Friday, August 5, 2011

- Obstructed

The room is hot. I guess the patient didn't like having the AC on so much. She's been here for days and recently returned from having a pacemaker put it. When we walked in, one nurse has her brow furrowed, attempting to ventilate the patient, with difficulty. She has no airway in. We were paged out for a respiratory arrest. The other nurse stares at us.

And that's all they're doing. I look at the monitor they have the patient hooked up to- an ugly complex obviously being fueled by the new pacer marches across the scene. I check a pulse.

"I don't feel a pulse. Start CPR," I tell Benni, my partner.

"Wait," says the nurse, grabbing Benni's arm. "She's got a rhythm. You don't do CPR with a rhythm. We just need to bag her and send her to hospital."

"You don't do CPR with perfusing rhythm," I correct her. "I don't feel a pulse. Go ahead, Benni."

The nurse gives me a dirty look that lights a rage in me so hot my eyeballs steam. "How long has she been like this?"

I guess the anger carries in my voice, because the nurse flushes and scowls at me. "Ten minutes."

"So she hasn't had a pulse for ten minutes?"

The nurse's face breaks and a look of fear flashes across it "She had a rhythm. We didn't check. "

I sigh and grab an oral airway from the bag, gently grab the BVM from the nurse, and try to insert the oral airway. She's got a lot of emesis, which I suction out. I then hand the BVM back to the nurse. I'm mad at myself. I probably could've made that a teaching moment and instead I let my anger get the better of me.

The BVM nurse is having problems, so after I push an epi through the conveniently preplaced IJ I have a recently arrived firefighter take over compressions and direct Benni to bag. I thank the nurse through clenched teeth.I can tell Benni is having a pretty difficult time trying to ventilate, even with the airway in. The patient's rhythm is unchanged, still a PEA. I grab my intubation equipment and, with the firefighter still doing compressions, intubate. The angle is horrible, but I can see the bottom of the cords and manage to slip my tube in. I watch it pass, but when I attach the BVM to the ET I can't bag, not even a little a bit. What the fuck? It's like there's no outlet for the air.

I pull the tube and reinsert the oral airway. Benni tries the BVM again, and now she can ventilate with no issues. What the hell is going on? I look back at the monitor. The patient's pulse ox is now picking up, holding steady at 79. I shake my head. At least air is going in. I push an epi and plot my next move. I as I'm disconnecting the prefill I look at the tube I pulled. At the bottom is a massive wad of blue gum, lodged in the tube. Oh.

I successfully intubate shortly after and about thirty seconds later, the patient's pulse ox goes to 100 percent, with a ETCO2 of 102. I go to check a pulse and realize I don't have to - I can see her carotids throbbing in time to the now organized sinus tach marching on.

We package and transport to the hospital, where I mention the gum and turn over care. The patient's pupils are large and nonreactive, and seem to stare up at me accusingly. But she doesn't blink, and when I move away, she stares lasers into the flourescents.