Code blue--2-ICU

"Code blue, MET, 2-ICU" blared through the overhead speakers at 0100 this morning. My resident and I were sitting in one of the doctors' workstations in the E.R., reviewing a patient's old records before going in to interview him. Glancing at each other, we dropped the things we were working on, and half speed-walked, half jogged out of the E.R. and up the stairs to the ICU.

As the second code of the day, I'd already seen my resident in action. An all-around excellent resident, I was thoroughly impressed with her calm manner, clear thinking, and swift directives in the first code. She rapidly assessed the situation, got report from the nurse, evaluated IV access, and was palpating a pulse while keeping an eye on the cardiac monitors, all while I was still trying to pull gloves over my sweaty palms!

This second, early morning code was a patient with delirium tremens from alcohol withdrawal who had respiratory arrest. He was holding his blood pressure okay, and simply needed ventilatory support. I was up to intubate.

But this large man with a small jaw and huge neck wasn't making it easy for us! I attempted laryngoscopy with the tool as pictured above, but his jaw was too tight. We pushed 10mg Etomidate (an inducing agent), and I attempted again. This time, he gagged and coughed every time I advanced the tube. Unfortunately, I hadn't put on a mask, but no secretions came my way. Another 10mg of Etomidate, 2mg Versed, and 100mg Succinylcholine (a paralytic) did the trick. Still barely being able to visualize the posterior aspect of the vocal chords, I advanced the tube. The respiratory therapists inflated the cuff, withdrew the stylet, and attached oxygen. CO2 return, mist in the tube, bilateral breathsounds, and chest rise were all good signs that the tube was in the right place!

Just as I had begun my third attempt, an ER attending who had been summoned arrived. I was vaguely aware of this fact, and was happy I was able to do get the job done without his having to step in. I feel like after all the OR intubations I've done, code intubations should be a little easier by now. At least it's one more under my belt! And the other good news is that by the time we returned to the ER, the attending had already seen the patient we were starting to admit, and told us just to go to bed! The patient wasn't going to the teaching service!