“Billy doesn’t like doctors,” she reiterates.

I’m running out of patience.

“Look, this isn’t a democracy – his vote doesn’t count. It doesn’t really matter if he says no. Just put him on the stretcher anyway.”

At this juncture a tiny light bulb appears above her head. Aha! A brand new concept! This time she and her husband pick up Billy and deposit him on the stretcher like they mean business.

“Now you sit still, Billy,” she says firmly. After putting up a token show of resistance he settles down nicely. I begin my examination.

Adventures in Paralysis (The Ventilator Blues)

Every now and then we ER docs supplement our armamentarium with techniques borrowed from other specialties. Rapid sequence intubation (RSI) is one such purloined procedure. It involves using induction and paralytic agents to facilitate emergency endotracheal intubation. In plain English, this means we sometimes give patients who are struggling to breathe drugs that render them comatose and paralyzed. We then move their tongue out of the way with a device called a laryngoscope and quickly advance a hollow 12-inch plastic endotracheal tube (ET tube) past the back of the throat, through the vocal cords and into the trachea (windpipe). When the tube is in place we attach it to an Ambu bag. Squeezing the bag rhythmically results in 100 percent oxygen being delivered to the patient’s lungs. Depending on the situation, the ET tube can subsequently be attached to a ventilator.

As the name implies, RSI allows us to rapidly take control of a patient’s breathing. Anaesthetists have long used coma-inducing and paralyzing drugs in the OR, but it wasn’t until relatively recently that it was recognized there was a role for these medications in the ER as well. RSI is an invaluable adjunct, and it has bailed me out of a number of airway crises. Usually it goes off without a hitch, but once in a while things can get a little hairy. Here are three cases from my Yikes! file.

Are You Sure This Stuff Is Going to Help Me Relax?

Several years ago I was working in the ER when we got word an ambulance was on its way in with someone who had been trapped in the basement of a burning building. Before long the paramedics arrived with an uncooperative man in his early 20s. His clothing was badly charred and he was covered in soot. Inspection of his throat revealed a raw, beet-red palate, and his sputum was speckled with carbonaceous material. It was obvious he had suffered significant thermal damage to his upper airway. It is generally recommended that patients with this type of injury be intubated early. If you wait too long, late attempts at securing the airway may prove to be impossible due to massive soft tissue swelling in the throat. In situations where multiple intubation attempts have failed, oftentimes the only remaining airway management option is emergency cricothyroidotomy, i.e., cutting the front of the neck open to directly access the trachea. Rumour has it that incising the neck of a confused, combative burn victim isn’t much fun. Intubate early and save yourself a world of grief.

As we stripped off the patient’s smouldering clothes and started IVs I advised him of my concerns regarding his airway. When I told him I thought he needed to be intubated he said: “Are you saying you want to stick a tube down my throat and put me on a breathing machine?”

“In a nutshell, yes.”

“Yeah, right! Like that’s ever going to happen! No way, man. I’m out of here.” He sat up and pulled out one of his IVs.

“Mr. Cotard, I think you’re making a big mistake. Any minute now your throat might begin to swell. If it does, you could suffocate.”

“I already told you, there’s nothing wrong with me. I’m going home.” He started tugging on his remaining IV.

“Hang on,” I parried. “What’s the big rush? Why don’t you stay a little while and let us keep an eye on you? If nothing happens, we’ll let you go.”

“Okay,” he agreed grudgingly. “I’ll stay for 10 minutes, max.”

With each passing minute he grew more restless and agitated. We had to continually remind him to leave his oxygen mask on. Eventually his oxygen sats began to drop.

“If we wait much longer to intubate you, it may be too late.”

“Not a chance!”

Moments later his voice started getting raspy. The ER nurses and I exchanged worried glances. Vocal cord swelling. Not long after that he developed stridor, a high-pitched inspiratory wheeze indicative of a precariously narrow upper airway.

“That noise you’re making each time you inhale tells us we’re running out of time. We have to intubate you now before your airway becomes completely obstructed.”

“No way!” he squeaked. “Stay away from me!”

“All right then, at least let me give you something to help you relax a bit.”

“Okay.”

I drew up four syringes of RSI drugs: thiopental, succinylcholine, pancuronium and diazepam. My patient eyed the syringes suspiciously.

“Are you sure this stuff is going to help me relax?”

“I guarantee it.”

I injected the thiopental and succinylcholine into his IV port. Within a minute he was unconscious and paralyzed. I then squeezed a pediatric-sized ET tube through his flambéed vocal cords, hooked him up to a ventilator and shipped him off to the closest burn centre.

We were later advised his inhalation injuries were so severe he required mechanical ventilation for more than a week. His subsequent convalescence was uneventful.

As you can see, occasionally we're forced to override an irrational patient decision in order to save someone from themselves. These situations have the potential to ignite ethical and medicolegal firestorms. Whenever I'm caught in this type of quandary my guiding principle is to do whatever I feel is morally imperative and save the worrying about potential repercussions for later. In other words, do the right thing! So far this axiom has not let me down.

How Come She’s Not Breathing Anymore?

One night I was paged to the Special Care Unit to evaluate a teenage girl in respiratory distress. The nurse caring for her informed me the patient had presented to the emergency department earlier in the day after having ingested a large quantity of unknown pills. She had been treated with activated charcoal and observed closely in the ER. Nothing untoward had happened, so after a few hours she had been transferred to the unit for further monitoring. Her breathing had started to become laboured a few minutes prior to my being contacted.

The patient’s breathing was rapid and shallow. Despite maximal supplemental oxygen, her sats were only 80 percent. Examination, bloodwork and a portable chest x-ray failed to reveal any obvious cause for her abrupt deterioration. I wondered about the possibility of a pulmonary blood clot. Before I could pursue that line of thought any further, her respiratory status took a turn for the worse. I decided to intubate.

I selected my airway tools and calculated the appropriate RSI drug dosages. While the nurse got the medications ready I studied the patient’s mouth and neck in an attempt to gauge how difficult it was going to be to intubate her. Her receding chin, small mouth and big tongue all suggested the procedure would be technically challenging. If I paralyzed her and then found myself unable to get the tube in I’d be up the proverbial creek. Like the saying goes, bad breath is better than no breath. I therefore decided to do an awake intubation, meaning I would numb her throat and upper airway with the topical anaesthetic Xylocaine and then gingerly advance the ET tube into place. Once the tube was in, I’d quickly sedate and paralyze her in order to eliminate the possibility of her inadvertently yanking it out. I went over the plan with her in detail. She said she’d try her best to cooperate.