“Doctor, come quick!” The anxious words pierce my reverie as I sit at my desk, attempting to chip away at the stack of unfinished charts piling up from the shift. I had been completing documentation and musing over my patients – Lauren the 86-year-old female with chest pain in Room 2, Bob in Room 33 with an ankle fracture, and Howard having his monthly psychotic break in Room 4. My sick patient is Denise, a pleasant, 72-year-old female who has early septic shock and is getting fluids and antibiotics while awaiting ICU admission. As EM physicians we are trained to be professional multitaskers, juggling multiple patients with various complaints simultaneously, so today is just an ordinary shift, but the plea for help immediately snaps me back to the reality of my environment. Being a good multitasker also means that when a nurse frantically runs out of a patient's room yelling for help, Lauren, Bob, Howard, Denise, and their problems all take a temporary back seat.
Arriving in the room, my eyes naturally jump to the patient, and then to the monitor, scanning for clues to the situation. “Doctor, I was about to wheel this patient to her bed upstairs”¦ then she stopped responding,” explains the nurse. I didn't really know the patient – she had been signed out to me as “a lady with stage 3 ovarian cancer, diabetes, and a recent surgery, being admitted for weakness with a new minimal oxygen requirement.” She was “stable” and awaiting an inpatient bed – nothing to do. Until now. I find that she is pale and cool, and the pulse oximetry monitor is blaring out a low frequency dronal tone, contrasting with my quickly rising pulse. I don't have to look at the numbers on the monitor to know what that low-pitched tone means. It's a sound every emergency physician dreads.
“Ma'am, ma'am, wake up!” I yell, but she isn't responding. Pinching her forearm does nothing to change her lifeless stare. Glucose”¦ normal. Naloxone”¦ no effect. She starts to gurgle as the oximetry tones continue to drop, and the nurse is now holding her in a jaw thrust. Out of the corner of my eye I can see the tech grabbing a nonrebreather. She's buying herself plastic between her cords.
Staff prep time gives me just a second to look through previous notes – and I see “multiple attempts required for intubation,” “difficult intubation,” “inadequate view” stamped all across her chart. “Great,” I mutter, as my mind is thinking of expletives. I know next to nothing about this patient, except the fact that what I'm about to do for her is probably going to be very hard. Briefly I wonder how this development will affect my six other patients scattered around the department. Refocusing, I inhale deeply and turn to the task at hand.
“Is everyone ready to intubate?” I ask, acutely aware of the rising tension in the room. With all equipment ready, we administer the sedative, quickly followed by the paralytic. As what's left of our patient's respiratory drive dissolves, her sats continue to drop, and now we're toying with oxygen sats in the 70s. Spreading open her mouth with one hand, I place a laryngoscope blade into her vallecula and take a good look at life or death.
Epiglottis. That's it. No cords, no arytenoids, nothing. Seconds are turning into hours as beaded sweat forms on my brow. Repositioning the head, cricoid manipulation – nothing seems to bring any other identifiable structures into view. Meanwhile I can hear the monitor behind me tick below 70%. The multitasker in me has become one singularly-focused person, intent only on the task at hand, and oblivious to the needs of Denise, Howard, or any other patient. In this moment, there is only one patient, and she needs a definitive airway, and quick.
I grasp a bougie and slide it underneath her epiglottis, hoping it can serve as my tactile eye and see what I cannot. Holding my breath, and sliding millimeter by millimeter, I finally feel an incredibly welcome “click, click, click” – and the wave of nausea rolling in my stomach is almost instantly dispelled. Tiny vibrations making their way up the long plastic catheter confirm I have found her trachea. Quickly sliding an endotracheal tube over the bougie finally provides the airway she needed, and we're able to bag her saturations back from the precipice. Her immediate danger has at least been temporarily removed.
However, my relief lasts only seconds; as soon as I leave that patient's room, I find that all of my other patients who have been on the back burner for the past 20 minutes are now boiling over. And so I transition back into multitasking mode. Lauren has a negative troponin but will need a stress test; Bob's ankle fracture still needs to be reduced, and Howard needs more haloperidol. To top off this constantly brewing chaos, I now have the additional responsibility of reviewing the patient I just intubated, and calling her up to the ICU. Again taking a focusing breath, I sit down to review labs and orders.
And then it came again – “Doctor, come quick!” Denise is now in full-blown septic shock. Surprisingly, I feel my adrenaline rising again, not entirely depleted after my harrowing airway. Here we go again”¦ just another typical day.
No one ever figured out what caused my intubated patient to decompensate. She eventually came around, was extubated, and did quite well. It is interesting, though, to reflect how the “easiest” patient quickly evolved into the most critically ill. Clearly, mastering acute patient care goes beyond medicine, clinical skills, and procedures. Whether with seven patients, 17 patients, or just one, multitasking is a key skill for any EM physician. While the art of juggling is probably inherent in all of us, we still spend our entire careers honing this one skill.
With interruptions coming every few minutes in the ED, we must be adept at changing, adapting, and then refocusing. Our oceans can go from calm to hurricane-force in a matter of seconds; we can go from “I'm sorry, you're dying” to “Congratulations, it's a boy!” within a couple of steps between rooms. Being able to master all of these convolutions and changes of emotion is something that we're built for, and may in fact be the true skill of the emergency provider.
Patients will continually surprise us, but our quick actions and flexibility will often save the day. Unlike other providers who might focus on one particular organ system or set of procedures at a time, in the ED, we focus on everything at once.