A is for Airway

I had to go home for two days to attend to my mother, but this is the blog entry I would have written after my last shift on Sunday night had I had a choice other than using her slow-as-molasses dial-up or typing out my entire post on my iPhone.

From the beginnings of medical school, you are taught the rules of patient assessment; you are taught the "ABC's" - Airway, Breathing, Circulation. You don't move onto B until you have established A. You don't move onto C until B is established. If at any time you lose A or B, you go back to the beginning. Emergency Medicine docs are all about the A. My first patient on Sunday night was all about the A.

While it's difficult in this setting to talk about the specifics of a case, let me just lay out the scenario for you. You get a patient who is having an allergic reaction and everything is swelling. When they start to cough and drool and can barely get their words out, you know you're heading for intubation (putting a breathing tube in.) When you get a heavier set person with a short thick neck, you know you should be prepared for anything. I asked for a scalpel to be nearby before I even thought about getting the standard intubation set up. And, I was later glad I did.

Now, I have performed tracheostomies on patients under controlled settings (i.e. in the operating room or in the ICU), but I never had to perform one in the Emergency Department on a patient that was rapidly becoming critically ill. We spend some time in the cadaver lab learning how to perform this emergency procedure, but somehow with all the beeping and buzzing of alarms, with the addition of other people coming in and out of the room, with the knowledge that the patient's family is standing right outside the curtain crying because their loved one is unexpectedly in a dire situation, it's not that easy. I know my landmarks, I know the technique, and now I know I can handle an attending standing behind me going, "So what are you going to do now?" after every failed intubation technique that lead up to this.

The somewhat surreal aspect of all this is that once I established the airway and we got B under control, I was about to breathe my own sigh of relief when suddenly C became a problem. Another round of medications, another round of procedures, another bout of handling the inevitable continued questioning, "So what do you want to try now?"

Nothing, I want to try nothing. I want to go outside and have a beer in celebration of getting a breathing tube in my patient. I want to be seeing the seven patients I got at sign-out who are currently languishing in their rooms. I don't want to be here now having to think about the C!!!!

That's when God, in His infinite wisdom, provides me with some comic relief. We get a heartbeat back, yeah! I step outside the curtain to talk to the two adult children of the patient and explain the events of the evening when suddenly a psych patient that had just rolled in starts yelling, "Get the &*^%$! off of me! Stop touching me! What do you think you're ^&%$ing doing?!?" Sitting on the stretcher just behind him is a woman who is wearing an oxygen mask because she was feeling short of breath. She starts to breathe faster. Her daughter, who is standing at her bedside starts yelling, "Momma can't breathe! Momma can't breath!"

Three security guards rush in and grab the psych patient. I tell the EMT's to take the short of breath patient to a room. Mayhem ensues as the SOB (short of breath) patient is being wheeled past the psych patient and everyone starts freaking out a little more and there's yelling between the two beds. The volume in the E.D. rises to a fevered pitch, and then... silence.

The SOB patient is in a room where she starts to calm down and breath slower, and the psych patient has been given drugs and he has started to fall asleep. I have talked to the family of my critical patient, and I start to do paperwork - history and physical, intubation note, cricothyrotomy note, tracheotomy note, code note. Almost three hours have passed since I started my shift, and I have been in with one patient the entire time. I watch them being wheeled upstairs to the O.R. for a more definative airway placement followed by placement in the awaiting ICU.

I grab my now-warm bottle of diet soda and take a long swallow before grabbing some charts and getting started with the rest of my shift....