The Airway

As an emergency physician it is all about the ABCs: Airway, Breathing, and Circulation, and it is always comforting for me to know that no matter the condition any patient presents, as long as the "ABCs" are intact, that person is, at least in the short term, stable. Every medical specialty has their area of expertise. A cardiologist obviously focuses on the heart, a pulmonologist the lungs, and one could argue that an ED doc's should be the ABC's.

I remember running to codes in the hospital as a medical student, and by the time I got there, 100 white coats would already be crammed in to the room shouting out orders. One order I never heard was, "Quick! We need a medical student in here stat!" A specific incident I will never forget is being on my psych rotation and hearing a code called out in the room adjacent to where I was standing. In a matter of seconds every psychiatrist was in the room and the psych intern had gone to the head of the bed. I though to myself this was going to be a train wreck, and before the on-call medicine team arrived the patient's front two teeth had been knocked out by the laryngoscope. Nothing against psychiatrist, but I wouldn't want them running my code. Lets just say intubating is not their area of expertise. I had intubated mannequin after mannequin in the simulation lab at the start of my M-4 year, and as I stood there watching the intern attempt to pass the tube I could name about twelve errors he had made.

Fast forward one year.

In the middle of a morning while I was on a medicine off-service, I had just made it to my call room when the code pager rang. I ran to the room and instead of seeing see it overflowing with white coats I was the only one. Thinking this was my time to shine I ran to the head of the bed and starting bagging the patient and asked the nurse to bring the airway cart close by. I had a good seal on the bag and the patient's oxygen saturation was rising. I looked up and saw that suddenly the room had filled with nurses, respiratory therapist and other in house docs. It was time to intubate, and for the first time I actually took a good look at the patient to see what I was about to tube. She was morbitly obese, had no neck or chin, and looked nothing like the simulation lab mannequins I had tubed previously. I grabbed the laryngoscope and opened her mouth only to see a colossal tongue and a pair of dentures floating around. I inserted the mac blade and she vomited everywhere. It was terrible; a total train wreck. A senior resident stepped in and he was able to get the airway on his third attempt by using a bougie, but it didn't matter as the patient didn't survive. I left the room seeing the medical students in the back with same looks on their faces that I had when I watched the psych intern. In retrospect I can see a few errors I made, but the problem was she had a terrible airway and I lacked experience.

Simulation labs are one thing, observing others run codes is another, but being the one actually calling the shots is a lifetime of experience crammed in to 20 minutes.