First to the crash call

I was on the ward reviewing a complex warfarin/clexane/tinzaparin drug chart.The patient decided to have an ACS as he was being switched from tinzaparin and warfarin to just warfarin following a PE. He was prescribed treatment dose clexane. The second troponin had just come back negative, and the plan documented that morning was to stop clexane and resume PE anticoaguation. My brain was about to herniate attempting to come up with a plan for the evening dose of warfarin/tinzaparin.

Then I heard a bed alarm go off in the ward.

I rushed to the scene, and heard a nurse say “Oh no, she’s aspirated”.

There was vomiting dripping out of the mouth of an elderly, obese woman. There was no way air could be getting in. There was massive seesaw breathing, and her whole body contracted with each inspiration like that vein that won’t release blood during venipuncture as you pull back on the syringe. There was no chest expansion at all.

It really helped to have done ALS weeks before. I asked for the suction, a size 6 nasopharnygeal and all the oropharnygeal airways in the trolley. Whilst the equipment arrived, I did a head tilt/chin lift, and looked inside the mouth. All I could see was the tongue, and vomit.

I asked the nurses to put out a crash call, as I wanted an anaesthetist fast.

I felt for a pulse as I waited for the trolley. I could feel a good carotid pulse.

Once the equipment arrived, I suctioned about 100ml of vomit from the mouth. It was now the tongue that was the main problem. I decided to use an oropharngeal. This was the first time I would do so without any supervision. I was initially confused by the presence of the tongue, as the mannequins do not have a massive tongue blocking the entry to the mouth. I remembered seeing an animation of where the orophrangeal is meant to sit and how it works (in part, keeping the tongue depressed and off the posterior pharynx). I realized it needed to be inserted directly above the tongue and did so, even though this required some significant forcing. It slotted into place and as I applied a non rebreathable mask with 15L/min oxygen, I saw some misting. There was also some chest expansion. By this time, the crash team arrived and the anesthetist took over the airway. After the patient was stabilized, the anaesthetist congratulated me on my airway management.

I can see what they say about confidence coming from experience. I knew how to do that for the last 4 years. However, it is only now that I have done it unsupervised and in a high pressure scenario that I now feel confident of dealing with an airway problem like that anytime, anywhere.

I love being on call.

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