My new vent - "We can't do this here!"

[RunnerRN, BSN, RN]

It seems that I've heard this more and more in the last few weeks.

Ex 1: unk amount of OD comes into a psych room (smaller, has all the appropriate equipment, but kind of tight). Pt will open eyes to pain or strong verbal. Decision made to intubate....that's fine, this patient obviously can't maintain his airway. ER MD, tech, and RT freak out, "We can't do this in here!" and decide patient has to be moved to a bigger room before tubing. They proceed to move patient out IN HIS UNDERWEAR and go past several hallway patients. Sats were 100%, it was a prophylactic intubation - not due to any emergent medical issue.

Ex 2: Mom w preterm labor coming in via EMS with known placenta previa. OB notified, ER physician insists patient be directly taken to L&D because "We can't deliver a baby in here." Um, we're the ER. We can handle it if the right people come down. Finally convinced MD we at least needed to check the baby first to ensure FHR still up. No, the ER isn't the best place to deliver a baby, but you can't take a mom upstairs (L&D is a 10 min walk) if the baby's HR is 70.

Ex 3: I'll spare the story, but it pretty much encompassed "We can't code this patient in here." Seriously. Would you like me to tell her to wait until we get a trauma room open?

What are people thinking? I'm an ER nurse, you're an ER MD. Give me the right equipment and we can tube in the bathroom if we need to. What drives me nuts is medics tube upside down in the rain, but my pampered docs can't handle it in a psych room.

[GilaRRT]

Good job doctor, RT, and tech for pushing to have a better area to perform an intubation, and I thought this was going to be another thread about a doctor making bonehead decisions. More working area, more space to manuver, additional space for equipment, and space for additional people should a difficult situation occur. I do not disagree with you co-workers decision to move.

You need to step back and rethink this casual attitude toward intubation. You want to give drugs that will take away your patient's ability to maintain any kind of airway, but want to complain about your co-workers wanting to perform the said procedure under optimal conditions?

This has nothing to do with medics intubating. Your comparision is invalid. We may have to intubate under suboptimal conditions in the field because we are forced to do so. This should not be the case in the emergency room. In addition, many EMS providers would rather intubate in the ambulance than upside down in the rain. I know I have done flights were we opted to move the patient to the ambulance and have a proper setup prior to RSI.

Somebody once told me the following: "RSI is one of the rare situations where you have a perfect chance at the clean kill." You do not cut the patient, bleed them out, or physically induce trauma. You put them to sleep, loose the airway, and have a clean looking corpse. Not something to phone home about.

Edit: Not trying to rip on you too hard, just want you to look at the big picture.

[Altra, BSN, RN]

I have to agree with Gila. Just because you can do something, doesn't mean that you should. It ups the frustration level enormously (and therefore creates the potential for distraction) when the logistics/physical environment of the room are poor.

And the ER is the last place I want to deliver a high-risk infant.

[RunnerRN, BSN, RN]

But was it necessary to push the patient through the hallway without at least covering him up? I was literally shoved out of the way by the bed being pushed by the RT. It isn't about having more room, it is about the attitude that the staff had that we *couldn't* intubate in that room.

And again, I dont' WANT to deliver a high risk infant in my trauma room, but you have to at least check the kid to make sure he can tolerate the extra 10 minute trip upstairs. What would happen if we let them breeze through the department and got upstairs and the baby wasn't survivable? All because the ER wasn't the ideal place to deliver. No one would be able to prove that kid was alive or dead when they came through the ER. I'm sure the ER would get slammed on that one.

The attitude that we simply can't do something because it isn't the ideal situation isn't an excuse, and it is becoming all too pervasive in the department. It isn't about me having a casual attitude about RSI or any other aspect of my job. If you can't intubate an ideal patient in a less than ideal situation, then what happens when you HAVE to intubate an anterior patient in a less than ideal situation?

[BrnEyedGirl, BSN, MSN, RN, APRN]

Unless Mom's life is in danger we send everyone 20wks or greater directly to L&D. This is per L&D policy as well. As far as RSI, code etc, it doesn't take much room to push some drugs and put down an ET tube, I can bag until we get to a room large enough for a vent! Sure as heck beats someone dying!

[rnmontana12]

I have to agree with the others. If mother had "known placenta previa" and was greater than 20 weeks, the fetus has a much better chance if they RUN to L&D (I don't know of many EMS people in that situation that would walk her there). If she were less than 20 weeks then maybe the best place for her was the ER, because it does not matter what condition baby is in if she is bleeding out. You have to save mother before you can even think about baby. Also we had a very similar situation with our psych room, only the triage nurse most likly would not put that patient in that room to begin with. If the person was not responsive to verbal, and needed to be 1:1 visual they would/should be in the trauma room in the first place, (I could not imagine doing charcoal in the "safe room"). Sometimes in the ER a persons dignity is not the first thing on our minds, although we try hard, we deal with what is most important first.

[heron, ASN, RN]

Judgement calls are rarely cut and dried ... it's always a matter of "Is this option more good than bad or more bad than good" ... always with an eye to what's the worst that can happen and what are the odds that it will.

I do not work in ER or in L/D ... but I can follow the logic of getting the pt into a more controlled/appropriate setting if there's time. Why go looking for trouble? Save your adrenaline for situations where you have no choice, I say.

[GilaRRT]

But was it necessary to push the patient through the hallway without at least covering him up? I was literally shoved out of the way by the bed being pushed by the RT. It isn't about having more room, it is about the attitude that the staff had that we *couldn't* intubate in that room.

And again, I dont' WANT to deliver a high risk infant in my trauma room, but you have to at least check the kid to make sure he can tolerate the extra 10 minute trip upstairs. What would happen if we let them breeze through the department and got upstairs and the baby wasn't survivable? All because the ER wasn't the ideal place to deliver. No one would be able to prove that kid was alive or dead when they came through the ER. I'm sure the ER would get slammed on that one.

The attitude that we simply can't do something because it isn't the ideal situation isn't an excuse, and it is becoming all too pervasive in the department. It isn't about me having a casual attitude about RSI or any other aspect of my job. If you can't intubate an ideal patient in a less than ideal situation, then what happens when you HAVE to intubate an anterior patient in a less than ideal situation?

Agree and disagree:

First, you are correct. Throw a blanket over the patient. In addition, pushing and shoving is a no no.

However, I will stick to my guns on this one. If you are going to RSI, you need the patient in as controlled an environment as possible. You keep throwing around words such as "have to intubate." Then, you talk about having to intubate a difficult airway.

First, a proper LEMONS and ULBT assessment will help you predict the possibility of a difficult airway. If a difficult airway is predicted, then the team must make a decision. If you are not confident that you can intubate the patient, you should not paralyze. End of story, you do not have to go along with a traditional RSI.

If you encounter a difficult airway or predict a difficult airway and choose to RSI, many giudelines require you to do so with a double back up in place. This means alternative airways and adjuncts such as ETC, King LT, LMA, ILMA, bougie, lighted wand, etc. In addition, a surgical airway kit must be ready to use. Havig extra space for setting up a double back up is a good decision.

Finally, never think of a patient as "ideal." Even if the said patient had a wonderful LEMONS assessment and no predicted ability to perform difficult BVM ventilations, you could still run into problems. What kind of OD was this. Beta blockers? what if you ran into significant bradycardia and hypotension during the intubation? Sure nice to have the space and supplies ready for TCP, pressors, and atropine. What about a hyperkalemic or hyperpyrexic crisis? What about anaphylaxis from the NDNMB you pushed? The same point holds true in these situations.

It is also nice to have space and resources avaliable when anesthesia comes in to play with their toys.

[SuesquatchRN, BSN, RN]

I love posts that make me go look stuff up!

Gila, are you in the armed services?

[GilaRRT]

Not currently. I am a private contractor. Funny, I spent 10 years in the military. Was holding a little one during my OB/L&D/neonatal rotation during my final year in nursing school as I watched the twin towers fall. Thought, I am out of here for sure. Did not deploy, then moved down south and missed my old units deployment. Spent many months getting ready for a delployment again, only to be sent to Louisiana after the storm. (An experience I do not regret.)

Finally, get out of the military to fly full time in 2006 and by sheer dumb luck missed an OCONUS deployment. Funny, I had to actually interview and compete as a civi contractor to "deploy" into the middle east.

[TraumaNurseRN]

Good job doctor, RT, and tech for pushing to have a better area to perform an intubation, and I thought this was going to be another thread about a doctor making bonehead decisions. More working area, more space to manuver, additional space for equipment, and space for additional people should a difficult situation occur. I do not disagree with you co-workers decision to move.

You need to step back and rethink this casual attitude toward intubation. You want to give drugs that will take away your patient's ability to maintain any kind of airway, but want to complain about your co-workers wanting to perform the said procedure under optimal conditions?

This has nothing to do with medics intubating. Your comparision is invalid. We may have to intubate under suboptimal conditions in the field because we are forced to do so. This should not be the case in the emergency room. In addition, many EMS providers would rather intubate in the ambulance than upside down in the rain. I know I have done flights were we opted to move the patient to the ambulance and have a proper setup prior to RSI.

Somebody once told me the following: "RSI is one of the rare situations where you have a perfect chance at the clean kill." You do not cut the patient, bleed them out, or physically induce trauma. You put them to sleep, loose the airway, and have a clean looking corpse. Not something to phone home about.

Edit: Not trying to rip on you too hard, just want you to look at the big picture.

I would like to note.....the pulse oximetry was 100% with a patent airway at the time......................, and they chose to wheel the patient in their underwear down the hall. This was not an emergent intubation, so there was really NO need to pretend like it was. 14 years RRT here with 11 ED RN (Intubated lots and lots).....Sure...since it was non-emergent, taking the patient elsewhere was a good decision...One with more room, and a monitor post intubation.

[GilaRRT]

Read my other posts please. I agreed that the patient should have been covered and agreed that there was no need for pushing and shoving. However, I will continue to stand by my opinion that going to a bigger room was a good decision. Once you push the induction agent and paralytic, your patient no longer has a patent airway.