Killer Marshmallows

Today I worked the third shift in a row of a killer weekend. It was so busy each day that no matter what we did, we were always about 10 patients in the hole. Today was particularly because I had a lot of very sick people . The most harrowing case was that of a man in his 40’s with fairly severe mental retardation. Like many people with these challenges, he did not have a great swallowing control – and likely had gag reflex malfunctioning. He was brought in by medics after he had nearly choked to death on marshmallows and hot chocolate. The episode was witnessed by family and when the police arrived, he was in severe distress. They performed a Heimlich Manoeuvre which resulted in the expulsion of the marshmallows – however he had aspirated a large amount of the liquid hot chocolate. By the time the paramedics arrived he was very hypoxic and in severe distress. He had also begun to vomit his earlier meal and was aspirating that as well. They were not able to intubate him due to his very difficult anatomy and his combativeness. He developed subcutaneous emphysema likely from the attempts as well. They finally settled on an LMA but en route, the guy managed to rip it out. He arrived in my shop covered with vomit and gurgling despite the paramedics attempts to ambubag him. After paralysing him with succnylcholine, I attempted to intubate him as well – he had a rigid neck (a chronic muscular condition he had) and very poor but prominent dentition. His airway was very anterior and despite the Sellick’s Manoeuvre, I was only able to see a tiny portion of his chords with a MAC 4 or a Miller laryngoscope. I could not pass the tube and had to reinsert the LMA just to get his O2 saturation back to about 89-90%. I called the Anaesthesiologist on call who came down with a very cool device called the Glide Scope. With it, he was able to pass an ET tube and we managed to get his pulse Ox up to 95%. He had MASSIVE subcutaneous air by now but luckily did not have a pneumothorax. Eventually he went up the ICU in bad shape. It was very sad having to explain to his elderly parents and his brother that his chance for meaningful recovery is poor due to his prolonged hypoxia and the severe lung damage he sustained. The only good thing about this encounter is that we are now going to get a Glide Scope for the ER docs to use (after we train with it).

Right after this case I had another crashing patient that was septic and on and on but that will be for another post. I am exhausted and need to crash myself.