Why My Daughters Are Going to Have the HPV Vaccine Strongly Suggested To Them

A beautiful little cherub sits on the stretcher. Not as cute as my kids, of course, but close. She's reading to herself. Groomed. Haircut is stylish. She's a vision of Nordic charm. Then you ask her how she likes her book. 'Good', she says, 'it's called Who Rang the Doorbell'. Hmmm. Voice is all raspy and soft. I can barely hear her.

That's because she's had genital warts lasered or chopped off her larynx like sixty gajillion times (aka, once every four to six weeks for a year or two). How did she get them? Her mom had asymptomatic HPV at the time of her vaginal delivery that was either missed or tested for and not caught. Now this little girl has to come in and get put under general anesthesia all the time. Today she has re-growth that's 'not too bad' according to the ENT doc. The clusters of new HPV growth are only occluding about 30% of her tracheal opening after six weeks. You can't even see her vocal cords anymore. Her larynx is a tube of scar tissue and virus. There's enough bleeding and swelling after the treatments that she's been hypoxic a few times from acute obstruction, and of course, if she didn't have the surgeries the virus would just keep growing until it blocked her airway and she died.

Compare that to some local injection reactions from the vaccine. Damn those pharmaceutical companies coercing young women into getting a shot just for profit, and forcing their immoral opinions on our young women.

Set-Up For Success

Normally, intubating children produces angst because we're worried if we miss, but overall they tend to be straightforward as long as you do a few simple things. For young kids, you should have their ear at the level of their anterior shoulder, perhaps put a towel under their shoulder to compensate for their giant heeds, use a straight blade, look up, and you're home free.

So when the anesthesiologist brings in a wee laddie in a crib in traction, meaning their legs are up in the air, their chin is slouched into their chest, there's no way to approach them straight from above like we normally do, and then he says, "let's intubate him on the crib", and, "I normally don't use a paralytic", that's an awesome set up. Sterling. Perfect.

We ended up using a paralytic. Then I got it the second time. Gives me a lot of respect for paramedics intubating with less than ideal conditions, including in cars, in fields, and so on. However, when you have time, it seems silly to me not to use every advantage the first time, every time. Ironic, since usually the anesthesiologists call us cowboys, not the other way around.

Life-saving skills

Stuff that saves people is cool. We can all accept that. The things that really save people, though, are usually not what we expect. Helicopter transport, hypothermia with a cool machine that self-regulates, ICU care, monitors that beep and whistle, recombinant clotting factors that cost more than an SUV per ounce, those save people, right?

Um, maybe; but things that actually do are often eerily simple. Good chest compressions. Needles in the mid-clavicular line. And airway management--with a mask and a chin lift.

Terrifyingly recently, anesthesiologists would do a suprising number of cases without intubation and without a machine, just bagging the patient with an ambu bag. You breathe for the patient, literally.

On peds anesthesia this week, the best cases were the ear tubes, becuase for five minutes or so it'd just be me and the bag and the patient not breathing. This skill, as much as intubation, saves lives. Just a bag. No big fiber-optic scope, no fancy stainless steel LED-lit laryngoscope or, as my trauma surgeon called it, 'dog and pony show'.

It's all well and good to talk about lifting the jaw up into the mask with your pinkie, ring and middle finger spread from behind the jaw to the chin, but like any motor memory task, it takes time to learn it. Once you do, there's no feeling like holding the jaw up, squeezing the bag, and watching that little chest rise just enough to avoid inflating the stomach while still giving them oxygen. And to think we walk around normally breathing without even thinking about it. Want to manage a person's airway? Learn to bag. Don't know what to do with a failed airway? Learn to bag. Save a life.

/sermon.

"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...

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.

Damn it all

Just had to intubate the Marlboro man, in room 3. Stubborn bastard wouldn't keep his sats up. Second time in a week.

This tube didn't feel like saving a life, it felt like ending it. He'll never come off the vent.

Airway Tip O' The Day

A colleague on flight had a horrendous trip the other day to a blast site. One victim was talking, had normal vital signs, but was hoarse and covered in black soot from the neck up due to the blast.

An indication for a tube if ever there was one; it had only been sixty minutes or so from the time of the blast and already she was unable to pass a tube a full size smaller than needed, and saved his life with a rescue device instead (a King LT). Which leads to the airway tip o' the day.

A bougie is a long, flexible plastic thingee used to find the trachea by feel and by the bend at its end, over which you can then pass a tube. Usually I think of it as a means to improve an airway with a bad view. She had a great view; he was just too swollen.

The tip is to use a bougie even with a great view in the setting of airway edema; if you can't pass a tube over the bougie, leave it in place, go one size down, continuing until you pass something.

Of course, this being the great frozen north, it was seven degrees where she was trying to intubate without the windchill, so the bougie probably would've snapped. The O2 tubing had already frozen. Sweet. Can't wait to start flying.

GCS of Seven

Most kids aren't that sick in the ED. Some are downright well. After working there for a while, you're sicker than most of them because they've given you GI junk and URI junk and maybe some rash junk, too.

When they ARE sick, good God, it's scary. We had an ambulance call, not a trauma call, come in the other day, of a 3 year old, head versus TV, and 'altered'.

To prepare in my head, though I would never be the one to do it as an Intern, I reviewed RSI doses--0.2 mg/kg etomidate, 2 mg/kg succinylcholine, estimate for a 3 year old about 15 Kg, so 3 mg and 30 mg.

He came in moaning, not in a C-collar, his right arm flexed, eyes closed. GCS? 1 for eyes, 3 for pediatric moaning, 3 for flexion posture--seven. Needed a tube.

We took him into the trauma bay, and held C-spine precautions while I realized I didn't know how to work the C-collars we have at children's because I've never done it. Having never done a peds trauma resuscitation, I was sort of useless--I could hold the bag on and do the ATLS algorithm in my head, but so what?

IV in 2 minutes, intubated in 5, CT scanner in 10. Pretty good. The kids are so small and everyone is so intense, pediatric traumas are frenetic. Everyone is close together. The sphincter tone in the room is incredible.

His CT scan showed a skull fracture and air all over, with 2 mm of midline shift. Hopefully he'll do better.

That's Peds EM this month--95% BS snot and wheezing or their leg looks funny but doesn't hurt, and 5% holy crap.

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.

Total Cluster Averted

Sorry for the long breaks between posts, life is hectic. I'm on OB which was been a great rotation overall. The other day, though, there was an interesting situation that could've turned out badly.

We were called to the post-partum floor for a woman who was having an (air quotes)allergic reaction(air quotes) after having some percocet. She was complaining of trouble breathing and tongue swelling. Her tongue did seem swollen and she did sound a bit stridorous but I could hear her talking from the hallway and she was moving air well. Blood pressures were high, not low as they would be in anaphylactic shock. Her O2 saturation was 100% the whole time. She was given 50 mg of Benadryl.

It got interesting when the OB and the anesthesia resident disagreed. OB didn't think the patient was anaphylactic--neither did I, frankly--but was more concerned about the airway. Anesthesia was worried about an epidural hematoma from the spinal anesthesia. Management differed. Anesthesia wanted an MRI, STAT (ha, I thought at first) which I managed to actually get within 15 minutes, yay me.

So the OB attending asked me to go with the patient to the scanner. Now, I didn't think the patient was in shock, but the MRI was fifteen minutes away through a maze of corridors. So here I was, wheeling this patient through the hallway with nothing but a bag-valve mask and a portable O2 monitor. So?

Well, in retrospect, that could've been a total disaster (especially since we went right past the cafeteria, which has giant glass windows). What's the treatment for anaphylaxis? Epi and airway. Did I have an airway? No. If she were to swell up? Bag-valve mask wouldn't work. I'd be doing impossible CPR on a pregnant lady in front of the whole cafeteria. IF WE THOUGHT SHE HAD AN AIRWAY ISSUE, SHE NEVER SHOULD'VE GONE TO THE SCANNER.

Nothing happened. She could'nt get the scan becuase she was claustrophobic and there wasn't a nurse and the anesthesia attending didn't want the scan anyway, so we just wheeled her back. But the important lesson was to make a decision about the plan and stick to it. The half-assed business of getting a scan but sending an Intern with a bag-valve mask with her--well, that could've been horrific. In the ED with all resources around me, frank shock would be a challenge for me right now. In the hallway?