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Facing burnout, the author became reinvigorated after skillfully handling a midnight emergency.
It could only happen to a gangster-or to an ED doctor like me. Three minutes ago, I'd never seen the guy. Now, with one slash of the scalpel, I slit his throat. From start to finish, it takes fewer seconds to do it than to tell you about it.
Of course, Mr. Alonzo Holmes shows up at a bad time, just after midnight. The on-call anesthesiologist has already hopped into her BMW, and tootled home to bed. Our community-hospital ED is rocking-stretchers filled, waiting room packed. What's one more patient-in this case, a 40-year-old male who felt something pop in his neck while changing a truck tire?
To ED triage nurses, most neck strains are a big yawn, yesterday's news, but not this one. Before anybody can ask why, triage bounces the pneumonia admit out of 12-A, and parks her in the hall. They zip Alonzo into the newly emptied spot. For once, no fuss about protocol. No mopping the room, no chart, no wristband, no nothing.
"Don't know what's wrong, Doc," Alonzo says, fogging his 100 percent oxygen mask. He's a big fellow-at least 250 pounds.
"I's jerking on this old lug nut, rusty as the devil, when something popped. I felt it right here." With a greasy, callused finger, he jabs the right side of his neck.
I do a quick once-over. Wall monitor BP is 170/108. Heart rate 136, regular. Oximetry 93 percent.
I grab my stethoscope. His lungs are clear. Heart fast, no murmur.
I palpate the neck. Left carotid arterial pulse 2+. Right carotid, 1+. Over the right carotid, the neck is spongy-firm, with the give of a half-ripe tangerine. Second by second, it's getting tighter.
"Hard to talk, too," says Alonzo, his base voice suddenly trilling, like a kid in panic.
It's contagious; my voice does the same thing.
"We're going to use a tube to help you breathe," I say. Winnie dives into the second drawer on the red crash cart, and slips a big-bore IV into Alonzo's right antecubital. "I'll give you medicine so you don't feel it," I tell him.
"Hope so," Alonzo responds, his words a combination half squeak and half whisper.
Winnie's pushing meds-Versed to relax the patient, succinylcholine to paralyze him. Respiratory scoots in, just in time to hand me the laryngoscope. Everything looks fine. Curved blade, light working, number eight ET tube, cuff deflated, stylette in the right place.
After you've been an ED doc for more than 20 years, as I've been, most ET intubations aren't a big deal. Gripping the laryngoscope, I grasp Alonzo's forehead and tilt his chin up. I open his mouth, insert the blade, and instantly know that this is a huge deal, a double whopper.
Intubations are guided by oropharyngeal anatomy-the base of the tongue, the epiglottis, the glistening white portals of the vocal cords. Not this time.
The oropharynx, every crevice of it, is distorted and obscured by what looks like a good-sized eggplant. No way am I going to squeeze any tube around this bulging prevertebral hematoma. But I try. Lift the tongue, suction, sliding the tube-no deal. Repeat times two-still no deal.