I injected 3 mg of midazolam and 100 mg of succinylcholine into her IV port. Succinylcholine usually effects paralysis within a minute or so. After a minute of cricoid pressure and bagging I put the laryngoscope in her mouth. I could see her vocal cords clearly. My ET tube was on a sterile towel next to the patient’s head. I didn’t want to lose sight of my target, so I said, “Could somebody please pass me the tube?” The patient picked it up and handed it to me. I almost quailed. “Hey! Aren’t you supposed to be paralyzed?” I asked.
“Am I? I guess it didn’t work,” she mumbled around the laryngoscope blade in her mouth. “Are you almost finished? This is kind of uncomfortable.”
I removed the scope and inspected the bottle of succinylcholine. It was nowhere near its expiry date. I checked the patient’s IV line. It was patent. What the hell?
“Ms. Selwyn, we’re going to try that again.”
“Okay, doctor.”
I gave her a touch more midazolam plus another 150 mg of succinylcholine and waited for her to go limp. Nothing happened.
“Aren’t you paralyzed yet?”
“Sorry, no.”
I sprayed her throat and upper airway with Xylocaine and tried to do an awake intubation, but when the ET tube reached her vocal cords she started thrashing about. Attempting to pass the tube was like trying to hit a moving target. I was worried about traumatizing her epiglottis and cords, so I pulled the laryngoscope out.
Before I could work out a Plan C, her oxygen sats fell off a cliff. I gave her a ton of midazolam plus a whopping 200 mg of succinylcholine. She still wasn’t paralyzed, but at least she was adequately drowsy. When I put the laryngoscope back in her mouth I nearly gagged. It looked as if a tiny grenade had just exploded at the base of her throat. The trauma of the preceding intubation attempt had caused the soft tissues of her upper airway to swell so grotesquely, I couldn’t spot anything even remotely recognizable. More and more alarms bleeped as her oxygen sats continued to tank. I was on the verge of asking for the cricothyroidotomy tray and a scalpel when a tiny air bubble appeared on the surface of one of the bruised lumps of flesh at the back of her throat. That bubble must have just exited the trachea! I aimed for it and pushed firmly. The tube slid underneath her distorted epiglottis and lodged neatly in the windpipe. Bingo!
A few months later I attended an advanced airway management course. One of the instructors informed us that once in a blue moon you run across a bottle of succinylcholine that simply doesn’t work. Apparently the anaesthetists call it “Bad Sux.” The solution? Toss it out and open a new bottle!
In my next life I’m hoping to come back as a librarian. I can’t handle all this excitement!
Koyaanisqatsi (Life Out of Balance)
“ Things fall apart; the center cannot hold;
Mere anarchy is loosed upon the world… .”
– William Butler Yeats, The Second Coming
Remember that high school science experiment with the tin can? Allow me to refresh your memory. You took a large tin can, sucked all the air out of it with a vacuum pump and then resealed the lid. Within seconds the can caved in, crushed by the surrounding atmospheric pressure. Kids applauded, your science teacher bowed theatrically and the jocks loitering at the back of the class rained an apocalypse of spitballs down on the hapless geeks in the front row. Ladies and gentlemen, I present to you Exhibit A, the Human Tin Can. Watch carefully as the pressure generated by running a busy medical practice while simultaneously attempting to be an involved parent, an attentive spouse and a dutiful son threatens to crush him like a bug. Will he implode? Place your bets, everyone, place your bets!
I, Carnival Duck (Apologies to I, Claudius)
I’m on call for our ER every Wednesday night, so I usually take Thursday mornings off. Or at least, I try to. In theory it makes sense – if I give myself a chance to repay my sleep debt, maybe I’ll be able to avoid premature flameout. In reality, though, it doesn’t always work out that way. Yesterday was Thursday. Here’s how the morning went.
Whether it’s my morning off or not, my daughters still have to get to school on time. Accordingly, my alarm clock went off at 6:55 a.m., same as always. I had just gotten home from the hospital about two hours prior, so I spent the next few minutes lurching around the room like an extra from the set of The Walking Dead. Eventually I woke up enough to help the girls with their morning rituals. At 8:15 I walked them to the bus stop. A few minutes later I was waving goodbye as their bus pulled away from the curb. I picked up my usual bagel and coffee at Tim Hortons and drove to the hospital. As I ate in the doctor’s lounge I formulated a battle plan. I would go directly to the medical floor, see my four inpatients as quickly as possible and then beat a hasty retreat home. I figured if I eliminated all nonessential intra-hospital contact I could be back in bed as early as 9:30. That would give me a solid three hours of sleep before my afternoon office began. The plan sounded good, but was it too optimistic? For doctors, sometimes going from Point A to Point B within a hospital is like running a gauntlet – everyone wants to take a whack at you. Nevertheless, I was determined to succeed. Avoid all side skirmishes, I reminded myself as I prepared to exit the lounge.
Beep-beep-beep! I checked my pager’s LCD screen. The number for the medical floor flashed at me ominously. Uh-oh. I picked up the telephone and called.
“Hi Dr. Gray! Just wanted to let you know two of your patients transferred back from St. Elsewhere last night, so we’ll be needing some orders for them.”
“Okay.”
“You should probably have a look at them, too. One of them keeps dumping his pressure and I think the other one’s starting to circle the drain.”
So much for getting home by 9:30.
I headed for my locker, which is located a few steps down the hall from the lounge. I hadn’t made it a third of the way when the nursing supervisor stopped me.
“There’s a problem with that patient of yours who was supposed to go to Timmins for a CT scan of his head today,” she declared. “He’s a DNR, and the other patient he has to share the ambulance with is a full-code.”
She waited for my response. Try as I might, I couldn’t identify the point where these two seemingly unrelated lines of data intersected. Eventually I sighed.
“The suspense is killing me.”
“According to the new EMS policy, they’re not allowed to transport a full-code patient and a no-code patient in the same rig. Two full-codes can share an ambulance, but DNR patients have to be transported by themselves.”
“ What?”
“New policy.”
“Which moron came up with that one?”
“I don’t know, but it means they won’t be able to take your guy.”
“But he already got cancelled once last week due to that blizzard! Besides, he’s perfectly stable. Just because he’s DNR doesn’t mean he’s planning on dying anytime soon. He’s probably less likely to cash out today than I am.”
She smiled wryly and said, “That is exactly what I told the attendants, but they said it didn’t matter – rules are rules. Should we rebook him for next week?”
“Don’t bother. What’s to stop the same thing from happening again next time? Tell you what, let’s temporarily switch him to full code.”