Don’t stick your tongue out at me!
Last shift was one of those nights where you can’t seem to catch any breaks. We were short two residents and the fast track PA called out sick, so not only did myself and the other resident have to see all the patients we normally would, but we had to cover the other two missing residents AND fastrack. Normally you might hope to catch a break on the weekend, but this was not the case. 9 traumas, 12 trauma cleared MVA’s, two of which ended up having broken necks. Ouch. So last night was chaotic. It was in the midst of one of these traumas that one of the attendings pokes his head into the bay “Hey, ERJ, stop what you are doing, I need your help out here, right now. And grab an intubation and airway kit.” I grab the gear and walk into the room, and instantly see “sick”. Patient sitting upright, massively swollen face, tongue the size of an orange, fully sticking out, drool pouring out around it.
The first consideration on these patients with raging angioedema, and any patient really, is to secure their air way. They have to be able to breath, and this woman was teetering on the edge of not being able to move any air in and out of her lungs. Anesthesia had now rolled into the room and the decision was made to intubate her now, rather than wait for things to get any worse. But to intubate, we need to be able to give IV meds. However, both our nurses and anesthesia resident have failed at getting IV access on her. Our tech has failed to get a working line with the IO gun. Surgery is hovering at the door like hungry vultures, cricothyroid kid in hand, waiting for us to call uncle. The attending turns to me and tells me to grab a central line kit and drop a femoral line in her. Did I mention she has a fear of needles? I grab my kit, elbow my way up to the bed, start mashing around for the femoral pulse, find it, shoot my lidocaine, grab my big canulating needling, see her eyes start to bulge and feel her start to squirm as she comprehends I’m about to stick this in her groin. Someone calls for 2 of ativan, which will help but not for a few minutes. I forge ahead, just medial to the pulse, and with great relief, see a nice return of rust colored blood as I pull back on the plunger. The rest is just muscle memory from all the IJ lines dropped in the ICU. Wire, needle out,cut, canulate, catheter, wire out, flush, secure. Like a boss, we now have access. Meds go in. The IV epinephrine starts to work…amazingly fast. Within a minute her tongue is markedly less swollen. She has stopped drooling, she can now talk. Holy hell, hold off on that tube a hot minute. Sad face for surgery and their cric kit. (ha!). Patient continued to improve and was able to go to unit without any oxygen what so ever. Only afterwards did I realize two things. 1) If I didn’t get that line, she was about to have her throat cut open by the surgeons. 2) I had never done a femoral line before. Which made me reflect a moment, maybe I shouldn’t have been been the one doing this line when the patients life was literally on the line. But no, this is why we do every single line up in the unit, sure the location is different, but the process is the same, the mechanics identical. And this is really the essence of emergency medicine, taking what you know and applying it to situations you may not have ever dealt with before.