Spiga


Trau·ma  Junk· ie  ( 'trau-m&  'j&[ng]-kE) n. Slang
  1. One who has an insatiable interest, devotion or addiction to responding and assisting people with serious injury or shock to the body, as from violence or an accident.

My First Time

The ICU at Trauma Hospital is always busy, as I've heard, and this particular day was no exception. Alarms were blaring in the background, post-op open hearts and GSWs were rolling in from ER and surgery 90 miles a minute. Nurses, doctors, and respiratory therapists were always present and on their toes. Every second that you had to sit, you find yourself practically waiting for something to happen. Experience, and even only six hours spent in this unit as a student, will tell you that much.

I finally had a chance to sit down and catch up on some charting. And since the RT and I had a few minutes to spare, I decided this was as good of a time as any to give report.

"Room 401 received their treatment, DuoNeb, at 0741. Sats were 98% on room air, heart rate 76 before and 81 after, breath sounds were diminished bilaterally, respirations--"

Suddenly, I'm cut off by a nurse who runs up to us rather frantically.

"Do you have bed 23?!"

"We do. Why?" I'm instantly visualizing the chart in my mind, thinking about what I have or haven't done.

"The doc wants to tube him. He's declining. Long periods of apnea and mental status has changed, we need you in there NOW."

I look to the RT and he looks back at me. We shrug our shoulders and make way to the room.

"Never a dull moment around here," the RT says, laughing a bit.

It's insane how things can change in an instant. That's what I love about intensive care rotation. One minute, your patient is sitting up on 40% BiPAP in no apparent distress, and the next minute you walk in to find a room full of people crowded around your patient and the monitor, with someone at the head of the bed squeezing an ambu bag the intubation supplies set out on the patient's bedside table.

It sounds sick. But it really isn't. Nothing validates your knowledge or assessment skills like a crashing patient, and your ability to act fast and play a part in their team of health professionals, well, their life basically hangs on that. And that is the best and worst feeling in the world.
Think, TJ, think...

A quick glance at the monitor reveals sats are 88 with bagging, HR is in the low to mid-50s, and B/P is plummeting. Even increasing the FIO2 on the BiPAP to 80% didn't help. All the signs and symptoms this patient was showing indicated intubation...and fast.

I make my way through the crowd of people, to my place at the head of the bed next to the intensive care doc. I'm noting the time, what size blade he is using, the size of the ET tube laying next to the patient's head, and many other things. I reach over and grab the ambu bag from the nurse, giving it a tight squeeze and releasing slowly. And again...about every five seconds.

The pulmonologist looks over at me, the laryngoscope with a size 4 Macintosh blade in his right hand.

Wait...right hand? What the hell? Everyone knows blade in the left, tube in the right...

I'd never have seen this coming, but he handed me the blade.

I'm sure I looked very confused at this point. I mean, I know I'm able to intubate. I got the checkoff in lab, but didn't see this coming.

"Go for it, kid," he gave me a nudge.

Okay. I can so do this.
I positioned the patient's head, placing a towel under his shoulders. I open his airway, using the "cross-finger" technique. I squat down just a little, and slide in the laryngoscope blade.
Vallecula. Epiglottis. Vocal chords. I'm surprised at how clear it looks. It feels like I've been down there forever, but it's only been about four seconds at this point.

Keeping a close eye on my landmarks, I reach for the size 8.5 sitting beside the patient, stylet in place. With the ETT still most of the way inside the package, I give it a slight crook at the end.

I apply a small amount of water-soluble lubricant to the tip of the tube, grasping it firmly in my right hand. I'm not really breathing at this point, because someone once told me if you hold your breath while the patient is without oxygen during intubation, you'll get an idea of how long it takes you to do it and be certain to keep it under 30 seconds from start to finish.

Before I knew it, someone was bagging my patient again. Visible chest rise. 23 centimeters at the teeth. Positive breath sounds in all lobes/bases. I advanced the tube just about a centimeter after the chest xray.

Sats returned to normal, HR increased, and the pt was doing well last time I left.

Having successfully intubated my first patient, I guess you can say I'm no longer a virgin. What was your first time like? I'm curious.

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