That Other 2% of the Time

I have heard a lot of people say that anesthesia as a specialty is enticing because it is boring and “easy money” 98% of the time.

Then there’s that other 2% of the time. I don’t know if I could stand a boring job.

A 70-year old guy comes in with “tongue swelling.”

“Like what, he bit his tongue?” I asked the nurse.
“No, it’s swollen. You need to see this.”

I go to see the patient and I can only understand about every other word of what the hell he is saying. Bad sign. Well – good sign that he is still breathing. Bad sign that he might not stay that way much longer.
I got a tongue depressor and looked in his mouth. All I saw was tongue. I could press his tongue down about a half-inch from the roof of his mouth and that was it.

Sphincter-tightening moment. This guy is going to need to swallow some plastic pronto.

I once heard one of the nursing supervisors say that “WhiteCoat is slick with things like this – he can get an ET tube up a gnat’s ass with his eyes closed.” This was one gnat’s ass I wasn’t touching. I had the nurse go dust off the cricothyrotomy tray and put it at the patient’s bedside. We started IVs and gave him all the standard “angioedema” medications.

Then we called the anesthesiologist.

This is where the situation became somewhat amusing.

Anesthesiologist gets to the ED. He’s disheveled because it is 4 AM. His hair isn’t combed. His shirt is on crooked. His sneakers look like he was playing sandlot football last weekend and never washed them. Thankfully, he’s got the fiberoptic scope with him. Then he briefly explains how he plans to put a tube down the patient’s throat.
The patient looks at him and yells (in a very muffled voice) “Who the hell are you? Where’s your goddamn name badge? You look like a homeless person!”
It’s hard trying to calm down a patient while biting your tongue and trying to keep from laughing, but I explained that this was the specialist that was going to put the tube down his throat to keep his airway from closing off.
The anesthesiologist sprayed some lidocaine in his nose and throat. Then he took a 5 cc syringe with lidocaine, stuck it through the patient’s cricoid cartilage and squirted the lidocaine directly into the patient’s throat. The patient coughed up some of the liquid, got pissed, and started swinging. It took him a minute to calm down.
Then the anesthesiologist told him that he needed to use a scope to put the tube down the patient’s nose and asked the patient “Which nostril is better for you?”
From the mouth with the ever-enlarging tongue comes the tirade: “How the hell should I know? What are you, some kind of kook? First you go jabbing needles in my neck, then you’re going to stick something up my nose? For shit’s sake, just let me die already, will ya? Just let me die.”

Now we have to make a decision. Put the patient out and risk complete occlusion of his airway or try to do it with him awake and swinging. The anesthesiologist opted to put the patient to sleep.

“Succinylcholine NOW!” He yelled.
The nurse turned to grab the syringe and he said in a louder voice “I need succinylcholine!“
“Get-ting it …” the nurse said in a tone reminiscent of my tweenage daughter right before she rolls her eyes at me.
“Versed, too. I need Versed.”
“Get-ting it …”

I started getting the cric tray ready. “Crap,” I’m thinking to myself, “I’m going to have to cut this guy. I just know it.”

The anesthesiologist is now in a full body sweat. He can’t see anything with the endoscope. We try to bag the patient and no air is going in. All you hear is air making a squeaking sound between the seal on the bag and the patient’s cheeks.

The patient’s airway is officially occluded.

Can my sphincters get any tighter?

The anesthesiologist grabs a laryngoscope to see if there is any way he can orally intubate the patient. He’s going to try to do it blind a couple of times. Unfortunately, he doesn’t tell us what he’s doing. He just grabs the scope and starts fumbling with the patient’s mouth. Of course, as luck would have it, the light on the blade doesn’t work.
“Get me another handle now!”

You can cut the tension in the room with a knife right about now.

I check the backup handle with the blade to make sure it works. He grabs it out of my hand. The pulse oximeter is down to 93%. The anesthesiologist’s hands are shaking and his shirt looks like he just played one-on-one basketball for the past hour.

“Give me a tube. I can see the cords!”

The respiratory therapist started unwrapping a tube.

“Tube, dammit!“

The respiratory tech shoves a tube in his hand. This time the anesthesiologist was the slick one. He threaded that tube into an inflamed hemorrhoidal gnat’s ass.

Everyone held their breath as the respiratory therapist bagged the patient. Condensation appeared in the tube. Capnography good. There was a collective sigh.

The tube was in place.

All of a sudden everyone was laughing and joking. The anesthesiologist went around shaking hands and thanking people. He left to go change his clothing.

Next patient – toothache for 2 weeks. Upset about the wait.

I just love emergency medicine.

Picture credit here – this guy takes amazing insect macros