PODCAST: The Guru vs. the Gump [Contraception]

Yes – after a number of months away from the Broome Docs podcast we are back.  The podcast has been on the back burner whilst I have been prepping for SMACC in Dublin and podcasting away over at Primary Care RAP.

This is an older file from the archive that has been neglected.  I have decided to drag it out for a few reasons:

  1. To keep you all amused
  2. As a bit of an experimental format
  3. to encourage my colleague – Dr Penny Wilson to do more excellent O&G podcasting on bits’n’bumps

Here is the link:

DIRECT DOWNLOAD here

DISCLAIMER:  the questionable humour in this podcast is entirely tongue-in-cheek, not that funny and should be ignored.  Please not angry emails>!

Casey

Palliative Intensive Care: Why not?

As you know, next May 26th and 27th is taking place in Barcelona the II National Conference on Humanizing Intensive Care.

One of the discussion pannel is called "Before and the end" and "Palliative Intensive Care: why not?", and will be moderated by Dra. Mari Cruz Martín with the speakers Dr. Enric Benito (Coordinator of Palliative care of the Balearic Islands) and Fernando Campaña (Nurse and creator of the collaborative blog Cuidados Paliativos + Visibles).

We have asked the speakers a summary of some of the key concepts for them about Palliative Care in ICU with the idea of attracting your attention and invite you to participate and share your experience in the discussion.


"We usually do many thing to delay death, and too little and late to mitigate the suffering", especially evident in the ICU enviroment with very peculiar characteristics, believes Fernando.

It´s easier to "do" instead of "stop doing" but we have to think about it, although it is difficult for all (family and professionals) and rethink the objectives when the ICU can´t cure and death is approaching.

Enric proposes reflections from his own experience as a professional with experience in the care of people dying after a chronic disease process and progressive deterioration.

- The process of dying is a human experience of a profound anthropological significance, involving: the person who dies, their relatives and also those who care for the person.

- Recognizing the depth and human significance of this stage can ensure a respectful look at it and taking care of and accompanying the process from a human perspective, promoting a close of the biography more harmonic possible to help and accompany those who leave.

-The progressive deterioration of the body and the biological aspects of the process are just the visible part from a biomedical perspective. The patient as aperson has in addition a subjective dimension, an inner life, a network of relations and ultimately, a transcendent dimension. From this perspective, the adaptive process of closure of the biography can be seen. The transcendent dimension, if we aspire to a comprehensive care of the person, should be equally recognized, assessed and attended.

-The process of dying is unique for each person, and how it´s done depends in part on factors of the biography, which the person has lived and the way of his/her life. And most importantly, how dying can significantly impact in the lives of those who loves and accompany the person.

In the scope of the ICU, we should establish a collaboration between ICU and Palliative professionals to explore, define and propose improvements in attention focused to ensure a good death in a consensual way.

This is a change from the "Mantra" that should not be: "This person is not going to die under my responsability", but "As we see he/she is going to die, we will take care of him/her and accompany in order to have a good die".

These are just a few of the ingredients of this pannel that surely will not leave indifferent anybody. We invite you to reflect and send us your considerations and questions. To do this, you can insert your questions as comments at the end of this post.

See you at the II National Conference on Humanizing Intensive Care within a few days.

Happy Wednesday,
Gabi

Pulmcrit Wee: My graduation speech – why we resuscitate

Below is my graduation speech. It is about why we are in medicine. As all resuscitationists know - whether nurse, physician, pharmacist, PA, or paramedic - resuscitation is hard work. We all could have chosen easier, safer paths to follow. Ten years down the track I have no regrets. I appreciate the great privilege of being here. Still, though, it's good to take a moment to remember how we got here, and why it is that we do what we do.

EMCrit by Josh Farkas.

Asthma, respiratory arrest: The bougie is in but I can’t pass the tube!

Asthmatic respiratory arrest, able to pass bougie but not the tube!

A scary case

We received and ambulance call informing us of a moderately unwell asthmatic in her 50s.

Next thing a paramedic pops his head in the ambulance door, points at resus and says “Chris, we’ll need you in there soon”

Intriguing (well, strange, but it was James).

I headed out to the ambulance.

It turns out the patient had been not to unwell when the paramedics got to the patient’s house: wheezy but talking easily.  They had given her a couple of nebulisers en route.  A few minutes before arrival at hospital the patient had suddenly become agitated.  The paramedics had given some IM adrenaline but she had continue to deteriorate.

So as I got to the ambulance I saw a large woman on the trolley in the back of the ambulance staring blankly into space and … not breathing.

We elected to dash to resus.

In resus I bag valve mask (BVM) ventilated her,  slowly and gently, with difficulty.

I briefly considered intubating but decide not to – the primary problem was with B not A.

I put in an oropharyngeal airway, little improvement.

I placed bilateral nasopharyngeal airways with good effect -> I could ventilate reasonably.  She had bilateral breath sounds with moderate wheeze.

Circulation check: No palpable pulse, sinus tachy on the monitor.  We started chest compressions for presumed PEA arrest.

After a minute of chest compressions we stopped and reassessed.  Good radial pulse.  I elected to give 100mcg adrenaline for immediate brondilatory effect (in retrospect 250mcg of salbutamol would have been a better idea but we had adrenaline in hand in a prefilled syringe for the PEA arrest)

Over a few minutes her oxygen sats climbed from 65 to 100%.

The senior nurse asks if I wanted any help.  “Yep, an anaesthetist might be good for this one”

An amazing nurse got in a good IV line in and baseline bloods were sent and 200mg of hydrocortisone was given.

We ventilated slowly and carefully for a few minutes.  Bedside ultrasound (at the depth limit of the linear probe) shows bilateral pleural sliding – no pneumothorax.

The anaesthetist (a good one, yay) arrives promptly. The patient is making weak respiratory effort but is unresponsive to pain.

We generally avoid intubation in asthma – patients with asthma don’t tend to do well on ventilators – so we usually try to mange them on BiPAP instead.   However it didn’t look like this patient was going to wake up anytime soon, so the anaesthetist and I decided we would intubate.

I decided to do an RSI even though the patient was unresponsive.  Intubation without drugs may have caused laryngospasm or worsened her bronchospasm.

We set up for an RSI with high flow O2 by nasal prongs and ramping (for obese patients we put lots of sheets and pillows behind their upper back and head to try to get their air way alignment optimised – this is called ramping).

Ketamine 150mg and rocuronium 100mg push.

Good view with a video laryngoscope, but she had an anterior larynx and I was unable to pass tube through cords even with a good hockey stick bend on the stylet and laryngeal manipulation.

I passed a bougie easily into the trachea but I was unable to advance a size 7.5 tube into the trachea.   The tip of the tube went through the cords but the balloon seemed to hang up at the cords.  I tried rotating the tube both ways but it wouldn’t go.

Sats had dropped to 85% by now.   I pulled out and we BVMd her until her sats were  back at 100% for a minute then started again.

Bougie, size 7.0 tube.  Same result.  I’m thinking : “Has she got a subglottic stenosis?  Are we going to have to cric (cricothyroidotomy) her?” I admit defeat for the first time in over 6 years since I’ve been a consultant, and handed over to the anaesthetist.  He has the same problem.  He then put another pillow behind the patient’s head and passed the tube easily.

He thought my initial ramping wasn’t adequate, the airway angles were wrong and the ETT tube was hitting against the anterior wall of the trachea.  Makes sense.

We generally believe that the key to ramping is  to have the tragus of the ear anterior to the sternal notch.  This is hard to see from the head of the bed and I should have got someone to have a look from the side of the bed.

ramp1

The blue line indicates the line from tragus to sternal notch

(image from http://crashingpatient.com/resuscitation/airway/airway.htm/)

Somewhere in the middle of all of this the internal medicine physician arrived and asked if we had done an ECG.  The senior nurse dryly replied “No doctor, we haven’t passed A yet.”

Then I had an all to frequent disagreement with the anaesthetist regarding ventilator settings.  This woman was’t tall.  I thought her ideal body weight (IBW) might be 60kg.  I wanted a tidal volume (TV) of 6ml/kg IBW = 360ml (lung portective strategy).  The anaesthetist wanted a TV of 500ml.  “You don’t need to worry about the airway pressures, the alveoli won’t see that.”

I reminded him that one of his colleagues had given my last patient life threatening asthma  bilateral pneumothoraces and set the TV at 350ml.  Later it was calculated that her IBW was 53kg.  We are often fulled thinking that obese people have big lungs.  Think of those CTs with tiny lungs surrounded by lots of padding.

In retrospect I am very glad I didn’t try a crash intubation on arrival in resus.  I think that would have been a disaster.  I think it was better to manage her airway with basic airways and adjuncts first, attempt to optimise her positioning, then to a controlled RSI.  Even if she had been a normal body weight patient I think I would still avoid intubation as patients with respiratory arrest from asthma will often respond to some BVM ventilation and wake up quite quickly and not need intubation.

Bottom line

Positioning, positioning, positioning for airways in obese patients.

 

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