“Gimme a Nasal Trumpet”

Let’s talk Lingo.

Think about the work you do and the language you employ throughout the day.  Every workplace has its own language, the words and phrases understood by the users in their particular place that refer to the work they are doing.   The ER is no exception.  Oh no!  We’ve got tools, medications, procedures, acronyms, enough Latin to keep things interesting and situations to make you laugh, groan and cry.  It’s fertile ground for intensive jargon, so let’s go scratch around and see what we dig up.

It comes to mind I could do an A-Z kind of thing, but that’s too regimented for me, so I’m ditching that idea right now.  I will start with A though, because that’s where we’re going to find “Vitamin A”!  No not that vitamin A.  I’m talking about Ativan.  I don’t see how you could run an ER without it.  It’s that elemental for us.  It’s a benzodiazepine, the family of medications including Valium and Xanax.  Ativan is used to stop seizures, sedate patients on ventilators, relieve symptoms of alcohol withdrawal (which can be fatal), calm people having panic attacks or relieve muscle spasm.  It can be used as an adjunct to potentiate a pain medicine when the patient is too wound up to relax and let the medicine do its job.  Sometimes, when someone is agitated and irrational they might be said to have an “Ativan deficiency”.  Happens all the time.

The airway is big time important in the ER.  Maintaining an open and functioning airway is really Job One.  There are a lot of things that you may die from, but lack of oxygen takes you down quickly, just a few minutes without oxygen and you’re done.   So we have a lot of  terminology pertaining to the airway:  We’ve got the Bougie.  Hi tech sounding name eh.  It’s just a flexible plastic rod about 2 feet long used to hold the space open when an Endotracheal (ET) tube is replaced with a new one.  When a patient has a breathing tube in and is on a ventilator, the tube has to be replaced after a period of time, or if there is a problem with the tube.  The vent (Ventilator) is disconnected and the Bougie is inserted through the lumen (opening) of the ET tube down into the trachea (the airway in your throat).  The balloon holding the ET tube in place is deflated, the ETT is removed over the Bougie which maintains the pathway for reinsertion of the new tube without having to use a Laryngoscope (the handheld Light equipped tool that pushes the tongue out of the way, opens the throat and allows visualization of the vocal chords, through which the ETT is inserted) and the new ET tube is simply slipped over the Bougie.

I’ve already mentioned the Laryngoscope, but there’s also the Glide-scope.  Same thing, but instead of being a sort of glorified flashlight it is a fiber-optic camera mounted laryngoscope.  Makes the job of inserting the tube a whole lot easier.    There’s the OPA.  This is not the cheer you hear in Greek Restaurants.  It is an Oropharyngeal Airway, a curved piece of plastic that is either tubular or I-Beam shaped with a flange on one end.  The flange acts as a stopper to keep the thing from slipping down your throat.    These come in different sizes to accommodate the different sizes of mouths and throats from newborns to linebackers.  This device is inserted into the mouth of a person who is either unconscious or neurologically impaired to the point they don’t have a gag reflex and can’t protect and keep their own airway open.  It keeps the tongue from slipping down the back of the throat and blocking the airway and the tubular or I-beam shape allows passage of air in and out without obstruction.

Another gadget that does the same job is the Nasopharyngeal Airway or NPA, also known as the Nasal Trumpet.  This is a flexible rubber tube with a flange at one end.  The flange  flares out and looks like the bell on a trumpet.   This item is inserted into either nostril and goes up the nose, bends around and back down to the top part of the throat, stopping short of the vocal chords.  Kinda gross, I know.  Obviously a Nasal Trumpet is not going to be tolerated by a wide awake person.  It’s used for obtunded individuals, same as the OPA.  You might see this in use if you ever have the misfortune to get a call from us to come to the ER because your fourteen year old little angel has gotten into the liquor cabinet on their sleep over at their friend’s house and is stuporous.  Not you personally mind you.  I know that you know we are talking about someone else here.  It’s just an example.  Lighten up!  What’re ya Ativan deficient?

Oh!  There’s the Tum-E-Vac.  This is an Orogastric tube. (A tube inserted orally , down the esophagus into the stomach).   This apparatus is connected to suction (conveniently located bedside in every room) and the contents of the patient’s stomach can be evacuated and the gastrum Lavaged, or washed out.  Yup we’re talking about having your stomach pumped.   This is used less often now than when I first started nursing and not just because it’s a disgusting mess either.  It is not without risk sticking a tube down the gullet. It can lead to vomiting, which can lead to aspiration (inhaling the vomitus).  Also if the person receiving the tube attempts speech, or breathing during insertion those activities will open the airway and close off the esophagus, so your tube will end up in the lung and not the stomach.  Believe me, that is not where you want to be with this tube.  There have been instances in the literature where the tube was in the lung and lavage was attempted (someone squirted water into the tube) and the patient has drowned.  Obviously care must be taken with this intervention.

“I need somebody to bag him”, is something you might hear.  This is another breathing support measure.  If the patient is having trouble physically moving air in and out, or stops breathing, a device called an AmbuBag is used to push air into the lungs.  It is used with an ET tube for manual ventilation or with a BVM (bag valve mask) in the non-intubated patient, over the mouth and nose and fitting snugly so when the bag is squeezed it forces air through the nose and mouth into the lungs assisting the patient with severe breathing difficulty, or doing all the work for someone in respiratory arrest.  You can probably imagine this is labor intensive, requiring a person to be dedicated solely to the task of ventilating the patient.  It’s meant as a short term measure.

Crikey!  I almost forgot the “Crike”!  (Not really.  I just wanted to use that lead in.  Corny I know)  This is a measure of last resort to establish a functional airway.  If you are unable to establish an oral or nasal Endotracheal intubation due to massive upper airway edema (swelling) or anatomical anomalies, or facial trauma or foreigh body obstruction, it may become necessary to perform chrcothyrotomy.  An incision is made in the front of the throat at the level of the crichoid membrane, just below the adams apple.  You would only do this if no other option was available and the person was just about to die right in front of you if you didn’t open a route for air to get in and out of the lungs.  I am thankful to say I have never been witness to this procedure.  I remember an awful scene in an awful movie though, “The Sweet Hereafter” with Ian Holm, where he is recalling a time when his daughter was very young and , in the night had been bitten by many many black widows and her airway was closing off.   While he was driving to the ER… he was on the phone with 911 and they guided him through it over the phone. What I remember is the anguish on his face as he describes how helpless he was watching his daughter dying and he had to do this to save her life.   Tough stuff to contemplate.  Would you do it?  Could you do it to save your child?  Luckily it isn’t that stressful at work, usually.

Um, let’s just leave airway there, shall we?  How did that bit start so light and get so heavy so fast?  Words are powerful and you’ve got to be careful with them.

Sometimes the names of things can become laborious when used in their full measure, so it’s just more practical to abbreviate.  Take “Appy” for example.  That’s short for Appendectomy.  That’s familiar enough to most folks.  How about “MRSA”?  Methicillin Resistant Staphylococcus Aureus.  That’s unfortunately become a household abbreviation also.  It’s one of the antibiotic resistant strains of bacteria which have sprung up due to over-usage of antibiotics in the era before it was known that bugs would mutate and evolve to withstand the stuff we used to kill them.  (I know, looking back it seems it should have been obvious nature would do this to protect itself, but it just wasn’t foreseen and prevented).  Even Staphylococcus is usually shortened to just, “Staph”.    How about ESBL?  Now we’re probably venturing into new territory for most.  This means Extended Spectrum Beta-Lactamase enzyme producing bacteria.  These bad guys produce a type of enzyme that inactivates most antibiotics, rendering them useless against this bacteria.  Infections with this are hard to get rid of and require use of antibiotics which are held in reserve for just such resistant superbugs.  Once rare, these bugs are becoming more common.

What else?  “Choly” for Cholecystectomy.  Surgical removal of the Gall Bladder.  “TURP”, Transurethral resection of the Prostate.  Yup, cringe gents, this is the insertion, through the willy, of instrumentation to nip away at the prostate when it either gets too big with age or is enlarged by tumors.  This procedure isn’t actually done in the ER, nor is the Chole or the Appy, but we prep people for surgical procedures and occasionally see them after discharge should complications arise.

“She’s in SVT”.  Sounds like a model in Cadillac’s lineup, but it’s a rapid rhythm of the heart.  Really rapid.  It’s characterized by a heart rate over 150 beats a minute with “Narrow Complexes” on the cardiac monitor.  To step this back, complexes are the squiggly lines you see on an EKG or heart monitor.  Sometimes the complexes have a predominant shape in the middle that’s narrow and sometimes wide.  They mean different things in terms of the way your heart is conducting electricity through the heart muscle.  Sometimes a person will come in in SVT and what they’ll be experiencing is just a little sense of a rapid flutter in their chest.  Often it’s more vague than that, either mild shortness of breath or fatigue or feeling light headed  or like they might faint.  Occasionally it can be corrected by use of the “Valsalva’s Maneuver” (Bearing down like when you are having a bowel movement.  This technique can get messy)   Sometimes a splash in the face with ice water can fix it.  Sometimes trying to blow through or into something that doesn’t allow air to pass easily (We have people blow into the tip of a syringe and try to force the plunger out).  Most of the time we use a really cool drug called Adenosine.  An EKG is done to confirm diagnosis of SVT.  An IV is started, preferably with a large bore catheter (Needle) to facilitate rapid infusion of the drug simultaneously with a pretty good sized bolus of Saline to quickly get the drug into the patient’s central circulation where it will hit the cardiac receptors and take effect.  What is the effect?  Well the stuff works fast and is metabolized fast… just a few seconds and it’s all gone.  But what it does is it resets the heart’s intrinsic pacemaker.  It basically interrupts all the electrical conduction through the heart for a very brief period during which the problematic conduction pattern is broken and the heart begins to beat in a normal way again.  The tricky part is that pause.  People say it feels terrible… like you’re dying, like you can’t breathe, like your chest is being crushed.  If you’re in my position pushing this potent stuff and watching the cardiac monitor as it spits out a continuous rhythm strip, your heart may want to stop too, because what you see is the heart speeding away, speeding away, speeding away and then Uh-Oh!  Nothing!  Asystole, the proverbial Flat Line!  The person becomes flushed and maybe groans or something, but then just like that, before you have time to really worry, NSR!  (Normal Sinus Rhythm)  Normal looking rhythm.  Normal Pulse.  The person looks relieved and usually reports that the light headedness, or fluttering or whatever brought them in is gone.  This is one of the very few drugs I refer to as “Like Magic”.

Another “Like Magic” drug is Proparacaine.  If you’re familiar with drug names you’ll probably be able to guess this medicine falls into the anesthetic category.  Novocaine, Lidocaine, Xylocaine, those kind of drugs.  This one, though is an eye drop that stings (kind of badly) for about half a second then, aaaaaahhh!  Sweet relief!  I don’t know if any of you have suffered with corneal abrasions or foreign objects in the eye, but I have .  Too many times in my previous life as a bicycle mechanic.  The eye is a very sensitive organ and a tiny scratch, or almost invisible particle of metal, glass, sand, what have you in the eye can be excruciating!  Many times a person will come into the ER with a story of days of eye pain, redness and swelling that is just not getting better like they expected.  This is torture.  (Maybe that’s why I remain squeamish about eye injuries to this day)  When you get someone who is in this condition and you can quickly get an order for some Proparacaine drops and get that stuff into their eye.  You are a knight in shining armor upon a brilliant white charger!  You are a salvation sent by God.  (Too much?)  It is a miraculous moment though as you witness the pain and suffering dissolve from that poor person’s face to be replaced by grateful tranquility.  It really is that fast and that remarkable.  I Love this stuff!  It is like I feel it myself.  The ability to produce such instant relief is extremely rare and satisfying.  A moment like this can sustain you through twelve hours of unbridled, bareback bucking Goat Rodeo mayhem.  Sometimes that’s all you’ll get.  And sometimes it’s all you’ll need.

This lingo stuff appears to be gathering more of a head of steam than I’d figured on, so I’m going to call time out for now.  Give you all and myself some time to think about this installment and move onto something else.  To be honest though, I’ve had fun with this and I’ve only begun to scratch the surface of this deep mine of possibilities, so I promise to return to the language of the ER another time.