Chapter 45: Meeting Jaw to Jaw Is Better Than War

August 6, 1990, McKinley, Ohio

"Morning Shelly; morning, Erin," I said when I walked into the surgical locker room on Monday morning.

"Hi, Mike," Shelly said. "Because Mary is on her paramedic rotation this week, Erin will cover surgical consults when you leave tonight; she's on a twenty-four-hour shift."

"OK. I didn't check the schedule; who's senior enough to do procedures tonight?"

"Rob Thornton."

I changed, but rather than head straight downstairs, I went to see Owen Roth.

"What's up, Mike?"

"With Mary out this week, having a PGY1 cover surgical consults could delay procedures."

Doctor Roth nodded, "I understand, but please look at it from the opposite direction — before we created the new Residency, that was the norm at all times. This week, just over half the time will be the old way. Next week, we'll be back to less than forty-eight hours. And next July, effectively zero, except for vacations."

That wasn't what I wanted to hear, but he had a point, and, as always, Chiefs had to balance resources.

"Understood. I felt I needed to raise the concern."

"Which I also understand, and, frankly, expect from you. That's not a negative comment; someone has to hold our feet to the fire, and that appears to be you. On a related note, Erin did approach me about switching to trauma surgery in June, which would mean we wouldn't have an open position. Doctor Mertens has informed me of several students who may be interested in Matching. What are your thoughts?"

"I have mixed thoughts on that," I replied. "First, I think Erin is an excellent candidate, and we did go out of our way to ensure she Matched here. On the other hand, if we don't have the trauma surgery slot open, we may lose some very good candidates. With the slot open, they'll apply for it, and likely list surgery or emergency medicine as their second choice; without it, they'll look to Indiana, Chicago, or one of the other programs offering trauma surgery."

"What would you do in my position?"

"Resign!" I declared with a grin.

Doctor Roth laughed, "Point taken, though, at some point, you'll be the best qualified candidate for Chief of Emergency Medicine, and you should strongly consider accepting."

"Talk to me in seven years when I'm an Attending! Before I answer your question, there's one thing I don't know – when can the Match slot be pulled?"

"Pretty much anytime before March 1st, though, that could create problems for those who selected the program. Ethically, I'd prefer to do it by the end of January."

"Then I'd interview the candidates and compare them to Erin. For anyone who might apply from outside driving distance, I'd conduct a phone interview and only invite them for an in-person interview if we decided to keep the slot open."

"Playing both sides?" Owen asked.

"Keeping my options open. I would not be unhappy with Erin, but I would like to speak to other candidates."

"Would that have changed your opinion of Mary Anderson?"

I laughed, "No. Guilty as charged."

"Let's talk when we receive the application packets. Until then, we do what we can do with our available resources."

"Thanks, Owen."

"You're welcome."

I left his office and quickly made my way to the ED, though I was about five minutes late. I went to the lounge, where I apologized to Gabby and Ron for being late, then poured myself a cup of coffee.

"Is it OK to get a chart?" Gabby asked.

"Did Doctor Mastriano say they were falling behind?"

"I don't believe so."

"Then we wait. I know that's not what you want to hear, but now that we're back to normal operations, we're mainly on EMS runs or surgical consults."

"So we just sit here?"

"You can study or read medical journals. When the waiting room is backed up, Doctor Mastriano or Doctor Gibbs will let us know."

"Doesn't that bother you?"

"If I was a regular surgical Resident, I'd be prepping patients for surgery, monitoring them in recovery, and caring for them in the wards, and my medical students would be doing what amounts to scut work. Here you at least have significant opportunities to do procedures."

"I hadn't thought of it that way," she replied.

"Don't get me wrong, I want as much action as possible, but this is the job."

"Mike?" Ellie called out from the door. "EMS four minutes out with car versus pedestrian."

"Car wins every time," I replied. "Thanks, Ellie. Who's my nurse this morning?"

"Kellie."

"Thank you. Gabby, Ron, let's go."

We left the lounge, and Kellie joined us as we gowned and gloved and put on goggles.

"See, all you had to do was mention it," I said to Gabby.

"You say that as if it's a bad thing!" she retorted.

I chuckled, "It is and it isn't. What are we doing?"

"ABC."

"Are you ready to perform an intubation if it wasn't done in the field?"

"Yes."

"We'll see," I said with a friendly smile. "Let's review the basic intubation procedure. What drugs do we use?"

"Etomidate and Succinylcholine, or 'sux'."

"Do you know the standard dosage?"

"Etomidate is 0.3 megs per kilogram of patient weight; Succinylcholine at 1.5 megs per kilogram."

"Why those two?"

"Quick onset, and short-lived."

"Correct. Contraindications?"

"I'm not sure," she replied.

"None for Etomidate," I said. "For Succinylcholine — hyperkalemia, wide QRS, or burn injuries. An alternative would be used in those cases, or simply dispensed with if possible. How do you position the head?"

"In the 'sniffing position'," Gabby replied. "The patient's head is elevated to a height of about ten centimetres, the neck is mildly flexed at the lower cervical vertebrae and extended at the atlanto-occipital joint."

"Correct. What's next?"

"Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down the right side of the mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen. At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords.

"Once the cords are visible, insert the tube in the groove of the laryngoscope and slowly advance it. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm the correct placement of the tube."

"How do we confirm that?" I asked.

"Attach a ventilation bag or ventilator and ventilate at about ten breaths per minute. Observe chest expansion and auscultate to confirm correct positioning by listening for bilateral lung sounds. If sounds are heard in only one lung, withdraw the tube slowly until sounds are heard in both lungs. If no sounds are heard, the tube is misplaced and should be removed. Bag the patient, then reinsert the tube correctly."

"Perfect. One caution — never rock the laryngoscope because you could damage the patient's teeth. One other point, which I'm positive you know, but didn't say, is to clear any blood, mucous, or vomitus from the patient's mouth and throat. You're ready."

"What if I run into trouble?"

"I'll be right there to help."

"Ron, have you memorized the EKG charts?"

"Yes. Smoke over fire; clouds over grass; chocolate on the chest."

"OK. I don't know what state the patient will be in, so I'll give actual assignments when we see him or her. Kellie, CBC, Chem-20, and ABG; hCG if warranted."

A minute later, Squad 3 pulled up, and Julie jumped out of the cab.

"Male, approximately twenty, name unknown; struck by a vehicle; BP 80/50; tachy at 120; PO₂ 90% on ten litres; unable to intubate due to facial injuries; head injury with blown left pupil; multiple extremity fractures including compound left tib-fib; belly rigid; cervical collar; two units of plasma plus saline; unconscious at the scene."

"Trauma 1!" I ordered. "Ron, get Doctor Mastriano! Gabby, EKG and monitor; I'll try to intubate, then crike if necessary. Kelly, intubation tray and crike tray before you draw the blood."

Everyone acknowledged my orders, and we quickly moved to the trauma room. We moved the patient to the table, and I quickly assessed the facial injuries as Gabby cut away his T-shirt and began attaching EKG pads. Isabella and Ron came into the room.

"Ron, Foley, please. Isabella, primary assessment. I may have to crike him because he has a broken jaw. Kellie, proactive mannitol, IV push!"

About thirty seconds later, I concluded I couldn't safely intubate, so I asked for the crike tray.

"Sinus tach!" Gabby announced.

"Blood in the bag!" Ron declared.