Main-stem intubation happens 10% of the time

I right main-stemmed one of my patients. Neither me, the resident, nor the attending noticed until the patient started desating later on in the case.  Nothing significant but she went down to 96% from her normal 100%.  The resident asked the attending why she was desating and Dr. Hudson asked him what things could cause a patient to desat. He was only able to name a couple reason (monitors not on correctly, increased MetHb) then Dr. Hudson said. "But you did check breath sounds after intubating, right?"  Well we didn't but the resident just paused, not answering, when the surgeon chimed in and said "her left lung appears to be somewhat deflated"  Bingo!  We pulled back the tube and we were back up to 100% in no time.  When we brought the patient back to preop and gave our report one of the nurses found out that the "student," as she affectionately called me, main-stemmed the patient.  Now, whenever she sees me in the ICU she will tell everyone around her that I main-stemmed the patient because I didn't check for breath sounds after intubating.  It appears that she is doing it all in good fun but if she keeps doing it I am going to start to wonder.

Take home message:
Tip of endotracheal tube (red arrow) projects below the carina (blue arrow) into the bronchus intermedius on the right.

Prolonged R or L main-stem intubation can lead to atelectasis in the hypoventilated lung and pneumothorax or tension pneumothorax in the hyperventilated lung.

Always check breath sounds even if the resident you are with doesn't