Like Butter

So far, I've had three really sick people this month--one sepsis, one status, and one angioedema. At the end of each, the staff has said it went smoothly. The last one even said, 'from my perspective, that was like butter'.

Which reinforces my sense that, if an Emergency Doc knows exactly what's wrong with you and knows exactly what to do, you're a sick, sick puppy.

All those other folks that confuse the heck out of me with wierd shooting pains in their foot and some shortness of breath and a headache and oh, yeah, I'm sleepy--nothing too terrible seems to happen to them.

"Then You'll Get One Case..."

Staff and I were sitting at the tracking board when a new patient popped up, that I signed up for. The chief complaint was 'allergic reaction'.

"That should worry you," he said. "You'll get all these people with rashes and minor stuff and you might get cavalier, and then you'll get one that's true anaphylaxis, or true angioedema, and from then on that chief complaint will cause a lot of sphincter tone." We walk to the room.

He draws back the curtain and the lady's lips are HUGE, both of them. He turns and says to the nurse, benadryl, cimetidine, and solumedrol, please...no audible stridor but she is uncomfortable, worried.

0.4 mg of epinephrine, 1:1000, IM, is given. The language phone reveals nothing--no known allergies, no medications, no recent changes. Her hands are swollen, as well, and she has hives on her chest. No wheezing. Still no stridor. At the end of the phone call with the translator, through which she has said nothing as her cousin translates because she can't talk, she says, 'my throat feels tight'.

She is wheeled back to the trauma bay, where we do all our airways and lines, nurses hurrying, which is often a great predictor of how sick someone is. Surgery is there with three other traumas but the trauma chief is very intent on this lady. Another predictor of how sick someone is.

I am tempted to ask if this is a 'learner airway', but it's assumed that I will take it. I've seen her posterior pharynx, it's not swollen, she's young, it should be easy, but the impact of lips the thickness of two fingers across each is daunting. The trauma chief has the cric kit and is gowned.

Etomidate, sux, and I walk the mac blade down the center of the tongue, posterior pharynx, epiglottis, and a grade I view of the cords at which point I know she's safe because if I can't get it someone will, then the tube is passed gently, and she's truly safe. All over but the sedation, and the workup. No labs ever drawn. Under it all, she was an easy airway--which means we did it at the right time.

These are rare. I remember those prophetic words--you'll get cavalier, and then you'll have one...

Poor Predictors

There are probably plenty of healthy people out there who don't take medications and don't see doctors. If, however, this is you, and you end up in the ED, and you're over the age when people normally start taking meds and seeing the doctor--say, forty--then these are bad signs.

Any other major medical problems? No? Any medications? No? Next question, always--do you see a doctor regularly or are you just in denial?

Alternative health nuts would say the western system is based on ilness not health blah blah dangerous medications blah spirit healing and so on, and for some, sure. If it works, great. But...

If you come in with a smoking history, painful lumps in your groin, axilla, and on your shoulder, and you have a cough, and you've lost twenty pounds since february, and you wake up soaking the sheets...sorry, dude. Giant, metastatic lung cancer for you. Now granted, lung cancer has no accepted screening. But maybe, just maybe, a family doc actively trying to get him to quit smoking might've made a difference. I sure didn't--outside of delivering the news as compassionately as I could.

He has a nine month old daughter. Damn, damn, damn. Add not smoking to helmets, please.

And to highlight why we get so paranoid--he had been to two EDs prior to this, and had never gotten a chest x-ray. Of course, he hadn't had four weeks of illness at that point, either. The last doc ALWAYS looks the smartest, but they have the easiest job. Catching it on the first go round? Now that's genius.

A Stye? Oh, wait, a hordeolum...That's an Emergency!

If you come in at 01:30 by ambulance into our ED with two months of eye pain that you just couldn't take anymore with no redness/swelling/discharge/eyeballpain/changesinvision/headache/fever/chills/nausea/vomiting and bumps on both eyelids that you haven't tried anything for, well, OK...no, please, tell your son who just got home from work that he doesn't have to come get you because we can call you a cab right after we dispense your tube of erythromycin ointment. Sure, no problem.

Oh, no, don't worry, we won't bill you for the cab or the ambulance ride or the visit or the eval or the ointment or the tissues. No, no. Thanks, taxpayers. You got this one.

Six shifts, I lasted, before I got mad about misuse of the ED. Not too bad. And remember, folks...85% of patients believe they have a true emergency, even if only 5% of MDs think so.

Super Bowl

There are a few people that lay claim to the airway in medicine. EM docs are a big one, and we usually spar with anesthesia. Paramedics handle tubes in the field in many systems, and then ICU docs are a third. Before my last airway, I had done anesthesia tubes, and ICU tubes, but the ED tube--that's a different ballgame. One of our lecturers calls it the 'super bowl' of airways.

When I heard that the first time, I thought it was a bit over the top, until I had a truly sick airway.

Sixty-something obese, small-jawed alcoholic with a bicarb of 3, Kussmall respirations, yet somehow still oriented, needs a tube. We positioned him ear to sternal notch as we were supposed to. First pass, and I saw cords but the mouth was tiny and I couldn't pass the tube. Terrible feeling. Someone holding pressure on the trachea was also less than ideal, moving it while I was looking--but still.

Bag with a nasal airway. Staff takes a look, 2nd pass with a bougie, tubes him blind and blood sprays out the tube all over (yay for gowns and masks!) and no color change. We place a King LT to bag him back up from the low nineties, which is not too bad, but he was dropping. "This is exciting", says my staff, who is a sharp, smart young doc we all love to work with.

Third staff comes in and looks, all smiles, like he's at the coffee shop chatting about donuts. Next pass, bougie again, downsize the blade to a 3 because the airway is anterior--always changing something, and this time bougie through cords visualized and the tube passes. More blood and no breath sounds on the left, so pull the tube back.

All good.

This was my first ED tube but not my first tube; a previous post talked about my anesthesia rotation where I was up to 13, then I had an ICU month with 6 and hit them all, so I was at 78% first pass success and about ten in a row on the trot, which is to say, nowhere near proficient, but not a total newbie. But this one was terrible. Sick, sick, sick. I see now why they call it the super bowl of airways. I see now why my attending said when I was setting up, 'got your bougie?', and 'got your King LT?' Up to 1% of ED airways are not tube-able. That's a lot. Many, many more are like this...badness. And it will go down as a procedure with no hypoxia, no hypotension, and no perceived adverse event.

I Say, Leave the Darn Thing Alone

The teaching about nailbed injuries is that if you have a crush injury or any sort of injury involving the proximal matrix of the nail it has to be removed, the matrix, or nailbed, repaired, and the nail replaced to keep the matrix open for the new nail. The worry is subungual hematomas.

A pregnant lady came in who had cut her nail and fingertip with a breadknife. She was on lovenox because it was a high-risk pregnancy. She had a linear laceration through her nail but it was three quarters of the way towards the tip. My staff indicated we should explore the nail bed and pry the nail up to see if there was damage underneath it.

I did that; her finger was numb, so I pryed up the end of the nail and it started bleeding like crazy. Surprise, surprise. Before, there was no visible hematoma, no bleeding from the nail. But the nailbed is so friable in a normal person, let alone someone anticoagulated, that it's a mess to reveal. This lady did have a laceration; I had to trim off maybe 3-4 millimeters of her nail to get to it, and then we repaired it with absorbable sutures.

But, before we started messing with it, it was FINE. According to Tintanelli, nailbed repair is required for open fracture underneath, disruption of the proximal matrix, and subungual hematoma. Some recent lectures on EM podcasts have disputed the subungual hematoma thing; the others I buy. Otherwise, I say LEAVE THE NAILBED ALONE. It bleeds, I don't think it helps proximally. Thoughts?

Oh--to take the nail off, gently dissect along the bed from the front with drivers, grip and pull away from the matrix along the axis of the finger, then repair, then suture the nail back in place through the nail itself with simple or matress sutures.