ADRENALINE: New 2013 edition by John Benedict Page B

said.
    “Very good. You’re with me. But there’s a major trap lurking here that I don’t think you’re even aware of.”
    Rusty hated when he missed major traps; there were so many in medicine. He concentrated very hard trying to come up with an answer. Dr. Landry appeared to wait patiently. Finally, with some disappointment Rusty said, “OK, you’re right. I don’t see it.”
    “Take it from me, there are some people you can’t mask ventilate. Usually, it’s the big ones, the three-hundred-pounders, but you never know for sure until you try, until they’re asleep.”
    “So you intubate them,” Rusty replied quickly, irritated that he was still missing the point.
    “You mean push the succinylcholine, paralyze them and then intubate?”
    “Yeah, right.” Rusty knew he had made a mistake but wasn’t sure how yet.
    “Herein lies one of the most dreaded situations in all anesthesia, my friend.” Dr. Landry paused to crunch on some chips, and took a quick look at the brunette’s table. “There are also people you can’t intubate. If you’ve just paralyzed this patient who you can’t ventilate with the mask, and now you discover you can’t intubate him, you’re screwed big time. Up the creek. Shit out of luck. You can’t breathe for him, and you just paralyzed him, so he can’t breathe for himself either.” Dr. Landry sat straight back in his chair, fiddled with his surgical cap, and looked straight at Rusty. “Get the picture?”
    “Yeah, I do,” Rusty said softly as the meaning sank in. “So, like, he dies?”
    “Well, hopefully not, although that’s possible. It’s emergency trach time.”
    “Yeah, right. I’ve seen that on
ER
.”
    “It’s not as easy as it looks, Rusty,” Dr. Landry said grimly. “By the time the shit hits the fan, and you’ve finished mucking around with your unsuccessful intubation attempts, your patient’s blue as hell and headed south fast. You probably have about one minute left to get the trach tray in the room, use it, and hook it up before he dies. Not a lot of leeway for error.” Dr. Landry wasn’t smiling anymore and looked more intense than Rusty would’ve thought possible.
    “Man, this airway stuff is pretty serious,” Rusty said in a subdued tone. He quickly switched his facial expression to match that of Landry’s. “Have you ever had a patient, uh, like that. You know, you couldn’t ventilate or intubate?”
    “’Fraid so and even worse.” A troubled look clouded Dr. Landry’s features.
    “Did they, uh, it turn out okay?” Rusty asked tentatively.
    “You be the judge. Back when I was a second-year resident, I once gave the wrong drug to a patient.”
    Rusty was shocked. He couldn’t imagine Dr. Landry making a mistake; he exuded such an air of capability. And he really couldn’t imagine an attending telling him about it.
    “Her name was Stephanie,” Dr. Landry said, “and she was having her first baby.” His eyes drifted as he focused inward on the memory. “She was my age at the time, and we hit it off nicely. I had just finished putting her epidural in. It worked great. She was so relieved that she couldn’t feel her contractions anymore. She gave me the sweetest smile, took my hand and shook it, and thanked me profusely. Then her BP dipped, which isn’t that uncommon. I was a little nervous and reached for the ephedrine syringe to give her BP a boost. I gave her Atracurium by mistake.” Dr. Landry’s face twisted in pain as he said this. “Do you know what Atracurium is, Rusty?”
    “Yes, it’s a muscle relaxant.” Rusty felt sick as the implications of paralyzing an awake patient sank in. But, he was also fascinated. “What happened?”
    “When she started gasping for air and whispering ‘I can’t breathe,’ I realized quickly enough what must’ve happened and began to try to ventilate her with a mask. I can still remember her eyes, her beautiful blue eyes wide with panic, staring up at me. I told her everything