Airways

I got the idea for this from Notes of an Anesthesoboist who published this on her blog

About a month ago I was on call, minding my own business, watching the Bruins when emergency paged me to come and intubate someone. When I first started in medicine emergencies were staffed by people with very little formal training who largely did a good job and knew their limits. Emergencies are now staffed by ER docs who are highly trained and don't know their limitations. Thus when I got the page, I knew it was going to be something difficult.

Therefore before I left the OR I took our fibreoptic bronchoscope, every other piece of equipment I could think of and more importantly an OR nurse.

Emergency was its normal confused state and it actually took us a few minutes to find the patient. To my relief he was lying flat on his back, breathing easily and was acyanotic even though the ER hadn't got around to giving him oxygen. He had ingested some type of home remedy the night before and was having swelling of his throat. A gastroenterologist had come and gone and left me a nice picture taken thru the gastroscope of his supraglottic region. There was a moderate amount of swelling. ICU had seen him and had a bed for him (I asked right away, I have been burned by ICU too many times).

In retrospect I could probably have intubated him with a big syringe and little syringe. But for some reason I went into oral exam mode and decided to do a fibreoptic intubation. Probably due to my inept topicalization and his bizarre agitated reaction to sedation, it was not that easy but by holding him down and giving lots of propofol we got the tube down and I only missed the second period.

Of course the only thing we anaesthesiologists are acknowledged as being good at is airway management. This and the above post made me think about my experience with airway management.

I spent most of my last year of training preparing for the dreaded oral exam. This meant hours spent imagining every possible scenario and how to deal with it in an organized fashion. At the beginning of my last year, I did a pediatric rotation (not because of a desire to do pediatrics but rather due to willingness of the pediatric staff to give time off to study for the written exam). At that time the ex-chairman of the department had gone back to work after a brief retirement having found that his university pension couldn't support himself in the style he was accustomed to. Of all the people I trained under he still comes across as the person I liked the best. He did know his limits however and I was advised when I came that when he was on call, I had to be on call as well.

One Sunday afternoon I was at home when I got a phone call from the ex-professor. He told me there was a teenager with facial burns in the ICU who needed to be intubated. I met him in the change room and he asked me how I was going to do it. I probably said something about taking a history and applying my usual monitors but the bottom line, I said was we have to do a fibre-optic intubation. He told me there was no way, that the child would tolerate that but after looking at the poor child he agreed and I intubated him fibre-optically thru the nose with a little ketamine at the chairman's insistence. It seemed to take a long time but time always seems to go slower when you are trying to do a fibre-optic intubation. On Monday I triumphantly told all the staff what we had done and the universal answer was, "why didn't you call in one of us?".

About a week later, the chairman went off on sick leave. He had started having chest pain and got an EKG which showed a recent heart attack. I think he probably had it that afternoon. He later had and angioplasty and 20 years later is still alive.

I had a similar episode on my first weekend on call as a staff. I was called to the burn unit to intubate somebody who should have been intubated 12 hours earlier. My oral exam training kicked in and with no hesitation I intubated him fibre-optically.

Since then all kinds of devices for difficult airways have emerged. Most of these are expensive and require some kind of trained help.

About 10 years ago when I was at the centre of excellence, we had a newly minted staff who arrived at our department as a self-proclaimed expert on airways. At the CofE we did a lot of head and neck tumours, burns, broken necks and reconstructive plastics. Apparently we had been doing this wrong. Our airway of excellence fellow would hold forth at rounds and I would sit at the back thinking, "OK wiseguy how many of these have you actually done?"

He had trained with a prominent academic anaesthesiologist who considers himself a guru on airways. I happen to know someone who was a resident at the same time as the airway guru. Seems the airway guru almost snuffed several patients due to his inability to manage an airway. Those who can't teach?

One of the reforms brought in was an airway rotation for residents. Now airways are a central part of being an anaesthesiologist so it is almost like saying surgery residents should have a suturing rotation (now that I think about it not a bad idea as long as they don't practise on humans). This meant that instead of being assigned to a room, a resident would be designed as the "AIRWAY RESIDENT" but only until 1530 on weekdays. Actually if you had time and warning, if the resident was around and if he actually came the extra pair of hands was pretty useful because at the CofE you take any help you can get.

Maybe I have been too tough on my former colleague who is a nice guy if a little full of himself. He only lasted about 5 years at the CofE before going to greener pastures which means he is much smarter than I am.

The other recent event which prompted this post is the announcement that the Trach-Lite light wand will no longer be produced. Good riddance I say. Trach-lites were a neat party trick in patients with easy airways but of course of no use at all in the difficult airways scenario. All things being equal which they usually aren't, I like to see where I am going when dealing with fragile mucuosal surfaces. This is not to say that I haven't passed tubes blindly thru cords, I have and many times I have never been so relieved to see the ETCO2 wave. It's just not something I start out with a mind to.