What a difference a day makes

So, unlike yesterday, when I just wanted to melt into nothing after the shift, I actually had a pretty decent shift today. I managed to get props from one attending for being particularly sympathetic to the needs of a patients family. They felt guilty about not wanting to subject dear old (over ninety and fading fast) dad to the horrors of 'heroic effort' care that they had inflicted on mom. I picked up on this, and in my own particular way told him that it was okay, and that if I was in his father's place I might likely want my kids to make the same decisions.

Also, my treatment strategies were uniformly accepted with little or no tweaking by the attending. I was also early in starting antibiotics. Actually, this brings up an interesting point; Emergency Centers are being pressured to begin antibiotics early. They keep track of how much time elapses between when you see the patient and when they get their first dose of antibiotics. While this is generally a good idea, some problems do arise. First, what you start doing is initiating antibiotics before you even know what you are treating. I don't mean that you don't know what type of pneumonia you are treating, but you do not know what the source necessarily is. You make a guess at what the cause might be, draw cultures, and then you start a wide spectrum antibiotic. Usually this works well, and by the time you have identified the source, they already got their first dose, and all you do is switch to a narrower, more appropriate drug. So, we get this patient is who is a poor historian due to age related cognitive impariment. He has a temperature, and a good story for infection. He also has a penicillin allergy. So, we switch up our broad spectrum a little but and include Gentamicin. No big deal, right? Well, When we do the Cat scan of his abdomen, we find out that the patient has only one kidney. This is a problem because Gentamicin can damage the kidneys. So, if the filtration of the Gentamicin is all lumped onto one kidney, it is more at risk, and it also has no spare. So, if his kidney takes a hit, then he goes onto dialysis, and he goes from being a regular medical floor patient on antibiotics for a few days, to an ICU patient who either gets his kidney back, or goes onto the very bottom of a very long transplant list.

Anway, the shift went well. The high point of the whole affair was when we had to intubate a patient going into DT's. It was the attending's patient, and he let me have a crack at it. After sedating and paralyzing him, I went in with the curved blade, and all I saw was a floppy epiglottis. I came out, switched to a Miller blade, and went back in. Two swollen red pillows that once were arytenoids were all I could see. I could not see the vocal cords at all. So, after the second try, the attending went in, and he tried. Twice. No luck. The attending decided to let me have one more shot at the tube before we "will have to come up with plan 'B'." So, I marshalled my forces, and got my gear together. I turned to the nurse on my right, and told her I felt like this was a high noon showdown between me and the patient in some dusty old west town. I wanted to hear some of Ennio Merricone's music from "the good, the bad, and the ugly." After we bagged the patient up to a saturation of 97% oxygen, (it was his max), I went back in,and was greeted with blood and froth. I suctioned it out, and lifted the blade. This time, I saw it. Sort of. Waaaay in the back, behind those red, angry pillows that were arytenoids gone bad, I could see a little inverted triangle of black that was the trachea. It was too small for me to see the vocal cords on either side that were millimeters apart. I advanced the tube, which obliterated my view once it went over the arytenoids, and. just. shoved.

I did not know if I was in. The respiratory tech said he thought I was.  The CO2 indicator went from purple to yellow (consistent with tracheal intubation), and I could see condensation inside the tube. We had breath sounds, and that was it. I had gotten it.  What makes it such a boost to my shift is the fact that I got an intubation when my attending couldn't.

Anyway, it was a really good shift.

Respectfully Submitted,
-doc Russia