My Pet Peeve

OK, so I can understand when the giant billboard in the side of the road in BFE Nebraska that says 'Abortion Stops a Beating Heart' uses some crazy EKG tracing that looks like V Tach, ironically, but I really can't stand it when people just sort of draw a squiggly line and call it an EKG tracing. And this one is on a book I got in the mail from a resident group. Really? Is that a tracing or not? I suppose perhaps a bit of a widenend QRS with a prominent R wave that might be in one of the precordial leads, but still? No P? And what's that squiggle where the ST segment should be? Is that some transient flutter wave? Gah! Please! Couldn't any med student after the first year draw a decent lead II P-QRS-T? For the love of Pete.

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FMOE: Toxicology Cases

Here are some tox cases, one or two liners with vitals and questions. Pipe up if you think you know the answer. Answers will be posted within a week or so. When we did these stations, they provided a scent in a bottle. I'll try and describe them for you.

Case 1. 21 year old genius shows up in the ED. His girlfriend is concerned because he seems weak, acts like he's drunk, and is unsteady on his feet as well as slow in his responses. She is holding a plastic bag with what smells like model glue in it. Afebrile, RR 23, HR 80, BP 120/68.

1. What chemical element was this genius probably exposed to, given the odor?

2. What secondary disturbance is likely causing his symptoms, especially the weakness?

Case 2. A 25 year old sportsman was golfing when he felt a prick in his finger with some scant bleeding after searching for his golf ball in long grass. He finished the round, and now has increasing pain and swelling in his hand. He is starting to feel a bit weak. Temp 99.5, BP 85/50; right hand is tender, swollen, and bruised.

1. What happened? What are you worried about next?

2. What is the treatment?

Case 3. A 4 year old girl is brought to the ED by her worried grandmother (mothers always let grandma take over these days). She has not been her self; she is sleepy, and vomited once earlier. She found an empty bottle in the girl's room. She gives it to you; it smells like Icy Hot (NO USING GOOGLE!) There isn't a label. Temp 38.2, HR 130, RR 36. Exam reveals a drowsy, slightly diaphoretic child, with coarse rhonchi bilaterally.

Basic labs: sodium 142, chloride 104, potassium 3.4, bicarb 15, glucose 78, creatinine 0.8, BUN 12.

1. What did the kid drink?

2. Med students, what is the disturbance seen in the labs and vitals? What can you do to treat her?

Case 4. Three sixteen and seventeen year old males (automatic geniuses, I was never stupid when I was that age) arrive in the ED, combative, mumbling, and completely incoherent. Found by the fuzz drinking funky tea. A representative exam on genius 1, temp 102.5, HR 140, BP 140/70; agitated, small pupils, with red, warm, dry skin.

1. What is the toxidrome (for non-medical readers, mostly my parents, a recognizable set of symptoms that identify a specific toxin)?

2. What is the antidote? When you would you use it? When would you NOT use it? What else can you give them?

Case 5. 3 year old Max is brought in by his father reeking of garlic, vomiting garlic, and not acting like his usual self. Temp 37.4, HR 145 and regular, RR 42. Hyperactive bowel sounds, coarse rhonchi, constricted pupils.

1. What did Max ingest? Why is it not illegal?

What is the treatment? Hint: he should talk to the geniuses above and get some of their tea.

More next week, with the answers! I love my job!


Learning a Craft, Revised

So I suppose to prove I'm not a total grinch I should mention that my favorite Christmas moment is a 3-way tie between watching my one-year old play with his toys before moving on to the next one, building a snow fort and then sheltering from the wind with my middle daughter on Christmas Eve, and playing chess with my oldest daughter for the first time.

But the post is about learning the craft of intubation. Everyone talks about the art of medicine, but the craft is just as important--and, if you look at how we learn procedures, it sure mirrors an apprenticeship. We start off watching, then do it under close supervision for years.

The skill of intubation is by far the most important of all EM procedures. It saves lives and no one else does them like we do; anesthesia has far more repetition but under ideal circumstances (no eating cookies or you wait another six hours for your surgery). This post is about learning the craft with a record of my first attempts, for what it's worth.

I'm in the OR this month learning the craft. Here's a list of my first attempts. DL stands for direct laryngoscopy, which is the way it's done almost all the time. ASA scores range from 1 to 5, with 1 being healthy, 2 being stable minor problems, 3 major problems but controlled, 4 major with threat to life, and 5 not expected to live for 24 hours. By definition all airways in the ED should be 4 or 5. All attempts are first pass only; if I missed, someone else took over.

1st attempt DL: miss, ASA 2, no predicted airway difficulty. Didn't position patient properly.

2nd attempt DL: success, ASA 3, no predicted difficulty.

3rd attempt DL: success, ASA 3, no predicted difficuly. At this point I feel pretty good about myself.

4th attempt DL: miss, ASA 1, great view, couldn't pass tube, no predicted difficulty.

5th attempt DL: miss, grade 4 view, had to change blades, no predicted difficulty. Now not feeling so good.

6th attempt DL: success, ASA 2, no predicted difficulty.

7th attempt DL: miss, no predicted difficulty.

8th attempt DL: success, no predicted difficulty.

9th attempt DL: success, no predicted difficulty.

10th attempt DL: success, no predicted difficulty.

1st attempt glidescope: success, predicted difficult airway secondary to morbid obesity, poor jaw opening, short neck length.

11th attempt DL: success, no predicted difficulty.

12th attempt DL: success, no predicted difficulty.

Tally: 13 attempts, 1 difficult; 4 misses, 9 successes. Rate: 69.3%. An experienced operator in the ED should hit more than 98 or 99% of attempts, but I don't have numbers for first pass success; I think I'd be higher if I had to get the airway and there were no one to back me up. It's a difficult skill.

This is the new world of accountability; you really want to know what your doc knows and can do? There it is. Best I can say is I'm improving, right?

About attempt 8, my body started to know what to do, and I've been successful since. You can describe the procedure in words and it doesn't help--you have to do it. It DOES help to know what you're trying to do so you can, in retrospect, figure out what you did wrong. But in the true sense of a craft, the only way to truly learn it is to do it over and over again.

Before I intubated, there was a sequence to memorize: apart from preparation (which is arguably most important) the motor skill itself involves positioning the head in a 'sniffing' position, scissoring open the lower jaw, placing the laryngoscope just off the midline to the right and slowly advancing down the tongue, sweeping to the left. As I do this I verbalize what I see for the supervisor to know whether I'm lost or found; posterior pharynx with uvula, epiglottis, then, after the blade is placed above the epiglottis and it pulls on the hyoepiglottic ligament, I should see arytenoid cartilage, posterior, and anterior vocal cords. Once in the correct area the laryngoscope, hand, wrist, and elbow are raised 45 degrees towards the feet as a unit without torquing the scope to move the tongue and jaw out of the way of the view. If I'm lost, it comes out as I verbalize; perhaps I only see soft tissue, perhaps I can see epiglottis but not cords. If I can't see at least the posterior portion of the cords, my chance of successfully passing the tube drops to below 1 in 2.

Now that I've done it, even as I type this, I have visual memories for each step and it is much easier to remember. We must read about procedures before we do them but initially it is a memorized scaffold for knowledge; then, the first time the task is performed correctly, there is a sense of recognition as you realize what it feels like to raise the epiglottis. The above paragraph is long and unwieldy; the motion itself, for even a relative novice on an easy airway, is a fluid progression at best, so I'm trying with a thousand words to describe a motion that is best described by doing it.

Language is a poor substitute for the experience but it's a necessary starting point and the best we have to try and get someone ready for 'the show'.

The same is true of confirmation; to carefully watch the tube pass between the cords is the best way and you can look after placement. Before it was memorized; now, when I've passed the tube and that tube stands in the way of hypoxia and death for the patient, looking for fog in the tube, chest rise, CO2 return, listening for breath sounds on both sides--all are almost reflex already.

Now for the long years of solidifying and refining the skill; working with more and more difficult airways, worse situations, even cementing the initial knowledge.

How this is learned is an ethical question these days--is it OK to learn on patients? After these few weeks, I would ask, how can I not? If I were to be intubated, I would not want someone who had only learned on simulators. It's different. Simulators are great and they help make rote the preparation, the scaffold of knowledge I was speaking of above that is required for analysis and learning of the skill. But there's no substitute for actually doing it live.