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Your dejected resident walks away from the patient’s bed to peek at the portable chest X-ray that was just taken.

“I can’t believe I missed that airway!” she says. “I haven’t had that happen in years!” You reiterate how difficult the airway was, and you compliment her on changing her approach between attempts.

“You know, Richard Branson once said, ‘Opportunities are like buses…there’s always another one coming’,” you say. “Why don’t you go see what the EMS call is all about?” Sure enough, the local flight crew is bringing in a 52-year-old male in respiratory distress. He is tachypneic and tachycardic and they are having a hard time getting a history from him. He was initially hypotensive, but his blood pressure has responded well to the liter of normal saline that they just infused. You have five minutes to get everything prepared.

In gearing up for a potentially tricky resuscitation, your once dejected resident is now full of energy. She organizes the troops, assigns roles, double checks all of her airway equipment, and prepares the ultrasound machine. The patient arrives a few minutes later and requires intubation. Like a pro, your superstar senior slides an 8.0 mm endotracheal tube gently through the vocal cords. As the RT’s hook the patient up to capnography, your resident attempts to auscultate for bilateral breath sounds.

“Something’s not right here,” she says. “I can’t hear any breath sounds on the left. I can’t even hear his heart sounds on that side.” Before you can even open your mouth to make the suggestion, she reaches for the ultrasound probe and begins scanning the patient’s chest.
With the phased array transducer, your resident takes a quick look at the patient’s heart in the parasternal long axis (Figure 1). She throws a quick smile your way, and says, “Looks like he’s going to need another procedure.” She obtains a few more views to confirm her findings and scurries off to grab the requisite supplies.

Figure 1: Parasternal long axis view of the heart (click on image to enlarge)

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What do you see on the parasternal long axis view of the heart? What procedure does this patient need?
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