The Anesthesiologist's Toolbox

A code blue is called when a morbidly obese patient is found pulseless. I am carrying the airway pager and arrive at the scene with ongoing chest compressions in an unresponsive man. One of my co-fellows is running the code, giving epinephrine, checking the rhythm, determining the cause of the cardiac arrest. When I get to the head of the bed, one hypothesis is clear. The patient has blood coming up out of the mouth. In medical training, there are a lot of situations that give me pause, and this is one of them. For an anesthesiologist, this is a nightmare situation. The respiratory therapist is unable to give effective masked breaths because of the blood and the patient's size. The patient is most certainly hypoxemic, and if we cannot get him oxygen, he won't make it. With ongoing compressions on a bed in poor ergonomic position, I suction the mouth and take a look with my laryngoscope. I can't see anything; only faint structures are recognizable, but I hear one of my attending's familiar sayings in my head: "Just put the tube in." It's really down to me; I have to secure the airway. So drawing on feel and experience, I slip the endotracheal tube in. I get positive end tidal carbon dioxide, and when we regain a pulse, the oxygen saturation is 100%.

I arrive to work to find two of my non-anesthesia colleagues desperately trying to get IV access on a patient. The patient has an AV fistula for dialysis on one arm, so only the other arm is available. I take a look at the legs and neck, but don't see any obvious veins. My medicine co-fellows' attempts with ultrasound guided IV access are futile, and the nurse tells me her best ED colleagues have tried and failed. Finally, my co-fellow asks for a central line kit even though the patient doesn't really need central access. I ask if I can give the peripheral a try. I stop by the operating room to pick up supplies and some lidocaine. The patient, who has been poked five or six times in his right arm, is wary of more pain and discomfort. But gently, I find and cannulate a small peripheral, and the patient gives me a hug.

There are a lot of things I have to learn in fellowship, but I am glad that my few years in anesthesia have given me a toolbox that few others have. These experiences have also boosted my confidence that I was ready to graduate from residency.