Feb 27

Soon…not yet, but soon

You’re not all that fat, but still a tricky airway to manage; I knew you’d give me problems when your head dropped back in that heavy, final way. Your wife didn’t know you’d arrested, but she knew you were very, very sick. I shut the back doors, shaking my head apologeticaly – no, no, you guys drive to the hospital, there’s not a lot of room in here, we’re going to be very busy.

She doesn’t want to watch this. She may think she does. She really doesn’t.

Your face is slick with sweat and makes my hands slip over your cheeks and chin, just a hint of middle aged jowl pulling your face away from the mask, reducing the efficacy of the seal, blowing oxygen around your face rather than into your lungs. When I do push air into you, your chest rises and falls while your stomach rises and remains. I’m breathing for you, but your stomach is filling up rapidly.

You say “Urp.”

A sludgy tide of orange vomit crawls up into your mouth while I’m doing chest compressions; passive regurgitation, we call it. Not vomitting, just opening all the tubes and letting fluids and pressures find their own levels. Your mouth brims with the stuff and as the vehicle bumps over potholes, you slop like an over fill soup bowl in a ferry’s cafeteria. Vomit cascades out of your mouth, up your nose, into your eyes and hair.

I whack the suction up as high as it can go, hoover the goop out of your mouth and nose; momentarily fret about the state of you – live fast, die young…

The bag and mask still won’t push air in. It’s blocked by something, but your mouth is empty, your nose is clear.

Fuck this.

I grab the response bag and pull out a laryngoscope with the longest blade I can find. The last time I did this was on a 64 year old man, with no teeth, having a laparoscopic cholecystectomy. I had two anaesthetists and an ODP watching me.

And the fucking bed and floor weren’t moving at the time.

Push the head into position, slide the blade down the right hand side and sweep the tongue, now lift…don’t lever on the teeth…lift, pull his neck towards the far corner of the room.

There. His larynx. Packed full of spew.

The suction catheter shimmies down along the laryngoscope blade and sooks the last of the gunk from his airway. His vocal cords wave at me, a fleshy “peace out” V shape, with darkness behind them.

You’d be such an easy intubation. I could shove a tube down there right now. It would secure your airway, you could vomit all you like and it wouldn’t matter a docken, I could concentrate on CPR, rather than clearing your throat of acrid lentil soup.

But you’re young. And you’re going to die. I’m realistic about this.

There will be a post-mortem. They’ll ask who intubated.

And the response will come back – “The unregistered paramedic in the ambulance.”

And I’ll be struck off before I’ve even practiced.

Sorry mate. There’ll be folk in my career who I’ll tube who AREN’T going to die. From the history your family gives me, your chances are terrible. I’m confident I know what stopped your heart today; I’ve never seen anyone survive this.

You’re a lost cause.

But I’m not.

29 Responses to “Soon…not yet, but soon”

  1. Angor Animi says:

    Good self control there Kal! If you don’t fancy such a challenge when the time does come to intubate a patient, you can always ask your mate to pull over. You can do quite a lot of damage with an ultimely jolt of a laryngoscope blade, even if you are just taking a look to suction.

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  2. Dumpling says:

    A good call but not one that sits very comfortably.
    You make decisions on the best outcome and this wasn’t
    going to be a happy ending. You have my respect.

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  3. Chris Rigby says:

    Agreed. I don’t know whether I’d have been able to restrain myself like that.

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  4. Chris Rigby says:

    Also, if you haven’t heard of it, I reckon this’d be a good contribution to the next edition of “The Handover” (http://medicblog999.wordpress.com/2009/02/27/the-handover-edition-1/) if you’re interested

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  5. Vetnurse says:

    To know what you can do or not do within your cabilities is more important than a piece of paper.

    I have known people with the paperwork do things that were way outside their abilities because they wanted to “have a go” to see if they could do something even though the patient could be left for more experienced hands, the outcome was never in doubt the patients died at some point during or after wards.

    Those l have known that have said ok l have not done … before but l have no choice if l do not the patient will die and they may die anyway. Those patients have a better chance.

    Know, understand and accept your abilities but also know when you need to go outside them and understand the reason for it.

    From what you have written now and in the past you are doing pretty good so far.

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  6. Stuart says:

    Knowing what you can do is one thing, but unfortunately putting that into practice without the paper leads to bad things. It’s unfortunate but that’s the way it works

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  7. Mako says:

    So the day came, that you didnt want.
    All because of a stupid peice of paper(Although its your get out of jail card).
    Correct decision dude.

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  8. wardbunny says:

    It’s all about not crossing that line where the current job stops and the next job’s training would take over. I feel that pain. I screwed up an agency shift by doing something a trained nurse would do without thinking. But I’m not a trained nurse and should have had permission.
    The Right Call. Not the easy one.

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  9. EEJ says:

    Huzzah! Just had to leave a comment again to tell you how much I enjoy reading your posts. PLEASE don’t ever give it up.

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  10. Elaine says:

    A difficult call but the right one.

    btw, how long does it take for the paperwork to come through so that you can be a “proper” paramedic as you deserve to be.

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  11. Medicblog999 says:

    Hi Kal,
    A couple of things:
    1) Simple enough comment for this job….Your damned if you do and your damned if you dont!!. Difficult decision to make but personally, I think you made the right one.
    2) I dont know if its the same up there as in the North East but we are being encouraged to use LMA as first line advanced airway management and not ETT anyway (but dont get me started on that one!!)
    3) Thanks to Chris Rigby for mentioning “The Handover” blog carnival. This post would fit in great with next months edition (theme of ‘A Learning Moment’). If your interested in submitting the post (I would love to have you on board), the next edition is being hosted by the Happy Medic. Just go to the link in Chris’s comment for more details.
    Great Post!

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  12. tyro says:

    As always, so-called ‘austere’ conditions that EMS works in demand my respect. EM docs always make fun of anesthesiologists for their clean, pre-oxygenated, glistening airways in the OR–you can do the same to us, I suppose, since the room isn’t moving. Great post.

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  13. Chris Rigby says:

    My third comment on this, I’m going to be training as a para soon (all going well). This is going to get bookmarked, to help me keep myself in check.

    Right decision mate – think of the greater good, which you did

    :-)

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  14. ladyk73 says:

    see… I wish I was restrained and logical like you…..

    I would have tubed him (if I knew how and was confident I could do it, and it would have made things better).

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  15. Stuart says:

    On a second reading, is it wrong I’m jealous that I can’t do it yet? :p

    When you’re doing something like that, is your mind as clear as it appears?

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  16. 'Manda says:

    Wow. I think that is what I fear most right now.
    There is that saying tho… “a little knowledge is a dangerous thing…”
    Case in point.

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  17. Fee says:

    Wow, that was a hard call. You did the right thing though, in this paperwork-led society of ours.

    *hugs*

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  18. Cath says:

    You did the only right thing. If someone ever asks why you didn’t and you explain abut the paper work, maybe they’ll speed up the process, also for others. We have an “emergency” law that we can use, because we have to do what we can to save a life. It isn’t a rule we should be relying on for our everyday work, and yet we have to. Unfortunately, this means our hospital never has to make a desicion as to wheter we should be given standing orders to intubate or not.

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  19. katie says:

    what a hard call, but the right one..x

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  20. Heyhoo says:

    Y’know..I read your blog and on occasions I slightly envy your job and the fact that you are doing something that makes a huge difference to peoples lives and, sometimes, just sometimes mind, I wonder if I could do your job but having read that post I absolutely know I couldn’t…I’m sticking to delivering exhaust pipes…I know my limits!! Well done you…have a hug x

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  21. Liz says:

    Correct call Kal, I’m curious what you think had caused his heart to stop? Was he in PEA?

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  22. Morpheus says:

    Very awesome story Kal, very good.

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  23. Blippie says:

    Sometimes our struggling service doesn’t seem proactive, but our pre-registration staff are protected and directed by a clinical instruction signed by our medical director … it emphasises that your competence is what is important, not the registration. All the motor skills (IV, ETI, needle cric, needle thorococentesis [*]) are encouraged, it’s just the legal aspects – the paramedic drugs – that are reserved until that piece of paper arrives.

    It certainly relieves our dilema … but it never eases the nerves of performing the skill for the first time on the road…

    Best of luck

    Blippie

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  24. Blippie says:

    [*] I think I spelt that right first time…

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  25. kirst says:

    What a great piece!!! So heartfelt. You made the right decision for you. Sometimes our instinct can take over, I commend your strength to hold back on an extremely hard call. I do look forward to reading your posts:)

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  26. Shawna says:

    I’m a Respiratory Therapist in Canada. We intubate. And we joke about the small tubes that EMS puts in our patient’s airway “like breathing through a straw” too much resistance. But truly we have great respect…when we put the tubes in, there are no lights and sirens, bumps in the road, speeds up and slows down. Sorry that you had to make a call like that, mate.

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  27. Blunt Bloke (ex station supervisor) says:

    It must be so hard knowing that you could actually give the treatment but because of legal issues you can’t do it. I’m so glad my own job is black and white about what we can do.
    I’m glad I have an easy job, as I don’t think I’d be able to make a call like that.
    Well done you.

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  28. Miss Waz says:

    Sounds like you dealt with that situation very professionally. You kept a grip on reality, a rare quality, and one you should be proud of.

    Big Hug, (cos you deserve one).

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  29. Caleycat says:

    Tough break but you know you did the right thing…..keep up the good work my friend.

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