Thin line of light...my first awake emergence intubation...

[lfesiam]

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Just want to share with you guys my first code intubation (correction: not awake, guy was in vfib)...this is one of those moments that I will probably remember for the rest of my medical school career...just an hour ago...

I am currently on my rural rotation...a very small midwest community...population 1000s...I am stationed in an ER run by very good FPs...the hospital is very old with limited resources, they can't affoard board certified ER docs or an anesthesiologist...

While working up a pancreatitis dude, the CHF/COPD/Homeless patient across the hall started desating....fast.... EKG shows VTach then Vfib.....holy crap...this dude is crashing.. **** is hitting the fan....lips turning blue...called for help....ran in the room.... started CPR... ER doc started the code...nurses took over chest compression, i got the ambubag, started mask ventilation....ABCs...getting harder to mask ventilate....crap....we gotta tube this dude....

ER doc said "so lfesiam, how many intubations have you done?"

"80 good ones, but I haven't done an awak--"

"No time, I'll give you one shot at it"...

now...the only intubations I've done was on paralyzed patients in the OR with anesthesiologists around to help out....

this was different...but hell, I can do this....

"what blade do you want?" - ER doc

"Mac 3 and 7.5 ET Tube...LMA, Succs or any paralyzer too please!!!"

So...no succs, no propofol, no sedation, no time...3 months of Anesthesiology rotations starting to kick in...acting on reflexes now...

...Took a quick look... vocal cords are opening and closing fast like the gates of life & death...the bed was rocking like a poor little sail boat in the middle of a hurricane from the chest compressions....

my only shot is to go in when the cords are open...1 second window.....that is all I got......totally different from intubating the surgical patient....

.....here goes... gotta timed it just right...I pushed in the tube....whew!...inflated the cuff...secured the tube...hooked on the ambubag...positive breath sound bilateral...sat starting to rise to the 70s....80s...90s....

"CLEAR!"...delivered a shock...

45 mins later after multiple rounds of drugs/shocks...the dude ended up at 90/60 with a pulse, sating low 90s...hooked him on the vent....done.... Called X-ray to verify the ETtube.

Walked to the break room...got a cup of coffee...sat down in front of this computer......and here I am typing......what the heck did I just do?

....sigh....the desparity of rural medicine...I am sad...

My advice to future medical students...Anesthesiology is everywhere...sieze the moment and don't shy away when offered....

PS: Will be doing rural anesthesiology in April 2009 in Thailand. Should be good times and will post any cool encounters.

 

[Fastrach]

Nice job! Only difference at our place would have been that in our ER, the student, ER resident, and ER staff would goose the guy, each after taking 2 looks with a Mac 4 and a Glidescope, only to then chime us overhead to bail their asses out (again) after things have become an absolute ****storm.

 

[drccw]

Good work...
just so you know though, this patient wasn't awake....
VFib- never needs any meds... you'll intubate a lot more code patients....
sometimes you'll notice that they are a little cold....

drccw

 

[lfesiam]

Good work...
just so you know though, this patient wasn't awake....
VFib- never needs any meds... you'll intubate a lot more code patients....
sometimes you'll notice that they are a little cold....

drccw

boy.. i was just talking to the dude a few seconds before he coded... amazing how fast things can change.

 

[DrDre']

Just agonal breathing on a freshie!

GReat job under pressure, Siam!

hope u are having fun otherwise.

Good work...
just so you know though, this patient wasn't awake....
VFib- never needs any meds... you'll intubate a lot more code patients....
sometimes you'll notice that they are a little cold....

drccw

 

[lfesiam]

Just agonal breathing on a freshie!

GReat job under pressure, Siam!

hope u are having fun otherwise.

hey Dr-DRE!! what sup dude!!! long time no talk.

still working on the "design", it will be schweeet.

 

[DrDre']

Nice.

I am eating some good thai food tomorrow. Will think of you. GL with your interviews. dre'

hey Dr-DRE!! what sup dude!!! long time no talk.

still working on the "design", it will be schweeet.

 

[lfesiam]

Nice.

I am eating some good thai food tomorrow. Will think of you. GL with your interviews. dre'

thanks Dre! Try ordering "som tum" on maximum spicy-ness.

Padthai is super easy!

My quick lfesiam's family authentic 1000 years old Padthai recipe:

1) soak rice noodle in luke warm water for about 10 mins
2) prepare sauce: fish sauce, tamarind juice, sugar (1:1:2), heat about 2 min in microwave, mix and set aside.
3) stir fry chopped shallot, garlic, pickled chinese lettuce until golden brown on med. heat
4) turn heat to high, add shrimp, tofu, egg, scallions or asian chives...stir for about 5 mins
5) add noodles, then pour the sauce over the noodles...how much sauce? add about 1/4-1/3 cup of sauce mixture per serving, stir until noodles are soft..about 5 mins (add water or cover the pan to trap in moisture if noodles are too hard)
6) add bean sprout, stir, turn off the heat right away
7) add juice of one lime, crushed peanuts, dry chilli pepper flakes, fresh scallions, cilantro, and any fresh veggies.

walah! enjoy.

 

[huktonfonix]

Awesome recipe! thanks. gotta try that out next time Ifeel like cooking.

 

[jetproppilot]

Just want to share with you guys my first code intubation (correction: not awake, guy was in vfib)...this is one of those moments that I will probably remember for the rest of my medical school career...just an hour ago...

I am currently on my rural rotation...a very small midwest community...population 1000s...I am stationed in an ER run by very good FPs...the hospital is very old with limited resources, they can't affoard board certified ER docs or an anesthesiologist...

While working up a pancreatitis dude, the CHF/COPD/Homeless patient across the hall started desating....fast.... EKG shows VTach then Vfib.....holy crap...this dude is crashing.. **** is hitting the fan....lips turning blue...called for help....ran in the room.... started CPR... ER doc started the code...nurses took over chest compression, i got the ambubag, started mask ventilation....ABCs...

ER doc said "so lfesiam, how many intubations have you done?"

"80 good ones, but I haven't done an awak--"

"No time, I'll give you one shot at it"...

now...the only intubations I've done was on paralyzed patients in the OR with anesthesiologists around to help out....

this was different...but hell, I can do this....

"what blade do you want?" - ER doc

"Mac 3 and 7.5 ET Tube...LMA, Succs or any paralyzer too please!!!"

So...no succs, no propofol, no sedation, no time...3 months of Anesthesiology rotations starting to kick in...acting on reflexes now...

...Took a quick look... vocal cords are opening and closing fast like the gates of life & death...the bed was rocking like a poor little sail boat in the middle of a hurricane from the chest compressions....

my only shot is to go in when the cords are open...1 second..that is all I got......totally different from intubating the surgical patient....

.....here goes... gotta timed it just right...I pushed in the tube....whew!...inflated the cuff...secured the tube...hooked on the ambubag...positive breath sound bilateral...sat starting to rise to the 70s....80s...90s....

"CLEAR!"...delivered a shock...

45 mins later after multiple rounds of drugs/shocks...the dude ended up at 90/60 with a pulse, sating low 90s...hooked him on the vent....done.... Called X-ray to verify the ETtube.

Walked to the break room...grab a coffee...sat down in front of this computer......and here I am typing......what the heck did I just do?

....sigh....the desparity of rural medicine...I am sad...

My advice to future medical students...Anesthesiology is everywhere...sieze the moment and don't shy away when offered....

PS: Will be doing rural anesthesiology in April 2009 in Thailand. Should be good times and will post any cool encounters.

Talented artist, cook, and now you're smokin' tubes in!

Nice job, Dude.

Nice job.👍

 

[geogil]

walah! enjoy.

Sorry, anal French purist here. I imagine you meant to say voilà, no? 😛😀

 

[lfesiam]

read up on crash airway and found this:

Crash Airway Management

This is the case when the patient is in agonal breathing and/or near cardiac-respiratory arrest. Timely intervention is crucial.

1) Oral awake intubation should be attempted first. Although topical lidocaine spray to the pharynx may help, sedation should be avoided or minimized as these patients are hemodynamically unstable and may suddenly collapse. If absolutely necessary, etomidate may be considered.

2) If BMV is indicated, up to 3 attempts may be attempted.

3) If the first attempt is unsuccessful and the patient is agitated or not relaxed, paralysis may be considered in experienced hands, keeping in mind the reservations about muscle relaxants in the ICU.

4) After 3 failed attempts, the operator should proceed to the failed airway algorithm.

 

[leviathan]

read up on crash airway and found this:

Crash Airway Management

This is the case when the patient is in agonal breathing and/or near cardiac-respiratory arrest. Timely intervention is crucial.

1) Oral awake intubation should be attempted first. Although topical lidocaine spray to the pharynx may help, sedation should be avoided or minimized as these patients are hemodynamically unstable and may suddenly collapse. If absolutely necessary, etomidate may be considered.

2) If BMV is indicated, up to 3 attempts may be attempted.

3) If the first attempt is unsuccessful and the patient is agitated or not relaxed, paralysis may be considered in experienced hands, keeping in mind the reservations about muscle relaxants in the ICU.

4) After 3 failed attempts, the operator should proceed to the failed airway algorithm.

Well done, man.

Just got back from Thailand; managed to take a cooking class while there. I can make a mean pad thai now.