The Tube Thief; or, The Unbearable Burden On My Soul

I was newly hired in my job, and undergoing the process of being field trained, when I responded downtown for a single car rollover crash. I was working with my worst field trainer – we just didn’t get along. In fact, I hated him. In hindsight, he was my best FT. He did the most to move me toward being a better medic. He did the lion’s share of the work switching me from a private ambulance medic to a big city medic. But that process was unpleasant while I was experiencing it. He was short-tempered, caustic, and impatient. Fun for everyone involved.

Anyway, we arrived to find a car on its roof. Actually, it was more on the driver’s arm than it was on its roof. It was a sandwich with layers that went ground, arm, car roof, patient torso, car seat, patient legs. It was going to take a while for the firefighters to get him out. He was unconscious, but breathing, with a pulse. While waiting for the extrication, I was daydreaming about the amazing ability of people to get a car upside down in a 25 mph zone on dry pavement. I was pondering how he got his legs under his seats while staying generally in them. I may even have had my mouth open and a faraway look in my eyes.

During the extrication, two other ambulances showed up. Downtown has a bunch of posts, so other crews could come visit while at their posts. Each ambulance had a trainee and a field trainer. Both of the trainees were hired at the same time I was hired. In addition to the second and third ambulances, a supervisor showed up on scene too. The supe was a salty old street dog, who had probably forgotten more about EMSing than I had ever learned, but at that point he had been off the street for quite a few years. Even a sharp blade can dull after disuse, you know what I mean? I expected him to watch and provide moral support. Supervise, you know? But the other two ambulances would be a problem.

See, this is why we try to get off trauma scenes with short scene times. The faster you can leave, the fewer “helpers” you end up with on the call. I couldn’t tell the other crews to beat it; they wouldn’t have left. I couldn’t ignore them; they would find their own tasks. I had to use them. That way they could be productive in a way that was useful to me. This is a trick, by the way, for all personnel on all scenes. If you don’t give people jobs, they come up with their own work. Their ideas may not jibe with yours.

I told one of the other trainees to work on vitals and nudity (patient nudity; the other medic could leave his own pants on). I told the other trainee to throw IVs. I asked my trainer to set up the equipment for me to nasally intubate the patient. Everyone was working, and best of all, they were working on tasks I chose. After about ten minutes, the patient finally came out of his car onto a backboard and onto the pram. He went into the back of the bus and magic happened.

Poof! That patient was naked with two IVs in about 17 seconds flat. I swear, it was like a magic trick. I think there may have even been a flash and a puff of smoke. Clothes off, IVs in, blood pressure announced. It was awesome. I was in the captain’s chair near the patient’s head and had commenced to work on the nasal tube.

At this point in my career, I had placed a few blind nasal intubations successfully. Like, maybe five. But it wasn’t a skill in which you would call me an expert. So I was having some difficulty. Making things worse, my trainer was in the CPR seat to the patient’s right focusing on my intubation attempt and judging. He was verbalizing his judgments, which were (of course) mostly negative. He was gasping, hissing, sucking his teeth, tisk tisking, and trying to talk me through the process using two words at a time. "You need... Wait, the... Stop. I want you to... Back off... Not that far..." On my left was the supervisor, doing the same thing. Both of them were awfully distracting. I wanted to scream at them to shut the hell up, that I knew what I was doing.

“Both of you: Relax. Please. I got this…”

“Your tube is too warm,” said the supe, with an exasperated eye roll. “You need a new one.”

One of the tricks to blind nasotracheal intubation is that the curve on the endotracheal tube matches the curve of the posterior pharynx pretty well. Once a tube “gets warm,” it softens. It no longer has the stability to hold the proper curve. I didn’t think I was going at the intubation attempt that long, but I considered the supervisor’s point of view. Keep in mind, he had been a medic since the Seventies. He seemed as old as my dad. Maybe he knew what he was talking about.

I shrugged and reached up to my right, where we keep endotracheal tubes, to grab a new one. My field trainer yelped a quick “No!” I grabbed a new tube and turned back in time to see the supervisor advance the supposedly flaccid warm tube into the patient’s nose. My trainer looked incredulous. The supervisor was grinning and chuckling. The other medics were looking horrified. I am sure they were picturing the awfulness of being in the situation they were watching. The tube was good. He intubated my patient with his feet still on the ground. He just leaned in and slid the tube down between the cords.

“Thanks, kid. Been a while since I got a tube. Have a good night.” He walked away, still grinning from ear to ear.

My trainer had switched from incredulous to enraged: “Always pull your first tube out!” he shouted. “I can’t believe you let fucking [REDACTED] steal your tube!”

The other trainees scoffed and snorted, red-faced, trying not to bray laughter in my face. The other trainers flat-out laughed at the situation. We took the patient to the hospital.

In my career since that day, I have pulled off the same move that [REDACTED] pulled on me. It has happened two or three times. Secretly, it is pretty heavily grounded in aligned stars, good karma, and luck when it happens. One way or the other, though, it looks incredibly badass to get a nasal tube from the side door, with at least one foot on the ground. Slide the tube down, who’s-your-daddy cough, make eye contact with the medic, sniff, say nothing, and walk away.

But it doesn’t soften the pain of knowing [REDACTED] stole my tube. It is a burden on my soul that I carry to this day.

Endotracheal Thinking

My internal dialogue, before intubating a patient:

Well, now, he doesn’t look especially good. That shade of blue isn't healthy. I need to sit him up. Why do people want to lie down when they can’t breathe? I guess I laid down after the workout at the gym yesterday, but that was different. I was seeing imaginary fireflies. Wait, the firefighter is talking to me… Uh huh, CHF history. Got it. Check his breath sounds, Bill. Oooh, nasty! Wet as can be. Rales almost all the way up. Feet? Swolled. JVD? Nope. There is never JVD. People are too fat for JVD. Need to get him moving; ask for the bed. What’s his pressure? Sweet, that is high enough. Give him some nitro. Maybe a little more. A little more. Yay, paramedic dose! At which hospital is he seen? Yeah, not going across the city to that place today. I wonder what caused this guy to overload? What else do I need to do: ECG, IV, pulse ox… Wait, pulse ox is done? Well, what does it say? Crap. Is it really that low, or is it a bad reading. Check the pleth. Crap again, that looks to be a strong wave; the sat is probably true. Is it time for more nitro yet? Nah, not yet. Has he been sick lately? Where was I? Oh yeah, to-do list. Aspirin? Neb would be dumb. Steroids? No. CPAP or intubate him? What other history does he have?

My internal dialogue, after intubating a patient:

Where is the tip of my tube? What does the capnography look like? Where is the tip of my tube? What else do I need to do? Maybe the ECG. Where is the tip of my tube? Keep an eye on dude’s sats and end-tidal reading. Where is the tip of my tube? I need to call to set the hospital up, but it will have to be quick. Where are we going, again? Where is the tip of my tube? What is to eat near that hospital; I’m hungry. Where is the tip of my tube? Why did we just make two left turns in a row? Is my partner lost? Where is the tip of my tube? Has his blood pressure changed? Where is the tip of my tube? Nitro! More nitro! Where is the tip of my tube? IV is in; I need to make sure that doesn’t get away from us. Shut that bad boy down. Where is the tip of my tube? What am I missing? Where is the tip of my tube? Seems like run-of-the-mill pulmonary edema, but what else could it be? Pneumonia? Near drowning? Where is the tip of my tube? What else makes pulmonary edema like this? Where is the tip of my tube? Remember that one fire-medic who insisted on calling both pulmonary edema and pulmonary embolism “PE”? You had to take his meaning from context. Where is the tip of my tube? I think he was usually interchanging the terms. There was no difference in his mind. Where is the tip of my tube? What was that guy's name? Where is the tip of my tube? How much longer to the hospital? Okay, almost there. Where is the tip of my tube? What is his capnography reading? Where is the tip of my tube? What else do I need to do before we get to the hospital to avoid looking stupid? Where is the tip of my tube? Am I ready to give a big room report? Where is the tip of my tube? How old is this dude, again? Born in 1948... duh... carry the one... screw it. Too much math. Where is the tip of my tube? Is the tube still good?

It is pretty distracting to intubate a patient. But I have no esophageal intubations brought into the ED in 20 years of EMS.*

No Goose Tubes!
Original source

*That I know of. When I was attending.

Syncope

Yesterday, I found myself standing at the end of a jet bridge at the airport. A group of firefighters with their fingers in their ears were standing with me, and we waited patiently as the airline staffer maneuvered the bridge to a recently-arrived aircraft. The jet bridge driver shut everything down, locked the bridge in place, and slapped the door of the airliner.  Someone inside popped it open almost immediately and a flight attendant looked around until she saw me. “Thirty-five charlie,” she told me.

Of course my patient was in 35C. Nobody ever needs help in the front of an airplane. If someone does need help at the front, the other people on the flight are apparently morally obligated to carry the ill party to the back of the plane. I smiled and boarded the aircraft. The other passengers were waiting in their seats for me to do my thing and get out of the way.  Some airlines de-board the plane, so the medics have to wait for everyone to get off before accessing the patient. This airline was being cool.

I like to be welcoming, so I grinned my most friendly grin and loudly welcomed everyone to Omaha. Most people got the joke and knew they were in Denver, but I always vaguely hope I give someone a reason to briefly worry about where they wound up.

I made my way to the back row and found a late-fifties female patient who looked to be completely well. There were three or four other people around her who appeared as though they were about to burst with the anticipation of telling me their story. I held eye contact with the patient, said hello, introduced myself, and asked her how she was feeling. She told me that she was completely fine; embarrassment seemed to be her only complaint. Asking around, I discovered that the patient had enjoyed a syncopal event without fall or seizure activity, but appeared to improve with time and oxygen. One of the firefighters had pushed an aisle chair* back to row 35, so I got the patient onto it, pretended to listen to her complaints that she could walk off the aircraft, and made a dumb joke about how she had to use the chair because it would be too much paperwork if she fainted again while I was standing around looking useless. I heard a more complete story from the nurses twitching with the excitement of delivering a handoff report and then followed the patient off the plane.

We moved up to the concourse so I could perform my job more fully. The patient was 59 years old, had no medical history, took no medications, and had no current complaints. She explained that she felt hot about an hour ago during the flight, so she stood to go to the bathroom. While heading to the john, she fainted. Something like this had never happened before, she reported neither recent trauma nor illness, and didn’t hurt herself when she fainted (someone caught and lowered her). She had a blood pressure of 128/72 and a regular pulse rate of 68.

Normally I have to be careful to preserve patient privacy when I write up a case study like this. I change details and make up parts of the call. This case study, though, combines dozens of patients with the same story into one tale. This call is one that I see at least once per shift at the airport. People faint on airplanes all the time. All. The. Time.

I bet someone is fainting on that plane right now... Source

The issue is that syncope can be a big deal. Most causes of syncope are benign, and it is one of the most difficult findings to diagnose even in emergency departments – let alone on an airport concourse. Some of the causes of syncope to consider include arrhythmia, ischemia, structural cardiac abnormalities, cardiac tamponade, pacemaker malfunction, occult trauma with hemorrhage, GI bleeding, ruptured AAA, ruptured ovarian cysts, ruptured ectopic pregnancy, pulmonary embolism, subarachnoid hemorrhage, neurocardiogenic syncope, carotid sinus hypersensitivity, orthostatic syncope, medication effects, TIA, CVA, subclavian steal syndrome, psychiatric syncope, transient hypoxia or hypoglycemia, vasovagal events, and so on.  The list is long. It is difficult to pare down, especially, as I said, on an airport concourse without the machine that goes ping.

My biggest goal when evaluating and managing the in-flight syncope patient is to not alter my normal practice. Patients deserve a full work-up, even when they are in a hurry to make a connecting flight and even when I will run the same call the next day. I try to evaluate everyone for ongoing symptoms, as well as concerning findings like seated syncope, syncope without prodromal symptoms, and alterations in physical exam and vital signs.

I offer transport to an emergency department for a complete evaluation, and am almost universally turned down. I have had some hysterically bad reasons for non-transport. One patient told me that she couldn’t be in medical danger because she had never had severe medical problems before. I pointed out that the fact that because people haven’t yet died doesn’t mean that they won’t eventually die.

Anyway, the in-flight syncope refusal is so common that I have a consistent speech that I give: “Listen, before I let you go, I need you to make your decision based on the information that I have. Fainting is caused by a long and illustrious list of problems. The most common reasons for fainting are usually less dangerous, but that doesn’t help us decide whether the cause of your event was life-threatening or benign. Your event could have been caused by a dangerous problem that could come back without warning. This event may be the only warning your body will give you before you suddenly die. It is unlikely, but a possibility that you need to plan for. I can’t tell you why you fainted. The safest thing for you to do is to go to the hospital.”

No no no no. No hospital.

“Okay, that’s your decision. You’re an adult and have been making decisions for a long time. I’m not going to take over for you now. There is one thing that I need you to understand, though. An airplane in flight is a really bad place to have a medical problem. A cruising altitude of thirty thousand feet is something like six miles. Being six miles above the ground isn’t like being six miles away from a hospital, however. If you have a medical problem in flight, you won’t be able get the help you need. What I will tell you is that if you don’t feel absolutely 100% normal in every way, the airline will reschedule you for free. Make sure you are feeling perfect before you get on the plane. Is that something you can agree with?”

Sign here.

*They make extra-narrow wheelchairs that fit down the center aisle of a modern airliner.