Of First Tubes and Delayed Closings...

The night started out just like every other night...diabetic refusal, drunk and disorderly at the mission. At 2300 we were posted way out east. I had just finished my chart from the drunk and was opening my napkin across my lap, about to enjoy some yummy salad the Hubbs had packed for me. Doot Doot Doot, "Engine 22, Medic 723 respond to a 1432 Sanderson road for PD reporting possible assault. Stage and await PD."
"Damnit! My salad looked so good!" I was pretty sure it was going to be BS but I packed up my lunch and put on my gloves and my eye protection. I even pulled out a set and built an IV lock. I taped a trauma band to the wall so that I would remember to give the number to MRH if it came to that. We drove over to the staging area (out of sight of the address given) and we waited. It wasn't 5 min before the radio chirped "Engine 22, Medic 723, you can clear. Non injury."
"Damnit! I knew it. Crap!"
We went back to our assigned street corner. My preceptor and his partner fell asleep. I played solitaire for a while before giving up and closing my eyes as well.
At 0415: "Doot Doot Doot! Engine 22, Medic 723 respond to 1432 Sanderson road for AS1" (this means someone has been assaulted or at least that is what dispatch is calling it). "Wait a second, isn't that?" "Yup". And we were off, lights blazing, sirens blaring.
We arrived to find the nastiest apartment. It was like some frat boys had moved in and locked the door behind themselves. There were holes in the drywall, dirt everywhere and cans of 4 Lokos in various states of consumption lined up along the sofa and the entertainment center. On the floor of the apartment was a young man. He was face down on a sofa cushion writhing around like a wild animal. He was flanked by his brother and a "friend". His brother was significantly older and appeared entirely sober. The same could not be said for the friend. The brother informed us that he had a seizure disorder and he took medicine for it. He said his friend had called when he had started seizing and he had rushed over. That was about eight minutes ago.
I was still half asleep but mesmerized by this creature writhing about on the floor intermittently drooling and thrashing about and then still, staring at us and demanding to know what was happening. Before long we were in the back of the ambulance (here after referred to as "the car" for you non-EMS type). Once in the back he was seat belted to the stretcher and I set to work obtaining vital signs. I got a manual BP and heart rate as my preceptor turned on the monitor. I was attempting to take a respiratory rate when it dawned on my sleep fogged brain that he wasn't breathing. "Ed, he's, uhh, not breathing...." I trailed off. Instinctively I took my pen and squished on his finger to elicit a pain response as I shouted his name in his ear. "Jake! Jake! You need to breath! Jake! Wake Up Dude! You need to BREA..." "GASP!" He tried to sit up and began thrashing around. "Where's my girlfriend?! What the hell?!" He was "awake" but he was staring right through me. He started wringing his hands together and staring at them in a trance. *Meth? or just the Lokos?* I wondered to myself. Nobody said anything about meth...Not that that means a damn thing.... As I was pondering all of this I was hooking him up to the monitor and putting on the end tidal CO2 monitor. This lets us know A. Is he breathing? B. Is he exchanging oxygen and CO2 properly? I hit print on the monitor as I pulled my pre-made lock off the wall and started an IV. "Guess I get to use this on you after all." I said under my breath. I pulled the strip from the monitor and looked at his wave form (this is the tracing that tells us how well his breathing is working and how regular it is) it was ALL jacked up. There were a few breaths and then nothing. I thought about checking the connection at the monitor but instinct made me turn my head and put my hand on Jake's chest. He wasn't breathing. AGAIN. I shouted and squished his finger. I rubbed my knuckles on his sternum. Nothing. I looked to Ed who was getting out the leads for the ECG and I said "He's not breathing." It was almost like Jake heard me because again, he roared to life. This time making less sense and becoming increasingly wild in his movements. "He's not going to tolerate a non-re-breather mask" I said out loud. "Let's just get to the hospital" Ed said to his partner who was at the wheel. We fired up and as we pulled onto the road Ed looked at me. "He's your patient. Do you RSI him?"

RSI means Rapid Sequence Intubation. It is when you decide that someone is no longer able to control and protect their own airway and you need to control and protect it for them by paralyzing and sedating them with drugs, placing a plastic tube in their trachea, inflating a balloon to prevent anything else from getting into their trachea and then breathing for them with a bag filled with oxygen. RSI is a privilege and a HUGE responsibility. There are many states who do not allow their medics to RSI patients no matter how sick or unstable. It is a highly controversial topic in EMS right now. However, it is the gold standard of care for securing and protecting a patient's airway. Rescue airways like the king or the LMA do not secure the airway if the patient vomits. This puts the patient at very high risk for aspiration pneumonia...the reasons I am a fan of RSI go on and on and the research indicating both its strengths and liabilities are the topic for another post.

"How far out are we?" I ask, my voice catching just a bit. "How far to the hospital man?" Ed asks the partner. "Ehh 5min" he says. Ed looked out the window. "Hmmm. I don't think so. I think we are further out than that. What do you want to do?" I froze for half a second. "He's getting worse. He is spending less and less time breathing and more time apneic. He isn't coming around if this is post-ictal. If he's been drinking he's gonna puke. He's not going to tolerate a non-re-breather. I want to take over for him. Let's RSI him." "Ok" says Ed. "Hey partner, call fire back, pull over and join us. We need to tube this dude."

I jumped into the airway seat and began setting up my stuff as Ed began sorting out the drugs. Partner joined us and attempted to place a mask on his face for a little added 02. He woke up and began thrashing around and wringing his hands. He tried to sit up and appeared to be seeing things that none of us were seeing. *This kid is tweaked out of his mind* I thought to myself. I thought through my airway algorithm as I pulled out tubes and checked balloons. I turned on the suction machine and flipped on all of the lights.
"Etomidate is in.....Versed is in..... Succs is in.....30 more seconds....10..9..8......Ok, go time"

I placed my hand on his head and tilted it back, I opened his mouth and placed the blade in his mouth sweeping his tongue to the side. I looked and all I could see was pink and secretions. I held the blade with my left hand and reached for the suction on the wall to my right. I suctioned and repositioned. I hit the release mechanism to lower the head of the gurney with my knee and it crashed down onto my lap. *SHIT!* "Cric pressure please!" *Oh Damn! There they are!*. "I am visualizing the cords. I am passing the tube through the cords. I am in. Bag please." The partner placed the bag on the end of the tube as I withdrew the stylet. I had a death grip on the tube with my left hand as I fumbled to place my stethoscope in my ears with my right. I listened over the epigastrum and then over the lungs. It was so loud in the back of the car with the suction pumping away next to my head but I KNOW what tube in gut sounds like and there was none of that. I bagged him a few times and as the tape was being secured I could feel his mouth working away at the tube and my fingers. "Guys, he's waking up. We need some more sedation on board". Just then the fire medic arrived and the partner jumped out and back into the driver's seat. We were on our way. Jake was starting to writhe on the gurney again and Ed handed the fire medic the Midazolam. It felt like an eternity passed as he drew up and double checked the dose. Finally, Jake relaxed again. I was able to bag him easily again without the disturbing feeling of trying to compete with his own respiratory drive. It felt like days later, we arrived at the hospital. We piled out of the car just as Jake began waking up again. "Shit! He is just burning through this versed guys" I pointed out. It had only been about 7min since the last dose. We rolled into the brightly lit room and the Doc and the respiratory therapist were waiting for us with arms folded. "Good morning" I said. "This is Jake. Jake was at home partying with some friends tonight and we are not clear what happened but Jake had a seizure. Jake has a seizure disorder for which he takes Dilantin. His family and friend say he takes his meds as prescribed and he has not missed any doses. His buddy says he smoked some weed tonight. We arrived to find Jake apparently post-ictal on the floor. Initially he was making some sense and interacting with us. As we loaded him in the car he began making less sense and began experiencing longer and longer periods of apnea interspersed with periods of violent disorientation. We elected to intubate him. Vital signs have remained steady. He has a 8.5 tube, 27 inches at the teeth and when he is properly sedated he is easy to ventilate. He is currently waking up and starting to buck the tube." As if on cue, Jake reached his hand up towards my hand on the tube.
The doc called for more sedation and the RT offered to take over my spot at the airway. I happily relinquished the responsibility and kept watching what he did as I helped the nurse hold Jake down until the Midazolam took effect. "Let's get this young man to the CT scanner. I want to look at his brain and we only have about 10 min before he needs more sedation" the doctor said. As I was gathering up the wires and cords that were spilled all over the floor the doc looked at me. "Is that your tube?" "Yes" I said. "Nice big one. Good work." I blushed. "Thanks" I said, "It was my first one".
Fifteen minutes later Jake was back from the scanner and being tended to in his room by a troop of nurses and the RT. Labs were being drawn, x-rays shot and the tube backed out a little from it's placement in his right mainstem. I went to the bathroom and slumped to the floor. "No fucking way..." I said to myself as my eyes filled with tears. "No fucking way..." Somehow the gravity of what had just happened hit me all at once and there I was teared up on the ED bathroom floor. Adrenalin was rushing through me. My hands were trembling uncontrollably and I thought I was going to be sick. I took a few deep breaths and started to feel it all. *I helped that boy. I helped him breathe. I just did right by that kid. I DID it*. As Ed bragged me up to everyone on the computer. "She got in there an placed it on the first try. Did it like a rock star."

I have arrived on the doorstep of my education. I am ready to learn now because NOW I understand that this job is about 95% no big deal, diabetic refusals, drunk tank brawls. But it is the 5% that makes it life and death. The 5% that makes all the difference. I understand what it means to have a young man's life in my hands. It is huge. It is a terrifying honor. I am ready to learn how to serve my patent's best interest in the 5%.

As if that were not enough for one week The Hubbs and I found out today that the sewer guy "needs more time" and thus we will not be closing on the first of the week after all. I don't know what that means. I don't know when we will close or when we will move. I cancelled the moving van today and then cried. I cried for the unsatisfactory nature of it all. I cried for wanting it to be over. I cried for wanting my mom. I cried out of exhaustion and exasperation. This week has been wonderful and awful all in one. I think I will lace up my sneakers tonight and take myself for a nice long run. The breeze is cool and the sun has gone down for the day. I won't sleep anyway so I might as well get some endorphins cranked up. Tomorrow's another day, I'm thirsty anyway, bring on the rain.....