Hello to All,
In the past few weeks we have had some good outcome cases that came through the ED/ICU:
A 50yo diabetic/htn man came in with significant chf that brought him to the ICU. One of my colleagues was covering the ICU and at 4am I got a call that could I come and help with the case. On my arrival to the ICU the man was being bagged with difficulty, sat’s were low, and he had a bull neck that had difficult to intubate written all over him. After some fentanyl and valium and three unsuccessful attempts at passing the ET tube into the trachea I was fortunate to succeed on the fourth try. The cords never were visualized. The glide scope or an eschman would have come in handy. I put the patient on the ventilator at a rate of 20 breaths per minute and within 5 minutes his heart rate went to 30 with a widening QRS. I took him off the ventilator and bagged like crazy (difficult with high pressures) gave epi, bicarb, atropine and his rate came up and the QRS narrowed down to normal. Remember that we don’t have ABG’s to help guide acid-base decisions but I was pretty sure that he was Mr. acidotic. I put him back on the ventilator, this time with a rate of 30 per minute, and he maintained good vital signs. 2 days later he decided to pull out his tube and flew off the ventilator just fine. His repeat EKG showed an MI, but except for a hoarse voice he went home feeling fine in another 3 to 4 days.
Another man came in to the ED with decreased mental status and minimal respiratory drive. He was around 30 and we postulated he probably took an overdose of some pesticide; a relatively common scenario. He was admitted to the ICU and over the next three weeks developed pneumonia (likely aspiration/hospital acquired), was ventilator dependent to the point of needing a trach, developed an expanding pleural effusion that I relieved with a chest tube, but in spite of it all he finally decided to get better and was eventually sent home walking and talking like normal. I’m glad I didn’t take him off the ventilator around day 4 when he was showing no sign off neurologic recovery and I thought he would be one of those cases with big-time anoxic encephalopathy. I figured since he was so young I would give him a little more time.
I am looking forward to returning to my Northwest ED Family in a few months. I have missed you all and appreciate the support I have felt from home. Just a few days ago I showed my kids the video I was given from all you guys over the Christmas season; they were very impressed with such a huge effort and show of affection.