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Memorable Moments

ED physician looked quite concerned and said he hadn't been able to get any IV access to give the patient fluids or antibiotics.

After a brief assessment of the child, it was clear to Tony and me that she was so ill she needed to be intubated immediately, before we transported her. But first we needed to get IV access so we could deliver sedation and paralyzing drugs to aid in the breathing tube placement. I was able to place an IV catheter in a scalp vein, while Tony got one into the bone marrow of her right leg. With the baby now paralyzed and sedated, we were able to place the breathing tube.

After we administered initial IV fluids and antibiotics, the pilot said we really need to go. We gave a brief description of the treatment plan to the patient's mother and then we were on our way. The tiny tube providing an airway got kinked easily, so Tony and I had to keep the patient's head placed just so in order to maintain her breathing. During the flight, we also had to raise the patient's blood pressure by administering a vasopressor drug intravenously.

While we were trying to focus on the patient, the pilot notified us of some icing and freezing rain ahead. We would need to fly lower than usual, meaning it would be a bumpy flight the rest of the way. We were by then 10 minutes out, and the pilot said we might even have to set down short of DHMC, at an alternative landing zone. The baby was very ill, and we were quite concerned.

But after 10 more minutes of flying at low altitude, with quite a bit of turbulence, we arrived at the DHMC heliport. We rushed the child into the pediatric ICU and transferred her care to the waiting team of doctors, nurses, and respiratory therapists. As we returned to the hangar, the weather continued to worsen. Tony, the pilot, and I looked at each other with feelings of satisfaction and relief.

The child was successfully treated for septic shock due to meningitis and was discharged about two weeks later. I have used this true-life scenario in training exercises to teach critical-thinking and crew resource-management skills.

Late one Saturday night, a man in his thirties came to the ED after being beaten up outside a bar.

Katherine Little, M.D.
Little earned her M.D. at the University of Vermont in 1988 and did her residency in emergency medicine at the University of Louisville. She joined the staff at DHMC in 1991. She is also a member of Dartmouth Medicine's Editorial Board. Here she shares several vignettes from the front lines of emergency medicine.

Years ago, before I went to medical school, I worked as an EMT. I once helped deliver a baby in the back of an ambulance in the middle of the night. We were just minutes from the ED, and the baby's breathing sounded like

gurgling because she had a lot of mucus in her airway. I was doing everything I could think of to try to suction out her mouth and clear her airway, but the baby's body was slippery and floppy even after I wrapped her up. The ambulance driver had called the ER on the radio to say we were having problems, so the moment we pulled into the bay, five people opened the ambulance doors and jumped in the back and started working on the baby. I sat there holding her steady for them while trying to stay out of everyone's way. They used a catheter to suction her out, and instantaneously her airway was cleared and her breathing got better. Then she started wailing, which is what you want to hear from the start.

One Sunday afternoon, a young man in his twenties got off a Vermont Transit bus in White River Junction, Vt. He was brought to the ED by ambulance because he had been acting funny—he was apparently talking as if to a companion, but no one was there. Then, after he got to the ED, he let his pet boa constrictor out of his backpack. "Baby" hung draped from the IV pole in his room. He asked us for a banana for Baby, and we scrambled around trying to figure out where to find a banana for his snake and what to do.

Late one Saturday night, a man in his thirties came to the ED after being beaten up outside a bar. Around his eyes were a lot of small cuts that looked dirty even after the lacerations had been washed out and irrigated. As I was trying to untangle the mangled skin tags and flaps and put everything back into position, he told me he had had teardrops tattooed on his skin where the cuts now were, so could I please try to make it look like it did before he got in the fight?

I also recall several memorable patients with hand injuries. Much of what physicians do involves our hands, so hand injuries are particularly worrisome if your ED patient is a physician—just as they are if your patient is a musician. I have treated fellow physicians for a variety of hand injuries, ranging from a deep cut exposing a tendon, to a splinter under a fingernail, to a sudden swelling of the ring finger. Such cases are never routine because in the back of your mind is the thought "I'd better do this right, or I could wreck a colleague's livelihood."

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