trach -- all you'll end up with is an insufficiently pre-oxygenated, wide-awake fat guy with a likely difficult airway and a bloody, rice krispy neck without any landmarks. I think conisdering options for above are acceptable, but I wouldn't pull that trach until I had a better sense of my success from above.

Regarding #2: I agree there is a good chance of false tract, but I wouldn't say that you don't know that you are in the wrong place until your patient turns blue. I think if you attempt to railroad over a Bougie or better yet a fiber, you just try to ventilate with in-line ETCO2. You should know pretty quickly if you are in subQ or the trachea.

Two random thoughts:

I agree that ativan was probably not the best choice on the part of the ED doc, but I don't really have a full sense of the clinical situation, the available tools, or the ED doc's skill set. I wouldn't reach for ativan, but I would certainly be considering ketamine.

Also, I think this is a another reason we (ie docs who are likely to be in this situation, such as EM docs, anesthesiologists, and full-CCM docs), must be familiar with surgical management of the airway. Watching a trach or a 100 in the OR is nice, but not the same as being prepared and practicing surgical airways.

HH

 

[IveGotTwins]

Here's another critical situation that you may find yourself in as an intern:

You're on a night float rotation. It's the middle of the night. You may or may not have been asleep since your internal clock is a bit off. A floor nurse pages you about a patient that you have no information about except for the one liner on the all important LIST which says nothing but "post-op" or "NTD" or "per (fill in surgical subspecialty here)". Her burning question that could not wait until morning or until the primary team to arrive is: "can this patient eat? He/she's really hungry."

What do you do now?!?!

 

[pgg]

Here's another critical situation that you may find yourself in as an intern:

You're on a night float rotation. It's the middle of the night. You may or may not have been asleep since your internal clock is a bit off. A floor nurse pages you about a patient that you have no information about except for the one liner on the all important LIST which says nothing but "post-op" or "NTD" or "per (fill in surgical subspecialty here)". Her burning question that could not wait until morning or until the primary team to arrive is: "can this patient eat? He/she's really hungry."

What do you do now?!?!

Heh. Nurses who'd page me with diet questions in the middle of the night filled me with irrational rage. Of all the inappropriate pages, this exact issue got under my skin the most.

The correct answer is always: "No. The patient won't die of hunger before breakfast. And while you're on the phone, please remember that 99.8 is not a fever and nobody cares if a Foley-less patient has been anuric for 4 hours."

 

[RxBoy]

Her burning question that could not wait until morning or until the primary team to arrive is: "can this patient eat? He/she's really hungry."

What do you do now?!?!

ICU nurses may be nagging, but they are by no means stupid. Used to date one, they know the patient game better than we think. They don't fight a war they can't win. An intellectual war would be suicide. But they are masters at the war of attrition. Ask a resident for an ativan order at 10 pm, they will refuse and might even give a logistical reason why. But ask them at 2 am, then 3 am, then 4 am.... It will bring any resident to their knees begging for mercy.

 

[dhb]

ICU nurses may be nagging, but they are by no means stupid.

I disagree

they know the patient game better than we think. .

That's because they're women... or gay (or both the worst)