It’s funny in EMS how you can get talking about something, and then something similar happens. You talk about a bad motorcycle accident or messy GI bleed code and then that’s what you get sent for. Why we were just talking about…
It’s really just random chance. How many times do people use the Q-word and then right away you get a call and it gets very busy? But then again how many times do people use the Q-word and you give them a hard time for saying it, but then nothing happens?
Monday night I wrote the post below (Intubation and Capnography) talking about how I had model tested putting the capnography filter on before intubating and trying to use the wave form while the tube was still being placed to aid in the intubation.
The next morning — the very first call. Not only do I get to try it when orally intubating, I get to try it nasally — and I haven’t done a nasal tube for years.
The call was for unresponsive patient with severe dsypnea. We found an 80 year old female with a GSC of 4-5 breathing at a rate of 60 with cool extremities. Unable to hear BP. Heart rate on the monitor 130-140. Blood sugar – 213. I attached the capnography filter to the end of the ET tube. Some of our ET tubes come with stylets already in them. I removed the stylet, but could not put it back in because it was too thick, so I used a thinner stylet we we stock independently. (Inside the capnography filter is a little bar through its diameter.) I went in, and had a hard time getting the woman’s jaw open enough to see the chords. We don’t have RSI so I was faced with what our intubation survey form calls “inadequate relaxation.” I could just barely get an occasional glimpse of the chords under the epiglottis, but couldn’t get the tube to pass through. Instead of checking by assessing breath sounds, I just looked at the monitor. The ETCO2 would just go straight and I’d know I had gone below the chords. I tried twice and then gave up. I imagined the woman in her comma dreaming about a demon with horns sticking a piece of cold steel in her mouth, and trying to lift her tongue up.
I ended up nasally intubating her, which I probably should have done first, but I like to get a bigger tube in. The nasal tube went in great. I used some neosynephrine, rolled the tube up in a circle to give it some natural curve, lubed it up with jelly and slid it into her right nostril. I used a 6.0 and watched the wave forms appear as I fed it into the hypopharanx. I kept feeding it slow. Then suddenly the form started getting smaller and then down to nothing. I pulled back and repositioned her head and then advanced the tube again, and felt it go through and had the big wave forms to confirm it.
Her SAT went up to 98% from the 80% and her ETCO2 came up from the mid twenties to low to mid thirties. About ten minutes later she puked, so I was glad I had her airway protected. She opened her eyes by the time we were in the ED.
(The next time I do a nasal tube I am just going to hit print button on the monitor from the start so I have a long strip to cut up and show the wave form changes.)
I’m still waiting to hear what was wrong with her. They were thinking sepsis and cerebral hypoperfusion.
A couple curious things about the call:
1. I was in the back alone when I was intubating her — we were on the way to the hospital. After I got the tube in, I thought I need some tape to tie this. I had laid out the mouth tube holder, but the tape was out of my reach. I couldn’t hold the tube and reach the tape. I could barely reach the ambu bag. I’m kneeling in the back of the bus, I’m calling to my partner to pull over for a minute to give me a quick hand — he can’t hear me — I’m getting tossed by the bumps in the road. I ended up just letting go of the tube and hoping it stayed in place, I remembered I had the capnography to tell me if I was still in or not. Its part of the reason I dislike the box ambulance. In the vans everything is in my reach.
2. When I brought the patient into the ER and showed the medical staff the wave form on the monitor, the RT took the capnography filter off the tube when she attached the patient to the vent, and then the doctor called for capnography and they handed him a colorimetric device.
Anyway, I’ll try not to write about hypothetical train wrecks or plane crashes for awhile.