everything out of the patient’s mouth and fitted the bag mask back on. The oximeter’s luminescent-green readout hovered at 60 for a moment and then rose steadily, to 97 percent. After a few minutes, he took the mask off and again tried to get the tube in. There was more blood, and there may have been some swelling, too: all the poking down the throat was probably not helping. The sat fell to 60 percent. He pulled out and “bagged” her until she returned to 95 percent.
When you’re having trouble getting the tube in, the next step is to get specialized expertise. “Let’s call anesthesia,” I said, and Johns agreed. In the meantime, I continued to follow the standard trauma protocol: completing the examination and ordering fluids, lab tests, and X rays. Maybe five minutes passed as I worked.
The patient’s sats drifted down to 92 percent—not a dramatic change but definitely not normal for a patient who is being manually ventilated. I checked to see if the sensor had slipped off her finger. It hadn’t. “Is the oxygen up full blast?” I asked a nurse.
“It’s up all the way,” she said.
I listened again to the patient’s lungs—no collapse. “We’ve got to get her tubed,” Johns said. He took off the oxygen mask and tried again.
Somewhere in my mind, I must have been aware of the possibility that her airway was shutting down because of vocal cordswelling or blood. If it was, and we were unable to get a tube in, then the only chance she’d have to survive would be an emergency tracheotomy: cutting a hole in her neck and inserting a breathing tube into her trachea. Another attempt to intubate her might even trigger a spasm of the cords and a sudden closure of the airway—which is exactly what did happen.
If I had actually thought this far along, I would have recognized how ill-prepared I was to do an emergency “trache.” As the one surgeon in the room, it’s true, I had the most experience doing tracheotomies, but that wasn’t saying much. I had been the assistant surgeon in only about half a dozen, and all but one of them had been non-emergency cases, employing techniques that were not designed for speed. The exception was a practice emergency trache I had done on a goat. I should have immediately called Dr. Ball for backup. I should have got the trache equipment out—lighting, suction, sterile instruments—just in case. Instead of hurrying the effort to get the patient intubated because of a mild drop in saturation, I should have asked Johns to wait until I had help nearby. I might even have recognized that she was already losing her airway. Then I could have grabbed a knife and done a tracheotomy while things were still relatively stable and I had time to proceed slowly. But for whatever reasons—hubris, inattention, wishful thinking, hesitation, or the uncertainty of the moment—I let the opportunity pass.
Johns hunched over the patient, trying intently to insert the tube through her vocal cords. When her sat once again dropped into the 60s, he stopped and put the mask back on. We stared at the monitor. The numbers weren’t coming up. Her lips were still blue. Johns squeezed the bellows harder to blow more oxygen in.
“I’m getting resistance,” he said.
The realization crept over me: this was a disaster. “Damn it, we’ve lost her airway,” I said. “Trache kit! Light! Somebody call down to OR 25 and get Ball up here!”
People were suddenly scurrying everywhere. I tried to proceed deliberately, and not let panic take hold. I told the surgical intern to get a sterile gown and gloves on. I took an antiseptic solution off a shelf and dumped a whole bottle of yellow-brown liquid on the patient’s neck. A nurse unwrapped the tracheostomy kit—a sterilized set of drapes and instruments. I pulled on a gown and a new pair of gloves while trying to think through the steps. This is simple, really, I tried to tell myself. At the base of the thyroid cartilage, the Adam’s apple,
When you’re having trouble getting the tube in, the next step is to get specialized expertise. “Let’s call anesthesia,” I said, and Johns agreed. In the meantime, I continued to follow the standard trauma protocol: completing the examination and ordering fluids, lab tests, and X rays. Maybe five minutes passed as I worked.
The patient’s sats drifted down to 92 percent—not a dramatic change but definitely not normal for a patient who is being manually ventilated. I checked to see if the sensor had slipped off her finger. It hadn’t. “Is the oxygen up full blast?” I asked a nurse.
“It’s up all the way,” she said.
I listened again to the patient’s lungs—no collapse. “We’ve got to get her tubed,” Johns said. He took off the oxygen mask and tried again.
Somewhere in my mind, I must have been aware of the possibility that her airway was shutting down because of vocal cordswelling or blood. If it was, and we were unable to get a tube in, then the only chance she’d have to survive would be an emergency tracheotomy: cutting a hole in her neck and inserting a breathing tube into her trachea. Another attempt to intubate her might even trigger a spasm of the cords and a sudden closure of the airway—which is exactly what did happen.
If I had actually thought this far along, I would have recognized how ill-prepared I was to do an emergency “trache.” As the one surgeon in the room, it’s true, I had the most experience doing tracheotomies, but that wasn’t saying much. I had been the assistant surgeon in only about half a dozen, and all but one of them had been non-emergency cases, employing techniques that were not designed for speed. The exception was a practice emergency trache I had done on a goat. I should have immediately called Dr. Ball for backup. I should have got the trache equipment out—lighting, suction, sterile instruments—just in case. Instead of hurrying the effort to get the patient intubated because of a mild drop in saturation, I should have asked Johns to wait until I had help nearby. I might even have recognized that she was already losing her airway. Then I could have grabbed a knife and done a tracheotomy while things were still relatively stable and I had time to proceed slowly. But for whatever reasons—hubris, inattention, wishful thinking, hesitation, or the uncertainty of the moment—I let the opportunity pass.
Johns hunched over the patient, trying intently to insert the tube through her vocal cords. When her sat once again dropped into the 60s, he stopped and put the mask back on. We stared at the monitor. The numbers weren’t coming up. Her lips were still blue. Johns squeezed the bellows harder to blow more oxygen in.
“I’m getting resistance,” he said.
The realization crept over me: this was a disaster. “Damn it, we’ve lost her airway,” I said. “Trache kit! Light! Somebody call down to OR 25 and get Ball up here!”
People were suddenly scurrying everywhere. I tried to proceed deliberately, and not let panic take hold. I told the surgical intern to get a sterile gown and gloves on. I took an antiseptic solution off a shelf and dumped a whole bottle of yellow-brown liquid on the patient’s neck. A nurse unwrapped the tracheostomy kit—a sterilized set of drapes and instruments. I pulled on a gown and a new pair of gloves while trying to think through the steps. This is simple, really, I tried to tell myself. At the base of the thyroid cartilage, the Adam’s apple,
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