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Jay Baker
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Our family took a running trip to Winthrop, Washington with our friends, the Ashworths, and we had a lot of fun. 
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Sun Mountain family trail running 50K/25K/1K
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This is what we'll be doing for Morning Report on Friday. 

Bonus Q: What is the difference between shunt, graft, and fistula?  

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Puget Sound low country crab feast
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Yesterday we tried awake intubation on a patient with angioedema, pretty significant tongue swelling and dysphonia.  Except we missed.  I wonder if this has happened to anyone else and what are your comments on our experience. 

Just so happened we had trained on awake intubation two hours earlier in the day.  I let my residents prep me up then stick the glidescope down my oropharynx to peep my cords.  It kind of worked but my gag reflex wasn't totally suppressed, despite using nebulized and atomized lidocaine, and we didn't get to the bougie despite multiple attempts.  We thought the lesson learned was the importance of coadministered sedation, which I didn't receive.  Maybe in part because the Army randomly pee tests me, but I also had to stay at work for the day.  

So now there is this guy in our ED with a huge tongue and, although stable minute to minute, we judged plastic was indicated.  We thought we were ready.  We set up with the EMCrit intubation checklist and got started after 15 minutes as there was no rush and we administered extended preprocedural denitrogenation, preoxygenation, and set up for apneic oxygenation.

Our hospital requires a physician to administer propofol so I pushed a total of 4 cc of heavy ketofol in 1 cc aliquots over maybe a minute (for a total of ketamine 30 mg + propofol 10 mg) to begin with some light sedation, with a larger dose to follow once the bougie was through the cords.  The resident inserted the number 4 glidescope blade but had real trouble getting it past the huge tongue and into the oropharynx.  He finally got around the cords, still no cords though, then the patient's saturation stepped off a cliff and fell into the 50s over maybe 20-30 seconds.

I was still down at the right ACF at this time while the RT started one-handed BVM at the top left after we pulled the blade out to bag the patient up.  The resident at top gave the blade to the senior with the attending staff standing by at the top and he put in an OPA.  This was difficult due to the large tongue and didn't help much so he put in a NPA as well.  There was also a similar failure to significantly improve and the patient's sats stayed in the 60s at best.  I finally noticed the RT's one handed bagging, all this of course is going on very quickly, so I reached up to take the mask from her.  I grasped it with both hands, slid my fingers under the angle of the jaw ans lifted while the sats shot back up to the 90s in about 5 seconds.  

I held this position for a few minutes and we decided to let the patient wake up instead of trying again.  We bagged a little bit longer but he continued to respire and eventually, in a few minutes, took over completely on his own.  We sat him up, cleaned him off, told him we were unsuccessful, and called anesthesia who came down and performed seated fiberoptic nasotracheal intubation with straight ketamine while the patient was seated upright.  They had trouble too with the laryngeal anatomy, which was swollen (I believe from angioedema primarily) and now somewhat bloody from our intubation attempt.  They got it after a few minutes and the patient went to the ICU.  I stopped by later in the day and his tongue was even more swollen.

Although it's dissatisfying to fail, it's more satisfying not to kill someone so I don't feel too bad.  And sometimes I learn more from failing than success.  I have certainly thought hard about this one.  Briefly, my lessons learned include-

1. Anatomy is the first fundamental.  Lift the jaw, and you'll lift the tongue out of the airway.  Even huge ones.  I knew this, acted on it, and saved this guy's life when I did it.  It's worth reviewing this simple intervention as the first you make every time.

2. Pathologic anatomy is the second fundamental.  That tongue was huge.  Maybe superior technique would have saved the day, but I'm not sure anyone could have got around that thing through the oropharynx.  I'll go straight to fiberoptic nasotracheal next time I take care of a tongue this big, if I'm not alone in a little community hospital at night.

3. Awake intubation is safer than RSI.  Thank God we didn't paralyze this guy.  I'll try it again.

What are your lessons for me?  

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Let's build a robust G+ emergency medicine circle, people!

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