Ned Stark Lesson in Airway.

Those who know me well will know I will use multimedia to teach the life lessons all Resuscitations need to survive and succeed.

Though his career was shortened by a madman of a young king called Joffrey, he is the owner of 3 quotes to live by.

"Winter is Coming."

"When the snows fall and the white winds blow, the lone wolf dies but the pack survives"

The last one is the essential one I will  focus on

 

 

 

The last one took a different meaning last night.

The Patient fell and sustained sign facial injuries. So much so that later after the Airway Act, the patient kept pouring blood from her face from her nose and mouth. Even required for Interventional Radiology to come in the damage control the hemorrhage even after Oral Maxillofacial Surgery attempted their version of damage control to stop the hemorrhage after the patient survived our care so far.

RSI was given for lethargy and presumed worsening mental status of the patient who had come in at the highest Level of Trauma alert, Trauma Alpha. Surgeons were there plenty, and The Resuscitation/Red emergency medicine resident and Red/Resu.scitation EM attending were there to manage the Airway.

The patient was given what we take for granted of course induced coma and paralysis with RSI to allow us to get first pass success on intubation via the mouth. Blood was pouring out of the mouth and nose already.

The cords were visualized, but with one glance taken away from the cords. The view you held beloved, became the view you never got back. And you placed it in where you had thought you had seen the cords before but only a murky bloody abyss was seen. The patient's pulse oximetry later dropped like a brick.

 

Bag Mask Ventilation for Rescue Oxygenation attempted. Sats drop, Blood sprays. about.

The blood sprays over the entire facemask.

Anesthesia called to Trauma Room. I am elsewhere and realize my only purpose in ER life is to Do things that aren't very nice. Life Saving. Game Changing decisions and procedures.

I got there before Anesthesia got there. I note BVM and decision to cut. Always better to cut a patient when the sats are up then to watch a patient die from lack of decision. King LTSD placed size 5. Patient was average height sized up as between 5 to 6 feet tall. No size 4 appropriate King LT found in the Airway Cart.

But found a size 5 King. Difficult to place and in after 2nd attempt. The mouth opening had to be covered as blood sprayed out of the mouth.

Sats rose to 90s% as the surgical airway attempted. More relaxed the scene became. Excessive devices used like a Trousseau Dilator after an initial cut with #10 blade used. A bougie was recommended to extend the capacity of the finger to cannulate the soon to be made the man made cricothyrotomy or tracheostomy.

The King LT was removed. Realized that there is not guarantee that I can cannulate the cords via the King LT while in place with a bougie despite the theoretical small chance in success. It was removed to allow the ETT to lessen the impediment of desired successful passage.

But the path that was deemed correct, #6 ETT in, was soon found to not trigger color change on the colometric ETCO2 device. No misting down the tube. No Chest rise. Someone had stepped on the quantitative ETCO2 device. Needing a new replaced one stat Now.

King LTSD replaced again by Me. Re-attempt in surgical airway commenced again by my surgical colleague. Sats dropping again.

I step in, having forgotten to get a 2nd glove to wear. blood now oozing from the neck. blood still oozing from the face. Left hand covered in blood. I was stuck on the left side of the patient. Extreme conditions make you perform in different conditions now. Patient dies if I don't adapt to what I teach. Fortunately I train in simulation and practice surgical airways monthly for my em residents.

 

I used my gloved hand on the right to perform my laryngeal handshake and stabilize the thyroid cartilage.

I used the pointer finger of the same hand to palpate the landmarks of what should be the cricoid cartilage and feel that desired divot. Patient's RSI medications had worn off. Hard to bag, since the patient started to move her head side to side like Stevie Wonder does when he sings despite attempted in-line cervical spine immobilization by another colleague. The patient needed paralysis again. Once done. I was ale to palpate finally the right place, stabbed the membrane, air sprayed blood out of the opening few times. Yelled for that fortunate friend called the Bougie aka Endotracheal introducer/exchanger. And that non-sentient friend saved my ass. Placed it and then with a new Quantitative ETCO2 device, wave form noted, misting, The device was in.  Wow, it was done.

 

"The you owe it to him to look into her eyes and hear her final words. And if you cannot bear to do that, I tell you this "Do not Paralyze the patient for RSI. Don't act like an ER/DR if you cant perform the essential act."

 

I looked at the patient's closed eyes. I couldn't hear her words. I heard the cardiac monitor speak for her. I heard the monitor cry as she suffered vital signs wise. I  felt her fear when she started to move likely in pain and scared for her life as I cut her neck and struggled with her to ventilate for her.

The man who passes the Sentence should swing the Sword"

 

Give RSI, "the Sentence". Then realize you should swing the Sword, cut with the scalpel

If you fail intubation

If you fail rescue ventilation/oxygenation with an LMA or King LT or BVM.

Cut, Cut, Cut. Man up. Be that person.

 

Thank you Ned Stark. Another episode re-watched. Another lesson learned.

 

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