is a little gap in which you find a thin, fibrous covering called the cricothyroid membrane. Cut through that and—
voilà!
You’re in the trachea. You slip through the hole a four-inch plastic tube shaped like a plumber’s elbow joint, hook it up to oxygen and a ventilator, and she’s all set. Anyway, that was the theory.
I threw some drapes over her body, leaving the neck exposed. It looked as thick as a tree. I felt for the bony prominence of the thyroid cartilage. But I couldn’t feel anything through the layers of fat. I was beset by uncertainty—where should I cut? should I make a horizontal or a vertical incision?—and I hated myself for it. Surgeons never dithered, and I was dithering.
“I need better light,” I said.
Someone was sent out to look for one.
“Did anyone get Ball?” I asked. It wasn’t exactly an inspiring question.
“He’s on his way,” a nurse said.
There was no time to wait. Four minutes without oxygen would lead to permanent brain damage, if not death. Finally, I took the scalpel and cut. I just cut. I made a three-inch left-to-right swipe across the middle of the neck, following the procedure I’d learned for elective cases. Dissecting down with scissors while the intern held the wound open with retractors, I hit a vein. It didn’t let loose a lot of blood, but there was enough to fill the wound: I couldn’t see anything. The intern put a finger on the bleeder. I called for suction. But the suction wasn’t working; the tube was clogged with clot from the intubation efforts.
“Somebody get some new tubing,” I said. “And where’s the light?”
Finally, an orderly wheeled in a tall overhead light, plugged it in, and flipped on the switch. It was still too dim; I could have done better with a flashlight.
I wiped up the blood with gauze, then felt around in the wound with my fingertips. This time, I thought I could feel the hard ridges of the thyroid cartilage and, below it, the slight gap of the cricothyroid membrane, though I couldn’t be sure. I held my place with my left hand.
James O’Connor, a silver-haired, seen-it-all anesthesiologist, came into the room. Johns gave him a quick rundown on the patient and let him take over ventilating her.
Holding the scalpel in my right hand like a pen, I stuck the blade down into the wound at the spot where I thought the thyroid cartilage was. With small, sharp strokes—working blindly, because of the blood and the poor light—I cut down through the overlying fat and tissue until I felt the blade scrape against the almost bony cartilage. I searched with the tip of the knife, walking it along until I felt it reach a gap. I hoped it was the cricothyroid membrane, and pressed down firmly. I felt the tissue suddenly give, and I cut an inch-long opening.
When I put my index finger into it, it felt as if I were prying open the jaws of a stiff clothespin. Inside, I thought I felt open space. But where were the sounds of moving air that I expected? Was this deep enough? Was I even in the right place?
“I think I’m in,” I said, to reassure myself as much as anyone else.
“I hope so,” O’Connor said. “She doesn’t have much longer.”
I took the tracheostomy tube and tried to fit it in, but something seemed to be blocking it. I twisted it and turned it, and finally jammed it in. Just then Ball, the surgical attending, arrived. He rushed up to the bed and leaned over for a look. “Did you get it?” he asked. I said that I thought so. The bag mask was plugged onto the open end of the trache tube. But when the bellows were compressedthe air just gurgled out of the wound. Ball quickly put on gloves and a gown.
“How long has she been without an airway?” he asked.
“I don’t know. Three minutes.”
Ball’s face hardened as he registered that he had about a minute in which to turn things around. He took my place and summarily pulled out the trache tube. “God, what a mess,” he said. “I can’t see a thing in
voilà!
You’re in the trachea. You slip through the hole a four-inch plastic tube shaped like a plumber’s elbow joint, hook it up to oxygen and a ventilator, and she’s all set. Anyway, that was the theory.
I threw some drapes over her body, leaving the neck exposed. It looked as thick as a tree. I felt for the bony prominence of the thyroid cartilage. But I couldn’t feel anything through the layers of fat. I was beset by uncertainty—where should I cut? should I make a horizontal or a vertical incision?—and I hated myself for it. Surgeons never dithered, and I was dithering.
“I need better light,” I said.
Someone was sent out to look for one.
“Did anyone get Ball?” I asked. It wasn’t exactly an inspiring question.
“He’s on his way,” a nurse said.
There was no time to wait. Four minutes without oxygen would lead to permanent brain damage, if not death. Finally, I took the scalpel and cut. I just cut. I made a three-inch left-to-right swipe across the middle of the neck, following the procedure I’d learned for elective cases. Dissecting down with scissors while the intern held the wound open with retractors, I hit a vein. It didn’t let loose a lot of blood, but there was enough to fill the wound: I couldn’t see anything. The intern put a finger on the bleeder. I called for suction. But the suction wasn’t working; the tube was clogged with clot from the intubation efforts.
“Somebody get some new tubing,” I said. “And where’s the light?”
Finally, an orderly wheeled in a tall overhead light, plugged it in, and flipped on the switch. It was still too dim; I could have done better with a flashlight.
I wiped up the blood with gauze, then felt around in the wound with my fingertips. This time, I thought I could feel the hard ridges of the thyroid cartilage and, below it, the slight gap of the cricothyroid membrane, though I couldn’t be sure. I held my place with my left hand.
James O’Connor, a silver-haired, seen-it-all anesthesiologist, came into the room. Johns gave him a quick rundown on the patient and let him take over ventilating her.
Holding the scalpel in my right hand like a pen, I stuck the blade down into the wound at the spot where I thought the thyroid cartilage was. With small, sharp strokes—working blindly, because of the blood and the poor light—I cut down through the overlying fat and tissue until I felt the blade scrape against the almost bony cartilage. I searched with the tip of the knife, walking it along until I felt it reach a gap. I hoped it was the cricothyroid membrane, and pressed down firmly. I felt the tissue suddenly give, and I cut an inch-long opening.
When I put my index finger into it, it felt as if I were prying open the jaws of a stiff clothespin. Inside, I thought I felt open space. But where were the sounds of moving air that I expected? Was this deep enough? Was I even in the right place?
“I think I’m in,” I said, to reassure myself as much as anyone else.
“I hope so,” O’Connor said. “She doesn’t have much longer.”
I took the tracheostomy tube and tried to fit it in, but something seemed to be blocking it. I twisted it and turned it, and finally jammed it in. Just then Ball, the surgical attending, arrived. He rushed up to the bed and leaned over for a look. “Did you get it?” he asked. I said that I thought so. The bag mask was plugged onto the open end of the trache tube. But when the bellows were compressedthe air just gurgled out of the wound. Ball quickly put on gloves and a gown.
“How long has she been without an airway?” he asked.
“I don’t know. Three minutes.”
Ball’s face hardened as he registered that he had about a minute in which to turn things around. He took my place and summarily pulled out the trache tube. “God, what a mess,” he said. “I can’t see a thing in
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