Friday, November 05, 2010


They say we shouldn't do it. They say that Rapid Sequence Intubation - the practice of sedating and chemically paralyzingly a patient to place a breathing tube in their trachea - is too dangerous for paramedics to perform. They say the studies show it's too risky. They say we're not good enough at intubating. They say you can support a person with basic techniques.

They say, they say. And in many cases - trauma in particular - I tend to agree.

And yet.

* * * *

Drugs got him here, and drugs will be his salvation. He wasn't breathing when the fire department EMTs arrived. Narcan helped his respirations, but nothing else. They're not sure what he took.

They've barely stopped bagging when we walk in. Not down too long, they say. History of drug abuse and suicide attempts. So we start the workup.

I start a line in his ankle, the only site I can find. My partner hooks him up to the monitor. He's breathing forty times a minute, but his oxygen saturations hover around 85%. He won't wake up and his lungs sound like a tire chain in a tumble dryer. Even with suctioning, an NPA, and more bagging, he doesn't really improve. His jaw is locked tight, and all I can do is run the Yankauer over his teeth.

The nearest hospital is 35 miles away, on windy, rain-slick country roads.

They say...

We load him in the ambulance, make a few more desultory attempts at BLS airway managment, and then make the decision.

My partner draws up the drugs. I get out my tools -- Options A, B, and C.

My eye briefly lingers on the small cardboard box of Option D. I can picture what's inside, the plastic package and scalpel and Sharpie-scrawled message some wise-ass coworker has left: "GOOD LUCK. STAY CALM."

I leave the cric kit on the shelf. Everything else, though - tube, bougie, King - I lock and load. Line them up neatly. Lights up. Suction running. All the positioning tricks I know. He predicts like a difficult airway, no matter which mnemonic or scheme I use. Nothing good about this. We can't get his sats over 90%.

My partner, holding two syringes, asks if I'm ready. The firefighter assisting us looks at me expectantly.

Well. I suppose. I'd better be, hadn't I?

He pushes the drugs, and I wait until he stops breathing. His jaw loosens, and I slide the blade into his mouth. Everyone is gathered around - the firefighter holding cric pressure, my partner pulling the patient's head into a better sniffing position - and all of a sudden I can see the cords.

"Whoa! Okay, tube, tube. Good. Okay. Through the cords. Stylette out. Balloon up. Get that capnography on. Ears? Okay, bag. Yeah? Sweet."

And then it's all over but secure the tube, clean up, sedation, NG tube, and so on -- all during the long drive in.

He's hard to sedate and fights us some on the way in -- maybe a speedball? -- but his sats slowly come up.

By the time we leave the hospital he's at 100%, sleeping peacefully with the aid of a versed drip. The doc shrugs her shoulders.

"Don't exactly know what's up. We'll have to wait for labs and imaging. Could be a few different things. Sounds like it was a tough one out there. Good job, guys."

* * * *

They say, they say, and sometimes I think they are right, and sometimes I think they are wrong.

1 comment:

vanderleun said...

Another amazing and fascinating essay.