Show Me the Head Mirror

Once upon a time, a very long time ago, I responded in a solo capacity to the report of a “down party” in a public area. At the beginning of my response I was unconcerned – down parties are a common call that usually entail waiting for the detox van. My concern increased slightly when dispatch let me know that the nearest AED to the call location had been pulled. My concern rose to a fairly significant level when dispatch told me that the HALO camera* showed CPR in progress. It sounded like there was work to be done.

I arrived to find two bystanders performing CPR on a very fat man. The obese patient did have the appearance of being quite dead, with the mottled, bluish skin color of pulselessness. One bystander was doing CPR and the other was performing mouth-to-mouth ventilations. Now, let me pause here a moment to point out that while this call was a long, long time ago, it wasn’t so long ago that mouth-to-mouth was a common thing. As a matter of fact, it may have been the first time I had actually witnessed stranger-on-stranger mouth-to-mouth.

Anyway, I started some additional help in my direction (solo arrests are not especially fun calls), confirmed pulselessness, restarted the bystander on CPR (he was doing a decent job of things, considering the patient was about waist high while supine), gave the mouth-to-mouth bystander some gum, and asked what happened. Apparently, the gentleman did the television-style chest grip before gasping and falling over. The AED had shocked the gent once.  Oh, and I didn’t really offer gum to the bystander. I wish I had. That would’ve been cool.

I attached my monitor and found the patient in VFib. I blasted him once at 360 joules and started a bystander on CPR again. Being that it was a long time ago, as I have said, my next step was to secure the patient’s airway with an endotracheal tube. Nowadays I would pop in a OPA and leave the patient on a non-rebreather mask, but not back then.

I got into my kits and pulled out a laryngoscope and a 7.0mm ETT. I grabbed a smallish tube because the patient looked like he was going to be a terrible bitch to intubate. He was big as hell, with no neck. His submental space looked short and his tongue filled his mouth. It looked like a giraffe’s tongue in a human mouth. He had something going on with his neck, because I couldn’t extend his head backwards. (I later found out he had a C1-L1 fusion, or something. It probably wasn’t that extensive, but there was a lot of neck fusing going on in his past.) His neck was so fused and he was so obese that his occiput wasn't able to touch the ground when he was supine. Add the fact that the patient was flat on the ground, not at waist height, or even a couple of inches off the floor like on the pram. It all added up to look as though an unpleasant tube was in my future.

Seriously, everyone knows that giraffes have big tongues. Photo courtesy Pixabay

I heard an insistent voice from my right: “I’m a doctor. Hand me your blade and tube.” This statement and demand came from the bystander who had been performing the mouth-to-mouth. 

My standard reply seemed like it would work here: “Doctor, huh?  Nice. Stand back, please.” 

The bystander was insistent. “I’m an anesthesiologist. Give me your blade and tube.”

“Not happening. But thanks for your help, sir.” Whenever you add the “sir,” it is polite. Right? In actuality I may have said something significantly ruder than this, but it was a long time ago. One’s memory fades with time. I’m quite sure I would have ended the sentence with “sir” though.

I bent down and started working through this mess of an intubation. The whole time I listened to Dr Anesthesiologist hiss, gasp, and tell me what I was doing wrong. “No, you’re… Wait, you should pull…  Hang on. We need to…” But there wasn’t anything especially helpful coming from him. When a police officer showed up, I asked him to chat with the doctor. Anywhere away from me.  

Long story short, I couldn’t get the tube. Another medic showed up and I passed off the airway responsibility to her. She got the tube, eventually, after quite a bit of struggle. In my defense, it was hard for her too. I started an IV, shocked the patient into asystole, gave a round of drugs, and handed the patient off to a transport bus. 

After the call, I found out that the anesthesiologist wasn’t an anesthesiologist. Or a doctor. He was thinking about going to nurse anesthetist school, though. Shock of shocks.

Not even a doctor. That is why I need to see the shiny forehead disk on a headband, called a head mirror, preferably associated with a white lab coat and shoulder-mounted stethoscope, before I will believe a bystander is a physician.

The head mirror and stethoscope combo is pathognomonic. Image courtesy Pixabay

I usually don’t want a physician’s help on scene anyway. Even in the case of a real anesthesiologist on an arrest, it would be unusual for that physician to intubate a patient at floor level, without good light, and without extensive equipment and available help. It would not be a normal tube for him or her. But it is a fairly common procedure for me. 

The most helpful physicians would be emergency doctors. But the best EM physicians know that a big part of their job is based on lab results, radiology, ultrasounds, and so on. Take all that hospital stuff away, and what do they offer that I can’t? Not a lot, if I am doing my job well. It doesn’t take physician-level education to know if someone needs to be transported to a hospital. Or to work an arrest. 

*High Activity Location Observation camera; street cameras that the city uses to monitor areas downtown and such.