I haven't been on here in forever, but I had to vent about this!!!
Today I was involved with a rapid sequence intubation of a COPD'er whose CO2 was 136 (I know, impressive right??) The doctor rushes into the room, the patient is lethargic but alert and his eyes are wide open. The MD immediately runs to the head of the bed laryngoscope and tube in hand..... I am taking over this patient from another nurse, and I immediately ask if the patient has received any sedatives at all? His response is "No" :uhoh3: Another nurse runs to the pyxis and grabs out a RSI kit (has succs, etomidate, etc in it) The nurse runs back into the room and is holding up the bag of meds "Are you going to order RSI meds????"
We stand back in sheer shock and disbelief as the doctor rams the laryngoscope down the patients throat as he is wide awake now and GAGGING!!!! He does not answer the nurse and continues to try to tube the patient, the patient is choking, gagging and fighting the tube as best he can. He desats to the 70s and finally the doctor stops. :smackingf
We ask AGAIN "Doc, what do you want to give this patient to sedate him??" As we're bagging the patient back up to the 90s, he states "I want to try it again" And starts attempting intubation AGAIN, with the patient choking and gagging.... One nurse walking out of the room, mumbling something like "this is BS" Finally, the doctor gets the tube in place, hands it to RT to get on the vent, I start bagging and the MD immediately starts heading for the door........
At this point I'm LIVID, I'm bagging the patient and I cannot even ventilate him because he is choking on the tube and the patient starts grabbing at it "Doc, we gotta knock this guy down, quick, this isn't right" The MD states "We got the airway, that's what's important" :confused: Is this seriously happening I'm thinking??? This is someones grandfather, someones father, Would you want this done to your family member????
"DOC, it doesn't matter if he has an airway, I CANNOT ventilate him, he's choking! And he's gonna pull this thing out!" He finally mumbles "Fine, I'll order some propofol...."
He orders a measly 30mg bolus for a patient of 113kg and tells me to start slow with the drip because he's worried about his pressure (which is 160s systolic at this point)....... Get my bolus given, throw the gtt up at 20 mcg's, and titrate it all the way up to 50mcg's, (while monitoring his pressure of course) until FINALLY this poor man is sedated....
This seriously ripped my heart out of my chest....... Would I want my mother treated in this manner???? As I'm titrating the gtt and the poor guy is still choking on the tube, I tell him "I'm going to get you comfortable as quickly as I can"
Is there any excuse for this??? Is there any reason at all that there could be no meds given prior to the intubation? Nothing?? This seriously ruined my day....
FYI: thiopental is no longer manufactured, and most anesthesia providers weren't using it for RSIs before it was discontinued
I know, but if we're going with the "gold standard" argument one goes with the other, do they not?
A patient that is actively fighting against the intubation is much more likely to have poor outcomes than one that is sedated/induced properly. There was nothing in the OPs description that would have lead someone to believe that the patient needed an awake intubation.
Agree 100%. I was simply trying to be a voice of caution aginst the "I would never allow no sedation/paralytics to be on board" crowd. Most often it is indeed appropriate to knock the patient down to secure an airway. However, as I assume your intimately familiar with there's plenty of situations when not only is it inappropriate, it's negligent. Trying to box someone into a single approach when your not familar with advanced airway management is not always being a patient advocate, it may be hastening their iatrogenic death.
Probably a poor case to try to prove my point as it sounds like a fuster cluck. I just saw way too many "nevers" to let it pass.
If your docs are topicalizing with just Hurricane spray they're not doing enough. I'm talking nebulizer lidocaine, lidocaine applied directly to the cords via atomization, and pain control waiting immediately at bedside. Sedation isn't necessarily the most important component anyway, but intubation is a painful procedure.
Nasal intubations create a host of issues in the long term mechanical ventilation patient.
Hurricane spray can be extremely effective if used properly. Lido 4% with an atomizer can be effective and so could a 30 minute nebulizer if you have time. We could also use Jackson forceps and a cotton ball to give a direct hit to the nerves depending on intubation method such as a moderately sedated or awake patient and a fiberoptic scope. Every patient is assessed for the most appropriate approach since what may work for one will not work for another. It will also depend on the method used for intubation. In our ICUs and EDs we have several devices to facilitate intubation.
We also have to think about the patient for post intubation and what type of ventilator they will be on. Some of the very worst scenarios involve those who are short sighted and only prepared for the intubation. Much damage can occur in the minutes after that when inadequate preparation is done to keep the patient from struggling.
Nasal intubation can create problems within 24 hours for some patients which is why it has not been recommended for over 15 years or at least as long as we have been getting serious about VAP which might be more like 25 years.
It's a foreign body. Yes, any patient who isn't obtunded or sedated with choke on it and be difficult to ventilate.
It's a hollow foreign body... This is just the ICU nurse in me I guess, but how do you think patients get extubated? They breathe through the ET just fine without sedation or mechanical ventilation in the ICU all the time. Do you think we magically extubate them while they are still paralyzed and sedated and then they wake up and breathe on thier own like it was never there?
Sure it is not ideal to intubate without RSI, and it sounds like the doc should have here if circumstances allowed. But being awake with an ET doesn't mean it magically turns into a vegetable and chokes you. Sure you may cough some, but don't go around work telling people that an ET is a foriegn body that chokes patients or they are going to think you are an idiot.
It's a hollow foreign body... This is just the ICU nurse in me I guess, but how do you think patients get extubated? They breathe through the ET just fine without sedation or mechanical ventilation in the ICU all the time. Do you think we magically extubate them while they are still paralyzed and sedated and then they wake up and breathe on thier own like it was never there?
When a patient is ready to be extubated the air hunger hopefully will not be there causing them to struggle. Whatever even such as a TBI hopefully will have improved which was causing them to have altered mental status and combative. How many times have you aborted an SBT during a vacation sedation due to aggitation? Why do you think wrist restraints are used when a patient is first intubated? Ever see a patient try to extubate themselves because the tube annoyed them? Patients will even tell you later it felt like they were choking because they could not expel the secretions either internal of the ETT or external at the glottic area. No, patients don't always take to a ventilator like a fish to water and many feel like they are going under water. This is why we spend over $40k - $60k per ventilator with the latest and greatest technology available. But, not all hospitals have that and must be creative to get a patient in synch with the machine. Not all have the fancy ETTs either.
I have worked with docs like that...horrible horrible people, say nothing of horrible doctor. An a hole doc I once worked with had a full in MI while working in my ER...went into cardiogenic shock and ended up tubed in the ICU...he came back acting like a different, decent person.
:uhoh3: Another nurse runs to the pyxis and grabs out a RSI kit (has succs, etomidate, etc in it) The nurse runs back into the room and is holding up the bag of meds "Are you going to order RSI meds????" 
As we're bagging the patient back up to the 90s, he states "I want to try it again" And starts attempting intubation AGAIN, with the patient choking and gagging.... One nurse walking out of the room, mumbling something like "this is BS" Finally, the doctor gets the tube in place, hands it to RT to get on the vent, I start bagging and the MD immediately starts heading for the door........ 
usalsfyre
194 Posts
I know, but if we're going with the "gold standard" argument one goes with the other, do they not?
Agree 100%. I was simply trying to be a voice of caution aginst the "I would never allow no sedation/paralytics to be on board" crowd. Most often it is indeed appropriate to knock the patient down to secure an airway. However, as I assume your intimately familiar with there's plenty of situations when not only is it inappropriate, it's negligent. Trying to box someone into a single approach when your not familar with advanced airway management is not always being a patient advocate, it may be hastening their iatrogenic death.
Probably a poor case to try to prove my point as it sounds like a fuster cluck. I just saw way too many "nevers" to let it pass.