Learning to keep up...

Today I had a bit of a trial by fire.  I had been plugging along, seeing my patients.  We were busy but not overly so.  Then the bottom fell out of the E.D.  At least for me.

I had about 2 more hours left in my shift.  I picked up first one patient and then another within about 15 minutes.  I had to  finish discharging another patient and then I was finally able to focus on my two new patients.  I was in the process of writing orders, etc on these two when I got called to another patient's room for an intubation.

Now intubation means putting in a breathing tube;  a skill I am required (and very excited) to learn.  It wasn't my patient, but the attending felt I should have the chance to try putting one in, and I wasn't about to argue.

So I went into the room.  Confident in my lack of knowledge.  Of course, I'd done anesthesia in medical school.  I think I remember intubating 2 or 3 patients during my time on the service.  But, I hadn't intubated anything except for mannequins for the last 4 years.  Oh, and a ferret and rabbit during an airway workshop when I was a surgery resident.

Under the guidance of my attending and the senior resident I went through the steps for intubation... when I was ready, I inserted the blade, lifted the epiglottis (covers your windpipe when you swallow so you don't choke on food) and looked for the vocal cords that are the "doors of the windpipe."  I lifted, lifted and suddenly, there they were!  Insert the breathing tube, check for a color change on a gauge meaning I was in the right place, and viola!


Of course, all the orders following intubation were left to me, and I still hadn't written my notes on my other 2 patients from about 45 minutes prior.  I was about to sit and start writing my notes when suddenly 2 traumas came in at the same time, and I was told to go in and assess one of them.  Now, I had 4 patients all of whom needed notes, orders, etc.

It took me an extra hour after my shift officially ended to finish cleaning up and signing out. 

In my 13 hour shift I saw:

left-sided pain - discharge to home, most likely muscle strain "oh yeah, I use crack cocaine"

abdominal pain - discharge to home, diverticulosis "great lady, former school teacher"

motor vehicle crash, rear ended - discharge to home, muscle strain "what kind of fun drugs are you giving me for the pain?"

abdominal pain - discharge to home, ovarian cyst

burn to arm - discharge to home, silver sulfadene to wound

chest pain - admit to medicine service, heart attack "last I checked in February I weighed 650 pounds but I think I've probably lost a few pounds since then"

weakness - most likely admit with a need for blood transfusions "I know I've seen you before"

heroin withdrawal - most likely admit for detox "I can't keep living the way I'm living" $40/day habit

shortness of breath - discharge to home, "I saw my primary physician in the office and he said to come here to make sure I wasn't having a heart attack"

weak and dizzy - admit to cardiology service, atrial fibrillation (heart arrhythmia) causing his low blood pressure

motor vehicle crash, T-boned - pelvic fracture will be admitted for sure

The patient I intubated was found wandering around a store not making any sense.  By the time she came into the emergency department she was unresponsive.  We intubated her for her own safety.  I'll have to wait to follow up and see why she was not making sense....

Tags: MVC, intubation, trauma, pelvis fracture