Conservative medicine stinks

 Working in any aspect of emergency medicine takes its toll on ones soul. I don’t think it matters if you are a caregiver, work for food services, or are a registrar, once you are thrust, like it or not,  into the chaos that surrounds illness and injury, the only things that truly matter,  is that you truly love people and actually strive to be the best member of the health care team that you are a part of.

Being ill stinks. Most illnesses aren’t fatal. With the advent of really great antibiotics and advances in surgical techniques as well as a host of very efficacious and cool medicines, you stand a better than average chance of going home and hugging your loved ones.  As with everything in life (and death) there are inexplicable, mysterious and curious things that happen, without warning, without any sort of prodrome, or forewarning.

Pardon my unambiguous language, but being of Irish heritage we learn early on from the elders in our wacky overpopulated families that “shit happens”. Perhaps it is the only axiom from the Bible that was purposefully omitted. As my sons would say “back in the day” we had very little to work with, not because it wasn’t available, but because the politics of medicine got in the way. Case in point. The procedure we use to ventilate someone who cannot support breathing on their own is known as Endotrachael intubation (ET). The procedure is pretty simple. It involves hyperventilating the patient for a short period of time to bring up their blood oxygen levels for the relatively short time they have no ventilatory effort while we place the ET tube. Once the tube is placed through the vocal chords, we assess the placement in two ways. Bilateral chest rise and listening on several points across the chest to see that the tube is where it is supposed to be help confirm proper placement of the tube. Agreed, this is a pretty simplified explanation as there a variety of reasons why the tube could be correctly placed, yet the expected outcome may not show its head.

The Eastern Coast of the USA has been traditionally more conservative than the rest of the country. This was no different in most of CT, NY, NJ, VT, NH and Maine.

 

It was a very long time after I returned from Kansas after graduating from the EMICT program which is, without a doubt, the best Collegiate based Paramedic program in the country. My friends and colleagues Jody Gragg, Jeanette Hornung & I were ready to set the world on fire and to a large extent we did. They were fro KS and stayed in their home state with progressive prehospital care and the two of them have changed the face of EMS in Kansas. I came home to CT where I never experienced air rushing out of a young Paramedics balloon as I did in my home state. I went to work (as I have mentioned before) for New Haven Ambulance, thanks TOTALLY to Bobby Tarutis. I love that man for his faith and trust in me. There is a special place in heaven for him.

So here is the disparity in airway management between Kansas and conservative New England.  Short of breath or apenic in Kansas, you get an ET tube in 15 seconds or less, although jealously I must confess I saw Jeanette do it in 11 seconds and Jody in 9. Bastards! In CT, You are short of breath or apenic; you get either an Esophageal Obturator Airway (EOA) or an Esophageal Gastric Tube airway (EGTA). The both were terrible, were hard to use, depended on a good mask seal with the face and if the patient vomited, all of it was forced back into the lungs.

In New haven is the Ivy league school Yale. We did a great deal of calls out of there, especially when the new freshmen came to town. 3 am, Chris Dunne &B I get a call over the radio that in the men’s room, in one of the quads, was a young male “down”, bleeding to death from his mouth.

Yale was a 30 second ride from our station and our contact to the patient was perhaps 8 minutes after getting across the quad,  up the stairs, past a bunch of “Gee.. I don’t know man” crap where we found a 20 something, well dressed young man, lying on his back, covered in what was a bright red fluid. It wasn’t blood but two very bad things became obvious in less than 10 seconds. First, the fluid was alcohol. Sloe Gin Fizz to be precise and the second was that he was on his back. Fluid flows down hill and his lungs were full of booze. Had we had and ET tube, we could have aggressively suctioned his lungs in an attempt to free up some space for oxygen to communicate with hemoglobin and up his chances for survival. Would he have died from acute alcohol aspiration anyway. But we didn’t have an ET tube. The Docs at the two local hospitals didn’t feel we could handle the skill. Instead, we placed an esophageal obturator, which was useless. Sad to report this freshman died and whether it could have been avoided by a more aggressive and aggressively efficacious airway management technique, Mom & Dad still had to bury their son.­­_­­­­­­