So while on call last week...

[DreamLover]

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I am a CA-2 (almost CA3 thanks goodness!!!) in what I consider to be a strong anesthesiology program. I was the senior on call last week when my pager goes off and it is the Pulmonary Fellow on call in the MICU. In my program, we are called for floor airways (yes, even with Pulm fellows if they feel uncomfortable) or any airway for that matter that has been sufficiently mucked with and needs saving.

The Case Scenario: elderly lady admitted from clinic earlier that day with PNA and resp failure, no sig heart, or renal history but she appeard septic when I arrived at the bedside since her MAP was 47. She had the rapid shallow breathing going on and was not following commands at this point. Sats on 100% NRB were 91%, no ABG done.

The Pulm fellow says, "I have a lady that I'd like to intubate for respiratory failure but my intern has never intubated before so I think it would be too rough for her to let him attempt. I'd like to be as least stimulating as possible so I want to do a fiberoptic intubation."

Note: this lady weighs 45 kgs and has no teeth, physical exam does not reveal any signs of difficult ventlation/intubation etc.

At bedside the Pulm fellow has and plans to give all of because she told me this: 6mg Versed, 20mg Etomidate, 100mg Rocuronium

yes, this is an 80 yo frail spetic lady with a MAP of 47

The Pulm fellows then says,"What I normally do is DL while I drive the scope."

I stood there with a puzzled look on my face.

To say the least, the lady got 6 mg Etomidate, 60 mg Sux, then immediately after a 5 sec DL and easy intubation with a Grade 1 view she got 1mg Versed and 120mcg phenylepherine...while they were hanging a levophed drip

The Pulm fellow still had no idea why I was puzzled that a DL while she drove the FO scope was not the least stimulating way to intubate this lady....let alone her proposed pharmaceutical assasination...

Does anyone think I was wrong for doing what I did or for being puzzled that the Pulm fellow (who is finishing in 1 year just like me) seemed to be clueless??

Please discuss...I'm okay with criticism, it's how I learn

 

[DreamLover]

Sure, I get not wanting to f*ck up the airway. However, I don't get the concern about stimulation, specifically. Nothing like a little laryngo-nephrine to keep the pressure from bottoming out...

I agree with you...but the Pulm fellow was worried that her heart rete was already in the 120's (with a MAP of 47 she did not seem too worried about) and she didn't want to stimulate her and make it worse (Yes, I did have the discussion with her that if her heart rate was less than that in this little old septic lady with a MAP of 47 she'd probably be in asystole if you know what I mean...but she just didn't really seem to get it).

I also had the discussion that without some volume, this little old lady would crump with the addition of positive pressure ventilation, when all we had for access was a crappy PICC line....this too was lost on her

Thus since I was there for the airway and am not in the ICU this month (Still glad my last MICU month was intern year and I've been dealing in the Surgical and Trauma ICUs since then), I left the critical care taking up to her and left that situation with my junior resident just kind of shaking my head

 

[rsgillmd]

I am a CA-2 (almost CA3 thanks goodness!!!) in what I consider to be a strong anesthesiology program. I was the senior on call last week when my pager goes off and it is the Pulmonary Fellow on call in the MICU. In my program, we are called for floor airways (yes, even with Pulm fellows if they feel uncomfortable) or any airway for that matter that has been sufficiently mucked with and needs saving.

The Case Scenario: elderly lady admitted from clinic earlier that day with PNA and resp failure, no sig heart, or renal history but she appeard septic when I arrived at the bedside since her MAP was 47. She had the rapid shallow breathing going on and was not following commands at this point. Sats on 100% NRB were 91%, no ABG done.

The Pulm fellow says, "I have a lady that I'd like to intubate for respiratory failure but my intern has never intubated before so I think it would be too rough for her to let him attempt. I'd like to be as least stimulating as possible so I want to do a fiberoptic intubation."

Note: this lady weighs 45 kgs and has no teeth, physical exam does not reveal any signs of difficult ventlation/intubation etc.

At bedside the Pulm fellow has and plans to give all of because she told me this: 6mg Versed, 20mg Etomidate, 100mg Rocuronium

yes, this is an 80 yo frail spetic lady with a MAP of 47

The Pulm fellows then says,"What I normally do is DL while I drive the scope."

I stood there with a puzzled look on my face.

To say the least, the lady got 6 mg Etomidate, 60 mg Sux, then immediately after a 5 sec DL and easy intubation with a Grade 1 view she got 1mg Versed and 120mcg phenylepherine...while they were hanging a levophed drip

The Pulm fellow still had no idea why I was puzzled that a DL while she drove the FO scope was not the least stimulating way to intubate this lady....let alone her proposed pharmaceutical assasination...

Does anyone think I was wrong for doing what I did or for being puzzled that the Pulm fellow (who is finishing in 1 year just like me) seemed to be clueless??

Please discuss...I'm okay with criticism, it's how I learn

You did fine. You probably had more patience than I would have trying to talk to a pulmonary fellow who does not seem to have a clue about the big picture. I'm surprised that a pulmonary fellow this late in the year would be so clueless.

 

[DreamLover]

She's not following commands? I would have just given sux (assuming no contraindications).

I considered that as well, I have intubated people like her with IV Lidocaine alone, or of course in code situations with nothing at all...and honestly, I probally used the etomidate becuase it was there already drawn up....

I asked the Pulm fellow why she wanted to give 100mg of Roc Vs Sux and her response was that, "I've just never used it before"

Is that normal? Do pulmonologists not ever use Sux?

The Pt's K was normal and this lady was up walking in clinic earlier that afternoon...I saw no contraindications to Sux, thus I used it

 

[thegasman]

on this patient i would just slip in the blade, then the tube. nothing else necessary, probably minimally stimulating. (she might cough once or twice - maybe not) if necessary <5cc of prop.

 

[jetproppilot]

I am a CA-2 (almost CA3 thanks goodness!!!) in what I consider to be a strong anesthesiology program. I was the senior on call last week when my pager goes off and it is the Pulmonary Fellow on call in the MICU. In my program, we are called for floor airways (yes, even with Pulm fellows if they feel uncomfortable) or any airway for that matter that has been sufficiently mucked with and needs saving.

The Case Scenario: elderly lady admitted from clinic earlier that day with PNA and resp failure, no sig heart, or renal history but she appeard septic when I arrived at the bedside since her MAP was 47. She had the rapid shallow breathing going on and was not following commands at this point. Sats on 100% NRB were 91%, no ABG done.

The Pulm fellow says, "I have a lady that I'd like to intubate for respiratory failure but my intern has never intubated before so I think it would be too rough for her to let him attempt. I'd like to be as least stimulating as possible so I want to do a fiberoptic intubation."

Note: this lady weighs 45 kgs and has no teeth, physical exam does not reveal any signs of difficult ventlation/intubation etc.

At bedside the Pulm fellow has and plans to give all of because she told me this: 6mg Versed, 20mg Etomidate, 100mg Rocuronium

yes, this is an 80 yo frail spetic lady with a MAP of 47

The Pulm fellows then says,"What I normally do is DL while I drive the scope."

I stood there with a puzzled look on my face.

To say the least, the lady got 6 mg Etomidate, 60 mg Sux, then immediately after a 5 sec DL and easy intubation with a Grade 1 view she got 1mg Versed and 120mcg phenylepherine...while they were hanging a levophed drip

The Pulm fellow still had no idea why I was puzzled that a DL while she drove the FO scope was not the least stimulating way to intubate this lady....let alone her proposed pharmaceutical assasination...

Does anyone think I was wrong for doing what I did or for being puzzled that the Pulm fellow (who is finishing in 1 year just like me) seemed to be clueless??

Please discuss...I'm okay with criticism, it's how I learn

Nice job.

 

[rsgillmd]

I considered that as well, I have intubated people like her with IV Lidocaine alone, or of course in code situations with nothing at all...and honestly, I probally used the etomidate becuase it was there already drawn up....

I asked the Pulm fellow why she wanted to give 100mg of Roc Vs Sux and her response was that, "I've just never used it before"

Is that normal? Do pulmonologists not ever use Sux?

The Pt's K was normal and this lady was up walking in clinic earlier that afternoon...I saw no contraindications to Sux, thus I used it

I reread your original post. All the doses are overboard, but 100 mg of Roc? 😱 She wants to paralyze a little old lady or an elephant?

Anyway, to answer your question, the pulmonologists where I did my residency certainly have used Sux, but where I did my internship they did not. Then again where I did my internship, even when the ICU attending was around he/she called RT to intubate the patients.

When she said she had never used Sux before, I would have asked the fellow if she had used 100 mg of Roc before? 😛

 

[rsgillmd]

Alternatively, maybe she was mixing up Sux and Roc in her head. Did you see the syringe labeled Roc or did she just tell you that is what she wanted to give?

 

[Licoricestick]

Alternatively, maybe she was mixing up Sux and Roc in her head. Did you see the syringe labeled Roc or did she just tell you that is what she wanted to give?

Even if she meant sux, the dose is still too high. 100mg is >2mg/kg for this patient.

Very glad to hear they called for anaesthetic assistance, sounds like the pulm fellow wanted to kill the patient. Why do a "least stimulating" intubation anyway? Chances are she's not going to mount much more of a tachycardia or get her BP up even if you intubate her without any hypnotic or opioid - otherwise she'd be better compensated.

That pulmonary fellow sounds like she needs to do a few more years...very, very scary.

 

[Gimlet]

I did an ICU rotation at a community hospital this year. Our board certified Pulm/CC attending tried to give the other anesthesiology intern and me a talk about drugs and techniques for intubation (he couldn't figure out that we were there to learn CCM, not anesthesia). After a couple minutes it became very apparent how little he actually knew...mislabeling classes of drugs, wildly inappropriate doses a la DreamLover's examples above, descriptions of DL technique that would compromise your view more than optimize it, etc.

It was pretty sad that the other intern and I, having done a couple anesthesia rotations each during med school, could tell that this guy had no idea what he was talking about, and probably had some dangerous practices that he was utilizing every time he went to a code in the hospital as the in-house intensivist.

Maybe I had a bad example, but it's scary that the levels of difference in knowledge of airway managment are so drastic between the specialties. I would expect Pulm/CC to be fairly adept among all the docs in the hospital, behind only Anesthesiology and probably EM. It's a pretty big gap, though.

 

[ssmallz]

When they call me to intubate a patient I choose the drugs and route, if they want to muck around w/airway, I'm goin back to bed. FWIW, I woulda just given a touch of etomidate and brutane, no paralytic necessary.

 

[cchoukal]

on this patient i would just slip in the blade, then the tube. nothing else necessary, probably minimally stimulating. (she might cough once or twice - maybe not) if necessary <5cc of prop.

+1. In my hands, this lady gets topical lidocaine, a towel over the eyes, and a few kind words.

I would look at this as an opportunity to educate the fellow (I know that seems weird since you're junior to him/her). People never really see us as consultants with unique information to share, but rather as technicians to be ordered around and discounted when they don't agree with our advice. But still, I would've pulled him/her aside afterwards and explained your reasoning in a patient, non-condescending manner. E.g.,

1) even though etomidate is "cardiac stable," whatever that means, it doesn't give you license to be irresponsible with dose calculations.

2) The pros/cons of obtunding spontaneous ventilation in general, and in a likely hypovolemic patient with an uncertain airway.

3) DL + FOB = WTF? Several brands of intubating oral airways exist (Berman, Ovassapian), and the tongue-grab and jaw thrust are more than sufficient to augment the FOB view.

 

[Intensivist]

l guess she proposed 100mg of Roc b&c in average healthy/near healthy adult it takes just as sux to produce paralysis, while avoiding "side effects" of sux. Other thing, etomidate in pt who is septic? Even though l think that story with etomidate and suppresion is exaggerated, maybe another agent, if any...
in your experience guys, what causes more drop in BP, small dose of fentanyl, let say 25 mics, maybe lil more or 30 -50 mg of propofol in cases similar to this one?

 

[jdh71]

+1. In my hands, this lady gets topical lidocaine, a towel over the eyes, and a few kind words.

I would look at this as an opportunity to educate the fellow (I know that seems weird since you're junior to him/her). People never really see us as consultants with unique information to share, but rather as technicians to be ordered around and discounted when they don't agree with our advice. But still, I would've pulled him/her aside afterwards and explained your reasoning in a patient, non-condescending manner. E.g.,

1) even though etomidate is "cardiac stable," whatever that means, it doesn't give you license to be irresponsible with dose calculations.

2) The pros/cons of obtunding spontaneous ventilation in general, and in a likely hypovolemic patient with an uncertain airway.

3) DL + FOB = WTF? Several brands of intubating oral airways exist (Berman, Ovassapian), and the tongue-grab and jaw thrust are more than sufficient to augment the FOB view.

I can't agree more with the spirit of this post.

Part of the culture of medicine is mother****ing other specialties to our colleagues in our chosen speciality ( "lulz . . . can you believe what the family medicine resident just did!?!"), and I'm not convinced that it is all bad - it has it's place. What really kind of sucks is when some sort of constructive education does not then occur in these situations.

I'm not a gas guy, but lurk the form because I'm trying to appreciate the anesthesia perspective on many topics (not to mention this is a fairly active forum with any number of interested "characters" to read on any given topic, medical or non-medical that gets brought up) mainly because I'm planning on being one of those pulmonary fellows. I guess that while I know you all may find yourself often laughing at my ******ed ass when it comes to intubation, I know I'd appreciate the education and rationale behind the decision making for induction agents and approach to intubation in any given patient if you think its wrong. I know some of this is institution specific, but most IM get very few intubations during residency (I've done a handful in the ED, ICU, and on the floor), and during fellowship most of us get a month rotating with you guys . . . anesthesia is 3 year gig right, so there is no way we can pick up all of your knowledge in our short time with you guys and in the few situations where we actually do intubate in the MICU. We all KNOW who's going to be best at it, so why not help and make us better?

 

[DreamLover]

Alternatively, maybe she was mixing up Sux and Roc in her head. Did you see the syringe labeled Roc or did she just tell you that is what she wanted to give?

Oh no...it was Roc....because I had to draw up my own sux...and she told me she had never used it before...(And yes, I agree...100mg of Roc in that little old lady was way overboard...all the meds were way overboard)

 

[DreamLover]

I can't agree more with the spirit of this post.

I agree as well, and I did talk to her, and even tried to d/w her the impending problems that will arise with PPV etc. I very nicely asked her why she wanted to give 100mg Roc Vs Sux and she didn't have a better answer than ,"That's the way they always do it, I've never used Sux before" sort of thing. And I did tell her that although Etomidate carries the "cardio stable" ID that it can and will drop the BP, especially in a volume depleted septic old lady just as that one (She didn't seem to appreciate my pearls of wisdom, but since she called for my help, we did it my way)

Part of the culture of medicine is mother****ing other specialties to our colleagues in our chosen speciality ( "lulz . . . can you believe what the family medicine resident just did!?!"), and I'm not convinced that it is all bad - it has it's place. What really kind of sucks is when some sort of constructive education does not then occur in these situations.

Like I said...I did what I could in a short period of time...after all, it was almost 3am

I'm not a gas guy, but lurk the form because I'm trying to appreciate the anesthesia perspective on many topics (not to mention this is a fairly active forum with any number of interested "characters" to read on any given topic, medical or non-medical that gets brought up) mainly because I'm planning on being one of those pulmonary fellows. I guess that while I know you all may find yourself often laughing at my ******ed ass when it comes to intubation, I know I'd appreciate the education and rationale behind the decision making for induction agents and approach to intubation in any given patient if you think its wrong.

Thanks, we all like this forum too, I think. And I wouldn't laugh at you. This wasn't a post because I was laughing at the Pulm Fellow...I was bewildered at the pulm fellow. When she paged me and I called her back and she was trying to tell me that she wanted to DL and do this FOI and I was so confused because none of it made sense I think my silence embarrased her. Her exact words on the phone to me were, "I can tell by your silence that you think I'm crazy." I tried to be as PC as possible but...yeah, pretty much...

I know some of this is institution specific, but most IM get very few intubations during residency (I've done a handful in the ED, ICU, and on the floor), and during fellowship most of us get a month rotating with you guys . . . anesthesia is 3 year gig right, so there is no way we can pick up all of your knowledge in our short time with you guys and in the few situations where we actually do intubate in the MICU. We all KNOW who's going to be best at it, so why not help and make us better?

Anesthesiology residency is 4 years, a mix of 1+3 or 4 depending on the program. I am pretty sure that the anesthesiology residents at my program and on here too, realize we do a ton more airways etc. I am more than willing to teach and be forthcoming.

I don't think any of us have an evil plan to watch everyone stumble and screw up, then swoop in and save the day with our superhero cape on (although that wouldn't be horrible) and then just laugh and laugh and laugh at you. I think anesthesiology residents are pretty laid back and fun to work with (relatively speaking to some of the other specialties). I know that I am approachable....at least I think I am

But don't get me wrong....if someone has screwed up an airway and calls me to come clean it up and it is a life and death situation, I am making a plan on my way there and executing it from the second I walk in the door. I take that very seriously and not much time for chit chat until the airway is secured and my heartrate begins to return to normal.

 

[jdh71]

Anesthesiology residency is 4 years, a mix of 1+3 or 4 depending on the program. I am pretty sure that the anesthesiology residents at my program and on here too, realize we do a ton more airways etc. I am more than willing to teach and be forthcoming.

Right 3 after prelim. I work with a lot anesthesia prelims. So their residency is 3 years. I was unaware of categorical gigs, which makes a lot more sense these days.

I don't think any of us have an evil plan to watch everyone stumble and screw up, then swoop in and save the day with our superhero cape on (although that wouldn't be horrible) and then just laugh and laugh and laugh at you. I think anesthesiology residents are pretty laid back and fun to work with (relatively speaking to some of the other specialties). I know that I am approachable....at least I think I am

But don't get me wrong....if someone has screwed up an airway and calls me to come clean it up and it is a life and death situation, I am making a plan on my way there and executing it from the second I walk in the door. I take that very seriously and not much time for chit chat until the airway is secured and my heartrate begins to return to normal.

I hope it didn't sound like I was implying anything bad about my anesthesia colleagues. In fact, I generally agree about the laid back attitude of many anesthesia folk, which makes them extremely easy to work with, but might also make them less likely to speak up. I wasn't really trying to be critical, just saying that I know *I* would appreciate the discussion about the rationale. I also know that too many pulmonary fellows tend to be douchenozzles and lack the willingness to admit they don't know.

FWIW, I would never myself understand the rationale of this particular pulm fellow wanting to do both DL and scope, nor the doses or choices of meds. I guess not all pulmonary programs are created equal either.

 

[maceo]

I would have just given sux (assuming no contraindications).

not the right answer on many levels....

 

[countingdays]

Seems to me the 6mg of Versed is far more shocking in this old lady than the 100mg of Roc. Rapid sequence dose of roc for an easy intubation pt who's gonna be on the vent a long time isn't a problem. With 6 of versed though, if she strokes from hypotension/hypoperfusion (with hypotension and tachycardia managed by avoidance of stimulation!), at least they'll have plenty of versed on board to confuse the situation.

 

[fakin' the funk]

Oh no...it was Roc....because I had to draw up my own sux...and she told me she had never used it before...(And yes, I agree...100mg of Roc in that little old lady was way overboard...all the meds were way overboard)

Most of the intensivist/pulm fellow-chosen dosages I've seen for etomidate/ rocuronium/midazolam/fentanyl are usually way too low, or injected and then NOT given time to circulate. 30 seconds passes between injection of 10mg etomidate into a 22g PIV and there they go with the DL.

I don't think that the specifics of the various IV "anesthesia" agents are taught much, or as discussed prior, maybe they're taught inaccurately.

And, given that these are generally very ill or frail medical patients, the potential adverse effects are emphasized or overemphasized. "You can never give propofol, it makes people hypotensive and gives them pancreatitis. The potassium is 4, that's too high to use succinylcholine."

So it's usually etomidate (nevermind the adrenal insufficiency angle) and rocuronium (nevermind the apnea angle).

 

[fakin' the funk]

Part of the culture of medicine is mother****ing other specialties to our colleagues in our chosen speciality ( "lulz . . . can you believe what the family medicine resident just did!?!"), and I'm not convinced that it is all bad - it has it's place. What really kind of sucks is when some sort of constructive education does not then occur in these situations.

Right on, brother. I think the inter-specialty backstabbing is totally unprofessional, and I think it weakens physicians as a UNIFIED entity especially when there are reasons to unify. Advanced practice nursing comes to mind.

There is room for humor ("the orthopedic auscultation area") and there is room for education/constructive criticism like this pulm fellow would have likely benefitted from...but the backstabbing nastiness is a total drag in medicine.

 

[DreamLover]

Right on, brother. I think the inter-specialty backstabbing is totally unprofessional, and I think it weakens physicians as a UNIFIED entity especially when there are reasons to unify. Advanced practice nursing comes to mind.

There is room for humor ("the orthopedic auscultation area") and there is room for education/constructive criticism like this pulm fellow would have likely benefitted from...but the backstabbing nastiness is a total drag in medicine.

I started this post for opinions about how I handled the airway, not necessarily about how I handled the Pulm Fellow...which I feel I did quite professionally by the way

I hate if I gave the impression that I didn't tell this Pulm Fellow why it wasn't a great idea to go with her original plan. I did, and I ended the entire episode with telling her to please call me anytime she has any worries about an airway and I would be more than happy to come help. There were no derogatory comments made toward her.

But I can't lie and say that I wasn't a bit shell shocked about her plan and reasoning for it...or lack there of...

 

[Jay K]

on this patient i would just slip in the blade, then the tube. nothing else necessary, probably minimally stimulating. (she might cough once or twice - maybe not) if necessary <5cc of prop.

+1. In my hands, this lady gets topical lidocaine, a towel over the eyes, and a few kind words.

3) DL + FOB = WTF? Several brands of intubating oral airways exist (Berman, Ovassapian), and the tongue-grab and jaw thrust are more than sufficient to augment the FOB view.

DreamLover - I agree, nice job.

I'd have gone the same route as cchoukal (similar to thegasman) with aerosolized lidocaine via an atomizer or just syringe with an angiocath (sans needle) in the posterior oropharynx.

Along similar lines as the DL+FOB, I'm always astounded by the lack of TEE or EGD insertion skills by cardiologists and GI's who ask me to keep the patient awake enough to swallow the probe for them upon command and then sedate them. I think a big part of the anesthetic for these procedures is facilitating the entry of the scopes FOR THE PATIENT in as comfortable and amnestic a manner as possible; Keep them awake enough to swallow your big ass tube? Crazy.

 

[DreamLover]

DreamLover - I agree, nice job.

Thanks

I'd have gone the same route as cchoukal (similar to thegasman) with aerosolized lidocaine via an atomizer or just syringe with an angiocath (sans needle) in the posterior oropharynx.

Along similar lines as the DL+FOB, I'm always astounded by the lack of TEE or EGD insertion skills by cardiologists and GI's who ask me to keep the patient awake enough to swallow the probe for them upon command and then sedate them. I think a big part of the anesthetic for these procedures is facilitating the entry of the scopes FOR THE PATIENT in as comfortable and amnestic a manner as possible; Keep them awake enough to swallow your big ass tube? Crazy.

After reading several of the recent posts about OP GI Suite disasters...I can't say I'm looking forward to that much myself....guess I'll just have to take each case as it comes. How often are cases really cancelled in private practice? I was under the impression that it wasn't many!!

 

[maceo]

Oh, were you there? Why don't you explain why not, instead of just writing that?

from your post you stated no need for a bunch of induction agents on this chick i would have just given sux,..(assuming no contraindications) while i agree with using sux. never use sux by itself. always use it with something to put the patient to sleep first. 1mg of versed 2 mg versed some amidate whatever.. but never alone.. also. just my cursory examination of the case i think i would just sedate with a little bit of whatever.. amidate propofol pentothal and put the tube in like that without anything... i have found off the floor intubations dont need much of anything...

 

[error404]

Our board certified Pulm/CC attending tried to give the other anesthesiology intern and me a talk about drugs and techniques for intubation (he couldn't figure out that we were there to learn CCM, not anesthesia).

Not too related, but why is it that during intern year, every time I rotate through, everyone shunts me the "this will be interesting for anesthesia" cases? (I mean, I get it, they're trying to be nice, but when they're not actually imparting knowledge and are stopping me from learning something outside my usual sphere, it gets irksome.)

/rant

 

[DO4lifer]

in a septic patient, ICU setting...etomidate would probably not be the best choice secondary to adrenal suppression.

i'd agree with the above posters, go with the minimum necessary to pop a tube in this low GCS, septic pt.

 

[Surfer]

1) why is 100mg ROC too much? You're putting this chick on the ventilator, load her up with a stick of roc and put her on an ativan/fentanyl drip.

2) why use sux instead of ROC? do you think she's a difficult airway? do you think that you will want to wake her up in 10 minutes?

I'd use a stick of roc, minimal etomidate, stick the tube in and then tell the medicine team to get a chest x-ray and sedation, and call me if they need help getting a real line for her.