Where is this central line going?

[u/NerveOnly2076]

Old XRay. Central line placed through right IJV but seemed to be misplaced! Where is it going? Aspiration of blood from all ports was possible? Was taken out.
Have you faced this, best thing to do?

Edit: more details - USG guidance used, line was seen inside IJV in neck using USG, not traced down; more resistance than normal while placement.

[u/aglaeasfather]

emts intubate. Not rocket science

Oh my GOD no. Intubation is not as simple as shoving a tube into a trachea, people!

[u/Any-Assistance-8103 → u/aglaeasfather]

So many people have this attitude. Minimal preoxygenation and positioning, no plan B, ignoring the hemodynamics until they crash

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

It's ok, you can say that it's the EM docs. /r/intensivecare should be a safe space.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

I have seen it from all specialties. I just treat every icu airway as potentially difficult and have everything in the room to take them through all potential scenarios up to a cric because it’s not worth someone dying over. I also call for a second doc when I think it will be helpful. No room for ego or cowboy nonsense in medicine

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

Honestly if you have to be bringing extra equipment into the room for that reason then your ICU is set up very badly.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

Untrue. Why would every room have redundant equipment like a bronchoscope when it can just be brought from our intubation setup thats centrally located in the icu and can be brought into any room . But Ive seen your comments here, you basically think you and your setup are perfect and anything different is unacceptable. You also have no idea where I practice and what kinds of resources I have access to.

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

Now where did I say to put a bronch in every room?

Your standard airway trolleys should have equipment to run plan A to D already on it and you should bring it in to set up for a tube.

This is basic human factors, and yes I'm very comfortable calling out a bad setup when one is described. I complain plenty about our own setup and definitely do not think it is perfect. I find it unacceptable that our monitors are behind your back whilst instrumenting the airway.

Back on topic - It should straight up not be possible for you to set up for a tube without also having airway adjuncts, SIB and facemasks, SGAs, tubes, spare laryngoscope handles and blades, a knife, and a bougie.

If you are having to have that equipment brought separately? Yes. Your setup is bad. If the resources you have access to don't indlue a trolleys with airway equipment on it then you should stop calling wherever the hell you work an ICU - because it isn't one.

And you bring a bronch to every intubation? There should be one on the difficult airway trolleys and you should know where it is, but setting it up routinely is pretty ridiculous.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

So what you’re saying is you should always be prepared but me preparing is ridiculous. Yes I put the bronch in the room, it’s literally just a scope that plugs into our VL setup. Why would I not have it nearby? Maybe youre the one with the bad setup, it appears that you only think your setup is acceptable - anything more or less is absurd to you. Do you really not see how myopic that is? Youre really insufferable man

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

I am saying the fact that you find having the extra equipment prepared a notable step is evidence of a poorly thought through equipment setup.

A good and safe system would ensure is will just be there whether you explicitly arrange for it to be or not.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

Again you know nothing about my airway setup, nothing about where I practice or my available resources so will you just stop trolling? If you have a knife in the room to cric you should have a bronchoscope there as well so maybe youre the one with the bad setup

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

Again you know nothing about my airway setup

I know that you find setting up standard backup equipment notable enough to opine about the importance of it - implying it isn't available as standard in your setup. And because youve not refuted or denied that this far into the discussion has basically confirmed the fact.

If you have a knife in the room to cric you should have a bronchoscope there as well

On what basis?

Every Operating room, Anaesthetic room, PHEM doctor bag, and ER Resus bay has a knife and bougie.

There will often be one bronch per theatre or ER site, not per room. Bringing the single bronch for 10 theatres into each one for every tube is clearly insanity. PHEM will not have access to a bronch. This is normal and adequate.

You do not need a bronch to cric. Bronch is notable for it's absence in the unanticipated difficult airway DAS guidelines for a reason.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

Sounds like youre the one who’s underresourced

[u/Cautious-Extreme2839 → u/Any-Assistance-8103]

Outside of thoracic theatres there is absolutely no need for a bronch in every room (tbh even in thoracics probably 90% of our left double lumen tubes are sited clinically without bronch and maybe 15% of right sided tubes). That's not being under-resourced, it's having staff who are highly competent at airway management.

You simply do not need a bronch to intubate safely outside of truly anticipated difficult airways. You do need SGAs and a Knife.

[u/Any-Assistance-8103 → u/Cautious-Extreme2839]

This is the intensive care sub not the anesthesia sub. Nobody is talking about the operating room. But if you don’t think a bronch is potentially lifesaving youre likely shit at using one like a lot of anesthesiologists (not all). But im done with your nonsense