Cutting Through Black Bubbling Blood

I swear I’ll get back to my normal posts, but I just need to share this event.

Some of you can probably guess what this will be about based on the title, but it was a first for me. An event experienced by most in my field, an inevitable danger we all face.

This Saturday morning I was hosting a visiting resident from the states, Janet. She is here for the week to conduct interview-based research with the practitioners here. She wanted to see the hospital, so I obliged by bringing her on rounds with me. Fili joined us for rounds and we only had a few patients to see. The day was light-hearted and we enjoyed a slow, comfortable pace to rounds. When we came across our familiar 70 year old nasal septal abscess, things began to change.

He presented to us a couple days before with the complaint of painful nasal congestion. One look in his nose elucidated the cause. Nasal septal abscess. Considered an emergency of sorts, a nasal septal abscess should be drained immediately in hopes to protect the structural responsibilities of the nasal septal cartilage. Leave it untreated for too long and the cartilage dissolves away running the risk of various nasal deformities. When we asked him how long its been a problem, he said “3 months.” Not knowing exactly what to take from that (typically these abscesses are ridiculously painful as was this one, but dealing with it for 3 months sounded unrealistic). Nevertheless, we gave him local in the clinic, made incisions, drained the abscess, sent for culture (including AFB), and packed the nares bilaterally. He didn’t tolerate the procedure very well, but people rarely do.

On rounds this Saturday morning, we were seeing him about 24 hours after the packing was removed. And, of course, there was re-accumulation. I had already explained to him the night before the possibility of surgery and I confirmed it now. His expression was that of joy and excitement as he explained to Fili that he was happy to proceed with surgery. The 3 of us joked about his abnormally enthusiastic response and I said aloud, “I like that guy.”

Fili went to go speak with the anesthesia people and acquire an operating room. We decided to proceed with general anesthesia in order to achieve a thorough, pain-free incision, drainage, and packing. I didn’t want this abscess coming back again. I didn’t think twice about it and I felt like we were doing him a favor using general anesthesia. Once the three of us were in the OR, I watched as the anesthesia team had our friend pre-oxygenate with a mask before pushing propofol and then paralytic. Two quick puffs from the anesthesia machine bag produced good chest rise and then I made my first mistake; I left the room.

Leaving the anesthesia team to do their job and Fili to set up the room, I left to show Janet the OR area. Its small, so it didn’t take more than 3 mins. When walking back into the room, I saw the endotracheal tube slightly bloodied and sitting on the chest of our patient. The anesthesia team didn’t look panicked, but I did notice tachycardia of 113 and a blood pressure of 180/100. Again, bag masking was successful and I made the assumption that the cuff on the ETT didn’t work and they needed to exchange it. When the anesthesia person went to intubate, I saw him struggle and attempt to apply cricoid pressure with the whole palm of his right hand (you really don’t need to do that, one or two fingers can easily achieve that goal). With a desat to 70 and no attempt to intubate, I suggested bag masking and re-applying sedatives and/or paralytics. We knew masking him was easy, but he clearly needed more time to work as his tachycardia and hypertension suggested consciousness.

My advice went on deaf ears. The two of them fumbled around, changed nothing and attempted again with the sats only in the 80. I allowed it to happen in the hopes that he would be successful. Again, another mistake of mine. After multiple jabs with the tube, his sats now dipped quickly into the 60s. I told him to stop, bag mask and apply more medication. He did mask, and a small amount of propofol was given. I appreciated no chest rise now and his sats didn’t recover as before. Assuming laryngospasm, I took the bag so he could apply two hands to his mask and obtain better ventilation. At the same time, I told the other guy to give paralytic. In my peripheral vision, I see him slowly saunter to the desk, pick up a vial of medication, stumble to find a syringe and slowly draw.  My vision is fixed on the pulse ox that dances quickly through the 50s,40s and now 30s, still with no chest rise.

I loudly tell the guys to move as I position myself at the head of the bed while simultaneously extending the neck and grabbing the laryngoscope. My direct laryngoscopy was useless due to the blood and saliva that had accumulated in the hypopharynx. In that exact moment, the was a power outage and the suction machine had switched off. I made one blind attempt at the larynx, but felt nothing familiar. I turned around to look at the monitor. Pulse ox: 0; heart rate: steadily declining from 80.

Every medical student, resident, nurse, or whoever would listen to me I’ve taught that if you are performing a cricothyrotomy or a slash trach, something wrong has occurred leading up to that point. An airway, if prepared properly, should always be attainable without relying on the extremely dangerous “life-saving procedure.” Of course, there are exceptions to the rule, but in my 10 years of training, I had never seen nor performed one.

In that moment, while I turned to review the vitals, I thought to myself: “fuck, I’m right, something wrong has happened and now I need a knife.”

Luckily, Fili had already prepared a 10-blade for the procedure which I sternly asked for. With all of my attention focused on the dark anterior neck skin of my previously enthusiastic friend, my left index finger acted like that medical scanner on StarTrek, somehow able to ascertain all the information about the patient with just one swipe of the device.  The thumb and index finger of my left hand then firmly grasped his cricoid as my right brought the 10-blade close. Everything else ceased to exist. There was no one in the room, there was no sound, I had no internal monologue, time disappeared; there was just a cricoid and skin. With an extremely heavy-handed vertical swipe of the blade, reality came rushing back induced by the sudden rush of abnormally dark blood.

For a split-second, I paused and considered the need for suction but just as quickly deemed it futile. I could feel the tip of the blade against the tracheal rings and one final heavy-handed swipe produced a bubbling volcano of that same abnormally black blood. My left pinky finger followed the bubbles and my soft touch receptors reminded my cortex of the feeling of intraluminal tracheal rings.

An endotracheal tube was produced by Janet simultaneously with my request of one. As I jammed it into the lumen, I thought to myself, “that was an intuitive move, Janet, well done.” I applied the anesthesia circuit and then pressure to the wound. Looking to the left, I watched his sats rocket to 100% as if his index finger’s capillaries took a huge gasp of air. His pulse and hypertension normalized. His blood turned a familiar bright red.

Now that I have taken account of the room, I notice that every scrub, nurse and anesthesia person available had flooded in. Seeing no need for a tracheostomy, and realizing their trouble was due to a slightly anterior larynx, I asked them to use the airway bougie to establish the transoral airway. The more senior anesthesia person that had clearly taken charge now, did it with one try. After threading the new endotracheal tube into the larynx, I remove mine from the neck.

I spend the next hour controlling bleeding in the neck, draining the nasal septal abscess and packing, and repairing the iatrogenic injury to the anterior wall of the trachea. I made sure the seal was airtight (just like my teaching in airway reconstruction in fellowship) and reinforced loosely with strap muscle. The skin was gently closed over the wound, leaving room for air to escape if it needed to.

As I wrote the Op-note and stayed close to him while he woke up from anesthesia, I took note of the Swiss cheese model of consecutive problems that led to this event.

  1. I shouldn’t have stepped out of the room after induction: If I was there the entire time, I could have intervened earlier or obtained more information about the situation.
  2. I should have demanded he wait to try again until he was properly sedated while bag masking was still an option or at least wait until he was satting in the high 90s.
  3. I should have demanded to understand what the issue was with intubation, although I assumed an anterior larynx, I didn’t know for sure.
  4. I should have told anesthesia to use a bougie if I was assuming the issue was an anterior larynx
  5. There should have been copious backup drugs ready to go in case of an emergency. The presumed laryngospasm could and should have been broken easily
  6. I should have intubated with the bougie myself on my attempt. I don’t know if this would have been successful doing it blind in a pool of blood, however.

Anyone of these issues separately aren’t life-threatening, but line them up in the perfect sequence and they are deadly.

The next morning, he was up, ambulating, eating, and feeling well. I explained to him what happened and apologized. His response was simple and beautiful: “I don’t care what you did if it saved my life.”

I will watch him closely over the next 5 days and then let him be on his way, but he and his experience will stick with me forever.