From the beginning of medical school, you are taught the rules of patient assessment; you are taught the “ABCs” – airway, breathing, and circulation. You don’t move on to B until you have established A. You don’t move on to C until B is established. If at any time you lose A or B, you go back to the beginning. Emergency medicine doctors are all about A. My first patient on Sunday night was all about A.
Let me lay out the scene for you: you get a patient who is having an allergic reaction, and everything is swelling. When they start to cough and drool and can barely get their words out, you know you’re headed for intubation (putting a breathing tube in). When you get a heavier-set person with a short, thick neck, you know you should be prepared for anything. I asked for a scalpel to be nearby before I even thought about getting the standard intubation set up, and I was later glad I did. Now, I have performed tracheostomies on patients under controlled settings (i.e., in the operating room or in the ICU), but I never had to perform a cricothyrotomy in the emergency department on a patient who was rapidly becoming critically ill. We spend some time in the cadaver lab learning how to perform this emergency procedure, but somehow, with all the beeping and buzzing of alarms, with the addition of other people coming in and out of the room, with the knowledge that the patient’s family is standing right outside the curtain crying because their loved one is unexpectedly in a dire situation, it’s not that easy. I know my landmarks, I know the technique, and now I know I can handle someone standing behind me going, “So what are you going to do now?” after every failed intubation technique that led up to this procedure.
The somewhat surreal aspect of all this is that once I established A and we got B under control, I was about to breathe my own sigh of relief when suddenly C became a problem. Then came several rounds of medications, another batch of procedures, another bout of handling the inevitable continued questioning, “So what do you want to try now?” I wanted to scream, “Nothing! I want to try nothing. I want to go outside and have a beer in celebration of getting my first cric. I want to be seeing the seven patients I got at sign-out who are currently languishing in their rooms. I don’t want to be here now having to think about C!”
That’s when God gave me some comic relief in His infinite wisdom. We get a heartbeat back, yay! I step outside the curtain to talk to the two adult children of the patient and explain the events of the evening when suddenly a psychiatric patient who was rolled in on a stretcher starts yelling, “Get the &^%$ off of me! Stop touching me! What do you think you’re &^%$ doing?!” Sitting on a stretcher rolling in just behind him is a woman who is wearing an oxygen mask because she is feeling short of breath. She starts to breathe faster. Her daughter, who is standing beside her, starts yelling, “Mama can’t breathe! Mama can’t breathe!”
Three security guards rush in and grab the psych patient. I tell the EMTs to take the short-of-breath patient to a room. Mayhem ensues as the short-of-breath patient is being wheeled past the psych patient, and everyone starts freaking out a little more, and there’s yelling between the two beds. The volume in the ED rises to a fevered pitch, and then… silence. The short-of-breath patient is in a room where she starts to calm down and breathe slower, and the psych patient has been given drugs and has started to fall asleep.
I have talked to the family of my critical patient, and I have started to do paperwork – history and physical, intubation note, cricothyrotomy note, and code note. Almost three hours have passed since I started my shift, and I have been with one patient the entire time. I watch them being wheeled upstairs to the OR for more definitive airway placement, followed by admission to the awaiting ICU. I grab my now-warm bottle of diet soda and take a long swallow before grabbing some charts and getting started with the rest of my shift. It’s what I’m going to do now.
Veronica Bonales is an emergency physician.
