The Learning Curve of Cardiac Life Support

There is a post in my archives in wich I ran my first code as a resident without any outside assistance from the attending.  It was nerve-racking, and I’m sure I was up all night afterwards.  I remember those days of the steep learning curve with a little bit of reverence for who I was back then.  WOuld I put myself through that again?  I’m not sure.

But I am sure of the fact that I’m a lot more confident than I used to be. It’s exactly because we put ourselves directly in the firing line of bad cases…bad hearts, bad lungs, guns, knives, bats and bricks that we learn to practice emergency medicine.

It’s days like the one I’m about tell you that leave me in awe of my responsibility as an ER physician.  This time I was the attending in charge, with a medical student wide-eyed at the entrance to the patient’s room.

She was a frail older woman who had been found by her husband, cold and gray on her bed.  He called 911 right way.  They were unable to intubate her in the field. Failure to intubate by prehospital personel is a huge red flag for a “difficult airway”.

We didn’t know any of the history until the paramedics rolled her into the room, pounding on her chest, bloated stomach with a bag mask spraying bloody spit every time they tried to squeeze air into her lungs.

“She needs a tube,” the paramedic shouted.   “Her vocal cords were too swollen, we couldn’t get anything in.”

Crap.  Swollen vocal cords in a cyanotic patient in cardiac arrest.  The thought crossed my mind, “It’s finally my turn to do a crichothyrotomy in the ER.”  Rather than being fearful of the proceedure, I visualized it happening with minimal blood and simply slipping a 5.0 endotracheal tube through her neck into her lungs.

I began shouting orders as I opened the bedside intubation bag…”Page anesthesia, get the crich set ready, get her on our monitor and attache the defib paddles.  Continue CPR with cricoid pressure…”

We didn’t need paralytics. I used a 4.0 Miller blade and slipped it into her throat. “Suction!” I shouted.  The respiratory therapist thrust it into my hand and I evacuated a pool of bloody spit from her throat.  I continued shouting orders… “Hand me the tube, stop CPR, give me some cricoid pressure…”

I could clearly see the false vocal cords and the arytenoid cartilage, two small bumps that sit above the vocal cords.  But I couldn’t see the vocal cords themselves.  As soon as CPR was stopped, the epiglottis fell down into my field of view.  Crap.

I repositioned the blade, visualized where the cords SHOULD be, and slipped a tiny 6.0 tube into her lungs.  Anesthesia had shown up at my side and helped secure the tube and check the placement.  The airway was in place, but I still had to manage the rest of the code.  I handed the tube over to the nurse anesthetist and respiratory therapist and continued managing the dozen or so people in the room.

“Resume CPR.  Set the vent at 12 per minute, 400 cc, 100% O2, 5 of PEEP.  Feel for a femoral pulse.  Start a 2nd IV line and bolus a liter of Saline.  Give an amp of calcium and bicarb.  Give another round of Epi & atropine. ”

It wasn’t looking good.  She wasn’t responding to anything, she had been down a long time and in asystole…no one would have faulted me for stopping right then and there.  But we had to try and reverse any of the causes of asystole before giving up, so we pressed on.

“Stop CPR,” I said, and all eyes turned towards the monitor.  Nothing. Flat line.  “Resume CPR,” I said.  I had to buy myself a little more time to look over my protocols and see if I was missing anything.  Nope, we’d done it all with the exception of putting a needle in her heart and lungs…but there was no history indicating she had tamponade or pneumothorax.

I waited a minute.  “Stop CPR”.  All eyes watched the monitor.  A rhythm. Sinus tach.  “Feel for a pulse,” I shouted.  “I can feel it,” said a tech.  “Check a blood pressure.”  “One twenty over eighty,” the nurse replied.

I was in disbelief.  She came in dead and now she was “alive”.  I reviewed the case in my mind…  I had secured an airway.  We continued circulating blood to her system and loaded her with meds to help stimulate the heartbeat and counteract deadly accumulations of potassium and acid in her blood.  I had basically followed simply Advanced Cardiac Life Support protocols and it worked.

Was it a “save”?  Well, she ended up dying anyway, but it at least gave her family some hope for a short period of time, and gave them time to gather at her bedside in the ICU to say their goodbyes.

I’ve come a long way since my intern year, and it’s hard to imagine how it is I’ve come to learn all this stuff.  But it’s pretty cool that I have.

Wash Your Feet Every Day

Every once in awhile I realize that Urban Blight Memorial is in a totally different world, and the patients there live a totally different life, despite being less than 10 miles from the downtown of a five time superbowl championship team, and less than 10 miles from where I grew up.

Yesterday’s fastest patient exam of the day went a little like this

She was wearing a stained purple sweatshirt that reminded me just a little of an oversized children’s dinosaur character.   “Hey Doc, my feet feel like they’re crawling,” she drawled.

Me:  Noticing that her boyfriend/fiance/husband didn’t have many teeth either.   “What’s wrong with them?”

Her:  “I just told you.  They’re giving me the creeps.”  She turned towards her boyfriend and smiled at him, large black gaps revealing yellowed stumps of enamel.
Me:  “Well let me see them, where are they?”

Her:  “Right there at the bottom of my legs,” she giggled through a snaggle-toothed grin.

Reddened skin, telltale scale and maceration between the toes ended my exam as soon as it started, and I think I held my breath through the entire thing.

My verbal discharge instructions hit them as if they’d never even considered it before.  “Wash your feet every day with soap and water, dry them off, and put on clean socks every day.”   I emphasized the ‘every day’ part.  The pair of them looked into each others eyes, raised their eyebrows in shock and giggled again.

I just about ran out of the room as I threw the nystatin script at them.  I grabbed an earl grey tea bag and meditated over it for about five minutes before my olfactory senses had recovered.

The ER Gift Card

Here’s a great viewpoint on the high costs of ER care and what ends up being a “class structure” for healthcare.  Let me know what you think.  If you like the article, give it a Digg.

http://www.la2day.com/talk/the_e_r_gift_card_the_perfect_stocking_stuffer

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Things overheard in a coffee shop

An otherwise not-worldly-wise looking woman, sitting at a table right in front of me.  She’s talking about living in Berkley, then moving ‘back east’.  She first mentions a women’s clinic.  Then she mentions a methodone clinic.  Then the people she met while working on a needle exchange program.

Here’s the kicker…she’s working on a “Narcan Project”.  She wants to give out Narcan at the methadone clinic.  Wha???

As sympathetic as I can be, somehow I think there is a limit to what you can do for drug abusers.
 

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