6.11.2008

Difficult Airway



Last night I had this patient...

...He was a 45 yo male with no significant past medical history who presented to the ER in the early evening c/o "I think I have something in my throat." After further questioning his story goes like this:

When I went to bed last night, I felt fine. No cold or flu-like symptoms, no trouble breathing...nothing. When I woke up this morning I felt as though there was something in my throat. Not all the time, but when I swallowed, I felt...like it was hard for the saliva to go down. I tried drinking cold water, then hot coffee, I ate a banana, but nothing seems to "push it down." I decided to come here because throughout the day it's been getting harder to swallow food, and it feels like it's actually bigger.

He denied having any similar prior episode of the same. He denied h/o allergies. He insists that he didn't eat anything prior to the onset of the symptoms (such as fish, meat, chicken, seeds, etc). He had no other "allergic-type" symptoms such as wheezing, chest tightness, rash/hives, pruritis (itching). No new exposures, no travel. He was not a tobacco smoker, or involved in a fire (i.e. smoke inhalation). And he had no symptoms suggestive of infectious cause, such as fever, pain, redness, etc.

On physical exam:
He was a well developed, well nourished man in no apparent distress. Talking in full sentences, handling his secretions without difficulty, and able to drink water and eat soft foods with little effort.

His vital signs were normal, including an oxygen saturation of 98% on room air.
His face was normal, with no signs of swelling, no redness/hives. His eyes were normal without evidence of allergic reaction. His throat exam revealed a left tonsil that appear edematous. But there was no pus, redness, uvula deviation, and there was no pain. External palpation - the left neck felt "full" compared to the right side, but no mass was felt, and again, there was no tenderness to palpation. Lungs were clear. And otherwise his exam was essentially unremarkable.

So...we put him on oxygen, I drew labs (basically because I had no idea if this was infectious, allergic, traumatic, etc...and with airway issues I like to have as much information as possible, just in case surgery/intubation/intervention becomes necessary). I ordered a CT of the neck.

He's cruisin' along, sleeping on the gurney, when I got the CT report back:

"Extensive soft tissue swelling surrounding the airway...with prevertebral soft tissue swelling...partial airway obstruction...."

WTF??!!

I call for ENT, no one is on call. I call the nearest THREE hospitals...and I got some combination of 'no bed', or 'no ENT'. Finally, I get a hospital 80 miles away to take this guy. The ENT surgeon there recommends steroids, IV antibiotics, and intubation prior to transfer. All of that makes sense. Especially since the patient is starting to have more difficulty breathing and swallowing. We'd held off as long as we could to allow the meds to work but...he was indeed starting to have more significant respiratory distress. We preemptively called anesthesia for an awake option since he would absolutely need intubation prior to transfer, but that was now...not an option. Now is the time to intubate...


The critical care transport team will be here in 20 minutes.

So, I round up the troops. Explain everything to the patient; and obtain consent. Move him to big resus room, throw in a central venous catheter (in the femoral vein of course, not going anywhere near the neck). I have my colleagues at my side (2 other ED attendings) with the difficult airway cart at the bedside. I call for anesthesia, but no anesthesiologist is available (which I didn't understand, I mean how can you have an open/certified emergency department without OR staff...including anesthesia, immediately available? But no sense arguing/complaining now). I anticipate a difficult airway. But based on the patient's clinical status, and the fact that there is no one else readily available to secure the airway...we have to try. Or else just watch the patient decompensate in front of us...


We give the drugs, and bag him successfully. Then I try to intubate him. When I look into the airway...all I see is red translucent *pillows*. The airway is completely edematous...and I have no landmarks. I try the bougie, but I think there was too much edema to hear/feel the bumps on the tracheal cartilage...so it didn't help much. My two colleagues gave it a try after me. We didn't want to poke around in there...but we felt like we had no choice but to keep trying. We thought about waking him up, but considering his situation prior to induction...realized that that wouldn't be the best option.

So we ask the nurse manager to call anesthesia again, and if no answer she'll need to call the house supervisor...or anyone that can get an anesthesiologist in here. When I explain to her that we need anesthesia to intubate...she responds with "well they aren't here because the ER doctors usually intubate." But, after unsuccessful attempts by 3 ER attendings, I felt pretty righteous in rolling my eyes at her..and showing a bit of annoyance. Why do I have to explain to her (right NOW) why the ER doctor needs the anesthesiologist? Just fucking do it already!!

With a really shitty attitude, she agrees to keep calling.

So after 3 attempts, it seems as though the guy is intubated. Good color change on the capnometer, good breath sounds. We secure the tiny 6.5 tube. But, he starts to desaturate. Adjusting the tube and bagging him doesn't improve the situation, so we extubate him, and bag him. We are able to bag him!!

The CRNA (nurse anesthetist) shows up (no offense, but I didn't want a nurse, I wanted the physician...someone who can work independent and has final responsibility). I appreciate her presence, and ask her her opinion...but I'm still frustrated, and asking the charge nurse to continue working on getting an anesthesiologist here. And it's even more bothersome that I have to then explain to her that CRNA does not equal ANESTHESIOLOGIST. Sometimes people need to realize that shutting up and doing what's asked is 'what's best for the patient'. This was one of those times!!

We try to intubate again. LMA is at the bedside, but isn't a secure enough airway, and as long as we can bag him...we do that. And of course doing a cric (cutting the neck) is last resort, and since we could bag him...no need to get all messy. The fiberoptic scope is not something any of us ER docs felt comfortable using. There were no other fancy (easy to use) scopes/toys to help us in the difficult airway cart (actually, minus the bougie and the stuff for a cric, the cart was kinda useless, IMO).

We put a tube in, but I suspect the patient isn't intubated properly because oxygen saturation is stable at 97%. When we bag him with *no* tube, he's 100%. Why is he not at 100% with a tube?

It seems like FOREVER, but the anesthesiologist walks into the room (turns out he *was* in house as I figured). I don't think I've ever been so happy to see a consultant in my entire career!! He stands at the bedside, offering suggestions....oh, you're doing a good job...continue....don't worry about the O2 sat, etc.

NO, we're not doing a good job!! Dude isn't even intubated!!!

Initially he doesn't want to get his hands dirty, but after watching the patient desaturate to 96%, 95%, 92%...

...he'll come up, just bag faster, bigger tidal volume, more oxygen.

...90%...88%....

I hand him a pair of gloves. We extubate him (again).

He goes to the head of the bed, does some 'anesthesia stuff' and the O2 sat goes up to 1oo%. What he did was pull the endotracheal tube back into the posterior pharynx, closed the nose and mouth, and bagged that way. Then he asks for the fiberoptic scope...

While that's being set up, he takes a look with the regular laryngoscope...and couldn't see anything!! (I always feel a bit vindicated when someone else tries to do what I couldn't do, and they can't do it either).

Bagging is effective. Now the transport team is here to take the patient to the 70 mile away hospital. But we can't send him without a secure airway.

The anesthesiologist takes a look with the fiberoptic scope...
...and can't see anything!!

(now I'm thinking to myself "wow, I had no chance of getting that airway")

The anesthesiologist asks for a surgeon.

We call surgery, and he informs us that he 'cannot do trachs'.

Now what?
***

So I get on the phone, and call the only ENT surgeon anyone knows that lives in the area (that sometimes works at our hospital). He is not on call, and may not even be in town...but I call him at home anyway. It is now well after midnight.

I BEG him...PLEASE, PLEASE, come in and help us!! PLEASE we cannot send this patient anywhere...and we cannot secure the airway. Anesthesia is here, and cannot get the airway!! The surgeon can't do a trach!! We are all alone!! PLEASE Dr. ENT?!! PLEASE?!!.....

We promise him wine...we promise him gold...we promise to never call him again...
...just please come in now and help us!!

I think he heard the desperation in our voices...and maybe he likes wine, but he agreed to come in!! He asked us to call the OR team in stat. He asked us to set up the patient's ER room into an OR room. He'll be there in about 10 minutes!!

We activate the OR team, we set up everything. The OR staff is there in the ER, setting up the room before the surgeon arrives. Then *he* arrives...the ENT surgeon. To save our asses. The anesthesiologist is able to maintain ventilation by using his 'tube in pharynx' technique. We are all so very relieved...as if a boat has been sent to rescue us off a deserted island!!

The ENT surgeon does the trach in the ER. Anesthesiologist controlled the airway throughout the procedure with respiratory therapist.

Before I even complete my documentation, the patient is gone up to the ICU!!
***

I'm so grateful that this ENT surgeon, who was not on-call...may not even get paid for coming in (since the patient had no insurance, and medicaid doesn't pay sh*t)...and will likely be tired the following day at his profitable private practice clinic...agreed to come in and save this guy's life!!

This was my first time dealing with a truly difficult impossible airway (and I did anesthesia prior to emergency medicine...AND I trained at a Level I trauma center in Los Angeles!!)...

...and never had I seen a situation like this!!


**let me add: This is just a story, not an M&M. Medically people have been trying to dissect this case, but it's not (get this) an actual case.
It's a story.
The point being...the ENT surgeon who was not on call, came in anyway...and saved this patient (despite not getting paid, or otherwise benefiting personally, and maybe even professionally, in doing so). We create (and change/disguise) cases all the time to exemplify or teach a point - and this is what I've done, and will continue doing...to make the point. To create dialogue, and entertain. This case is somewhat unique in that more and more the specialists are actually *not* coming in (for anything), and lots of people die as a result of this all across America...
...this is the unusual case with one that did.

134 comments:

melinda said...

Doctors like this dude are... well, seems to me that they are doing what doctors are meant to do. You can obsess about earning more money or having more education that the guy next to you, but the reason we have doctors is to save lives. Even when it is inconvenient. So if you ever see him again, tell him I said thanks. Guys like him make this world a better place.

S.O. said...

cool post, cool blog.

ERnursey said...

don't you have a percutaneous trach kit?

Bored Infovore said...

Did you end up finding out what caused this massive swelling?

The Happy Hospitalist said...

I would have gone MacGyver on his ass.

Theresa said...

Edge-of-your-seat medicine. I'm so glad you thought to call ENT, on call or not. I think you should give him wine, roses, candles, chocolate....

Anonymous said...

Hmm, a former anesthesiologist and current ED physician who is uncomfortable even trying a fiber optic scope? Yet you feel the need to insult others? I am willing to bet even the critical care transport team you called had been trained to do an emergency crich!

Sounds like somebody needs to attend an airway class.

Kudo's to the ENT.

Kate said...

About to start moonlighting at a small community hospital very soon and this entry scares the CRAP out of me!

Bruce said...

Congratulations on keeping your head and the airway! Way to go! Hope you showed your new best friend the post you wrote about him.

Anonymous said...

The patient should be the one buying th wine and cheese. Maybe that would make him feel obligated to pay or feel thankful.

Karen said...

"Hmm, a former anesthesiologist and current ED physician who is uncomfortable even trying a fiber optic scope?"

She didn't say she was an anesthesiologist. And even for anesthesia, the scope is not easy, and success requires a certain type of patient. Obviously this was not the right type of patient (as it didn't do the trick).

-----------
"Yet you feel the need to insult others? I am willing to bet even the critical care transport team you called had been trained to do an emergency crich!"

Sometimes, in life/death situations, everyone cannot be made to feel 'important' (i.e the CRNA or the nurse manager). I disagree that anyone was insulted.

Doing the cric is a last resort. They had adequate ventillation. A trach is preferable to a cric, and serves as a longer term solution. They had a willing surgeon, and the patient was stable enough to wait for him. There is no indication that they were UNABLE (or otherwise lacked the skill) to do a cric.

Why do a sloppy and temporary cric when a trach could be done?

M said...

Well, you are simply lucky things worked out.

I find it hilarious that you think the CRNA isnt as good as any Anesthesiologist, afterall, the ones doing al the tubes and work in the OR ARE the CRNAs. Too bad your lack of understanding that there isnt a difference caused the delay in a real airway expert looking and treating.

Anyone who cannot do an emergency cric who is in anesthesia or the ER needs to quit.

Ten out of Ten said...

Well done, and welcome back -- hope you're enjoying the sunshine.

Interestingly, something very similar happened to me -- a patient that I couldn't intubate but could ventilate. Same for anesthesia. The on-call ENT lived over 30 minutes away, I called another ENT not on-call who I knew lived 5 minutes away. It was after midnight, he came right in and took care of business.

I found out he liked scotch. That's something I don't know much about but I went to a liquor store and bought him the most expensive bottle there.

Anonymous said...

Hands down, the best airway man I ever knew was nurse anesthetist. Just one story:

Obese male with no neck, in his sixties, was smoking in his car on a rainy night, windows rolled up. Dude is on oxygen. Kaboom.

Comes into the ER and the ER doc notes char around the patient's nostrils and stridor. ER doc calls me (ENT) and our nurse anesthetist. Not only does the patient have no neck, he has no neck flexibility, either. The thought of traching this patient is giving me conniptions. The thought of doing a cric doesn't make me feel much better, either.

Fiberoptic exam shows airway edema, but no incipient airway disaster. I figure the nurse anesthetist could intubate . . . but won't he have the same problem as I would, since the patient can't move his neck?

I remember him straddling the patient, his knees on either side of the guy's head. Something like that. It looked bizarre, I remember that much. But somehow he got a good angle and was able to pass a laryngoscope and intubate. Man, was I impressed.

Moral of the story: degrees don't matter. It's what they know.

And I have to agree with the others who say that emergency cric is a must-know procedure. If the doc is comfortable with cricothyrotomy, it takes a lot of the pressure off in these situations.

ER doctor said...

hmmm...interesting comments. it was quite a scene.

i don't know what caused the swelling.

we didn't have a percutaneous trach kit.

to clarify:
thanks karen, i am indeed *not* an anesthesiologist. i don't use the scope to 'practice' on a patient in extremis. especially when i have an anesthesiologist who is 'better' with the scope...AND, the patient was being oxygenated well via other techniques.

i can and *have* done crics...just in this case, with this guys neck all swollen (and a CT that shows distorted anatomy) i considered all options.

what we decided (and in retrospect was the best decision) was to continue managing the patient with bag ventilation since we had an surgeon willing to come in and provide a definitive airway.

why the assumption that we lacked the skill to do a cric simply because we had a better option...is beyond me.

regarding crnas - i understand their role in our hospital very well (i.e. there's no "lack of understanding"). crnas work under physicians where i work. degrees do matter. legally they matter. in society they matter.

i was very appreciative that the crna came down...but i wasn't willing to stop with that. she has a physician supervisor...and even if she was 'super crna' and could do cool tricks...i wanted her supervising physician at the bedside with her. if she could work completely independent of a physician, and take final responsibility - legally/financially, etc. then okay. when the midlevels can be sued all by themselves...then they can have all the responsibility they seek. until then the supervising attending needs to be present.

this is also true of residents who typically have better technical skills than their attendings...but i wouldn't *not* call the attending just because the resident is capable. that's irresponsible.

besides, the crna couldn't scope...and really, we needed someone who could offer more than what we'd already tried.

thanks for the comments. the point of the post was that the ent surgeon was awesome...and good doctors should be appreciated.

ER doctor said...

m said:
I find it hilarious that you think the CRNA isnt as good as any Anesthesiologist, afterall, the ones doing al the tubes and work in the OR ARE the CRNAs. Too bad your lack of understanding that there isnt a difference caused the delay in a real airway expert looking and treating.

Response:
This post doesn't even make sense to me. The "real airway expert" in THIS case...was the surgeon. The CRNA didn't help at all. Are you suggesting that the CRNA is the "real airway expert?"

Anyway, it's not about whether an individual CRNA "is as good as" an anesthesiologist. It's about having the supervising physician present. I don't care who's better, really. I just need the appropriate people notified and present.

Actually, it was the lack of understanding that they are indeed NOT the same that made it difficult to get the anesthesiologist to the bedside. CRNAs may be great at 'normal' intubations in the controlled setting of the OR...but this was not that situation. AND...this CRNA couldn't scope, so we were indeed waiting for the physician to come and try something we hadn't yet tried.

You have it all twisted...

ER doctor said...

M said: Well, you are simply lucky things worked out.

Response:
We were ALL lucky things worked out...especially the patient. Because much of what happens to us in life is not within our control, when something "works out"...I'm not ashamed, or too foolish, to thank "good luck." ;o)

ANON said:
in telling the story of the'super crna' - "...The thought of doing a cric doesn't make me feel much better, either."

then later, "If the doc is comfortable with cricothyrotomy, it takes a lot of the pressure off in these situations."

Response:
No it doesn't...

scut monkey dance said...

Can I ask why you switched from Anesthesia to Emergency Medicine?

Anonymous said...

Great story. Because of the length I've been putting off reading it, but it was definitely worth it!

Anonymous said...

'crnas work under physicians where i work. degrees do matter. legally they matter. in society they matter.'

'if she could work completely independent of a physician, and take final responsibility - legally/financially, etc. then okay. when the midlevels can be sued all by themselves...then they can have all the responsibility they seek. until then the supervising attending needs to be present.'

Are you a lawyer or a doctor ?? When your priority in a tough clinical situation is covering your own ass ----- if you fixate on the medical-legal considerations ----- then you need to step away --- before someone is compromised as a result of your fear of litigation.

You cannot be risk adverse and be a good emergency room physician; they are mutually exclusive attributes. You have to possess the nuts to do the right thing regardless of the personal cost.

If a board certified ER doc cannot independently manage a difficult airway (when there are no surgeons / ENTs in house) then why have emergency physicians at all --- why not go back to the days of staffing ERs with General Practitioners?

girlvet said...

man, and I thought only nurses trashed each other....

Anonymous said...

The Critical Care team should have been able to do a field cric on the patient!

This sounds like a long shot but I guess nobody has any experience in nasal intubation there? Maybe the swelling was to bad but if you woke the patient just enough, threw on the BAMM and gave it an attempt its not like you had any luck with all the other attempts.

ER doctor said...

anonymous posting makes it difficult to have a discussion, so if the comment sounds stupid to me (with no name attached)...i'll likely delete it. identify your profile, your blog, etc...we can have a discussion, even if i completely disagree with your position.

my blog, my rules. :o)

that being said, as for the anon (;47 post: (the one that's seems to be written by someone who actually may have some experience and is not simply insulting me, or pushing some CRNA agenda)...

"...not being risk adverse...just be a good doctor...yadda, yadda, yadda" - sounds noble and holier than thou. but in practice, i actually don't know any physicians who say 'to hell with risk management.' our entire healthcare system is f*cked up, and litigation plays a huge part in that. so...all that 'just be a good doctor and you'll be okay' rhetoric, is just that. you need to be able to defend your actions to your director, to hosptial CEOs, jcaho, CMS, patients/press ganey, etc. etc....that is real life. don't hate the player...

but you knew that if you actually work in healthcare.

and for the last time, in this situation the scope didn't matter. and if you had any experience with difficult airways, you'd know that the scope, or the crna, or the er doc isn't always the definitive solution. sometimes...its the surgeon.

a crash cric would have been indicated if all else failed. maybe you would benefit from a review of 'the indications of cricothyrotomy' if this is not well understood. anyone who thinks that a sloppy cut in the neck in the setting of massive neck swelling of unknown etiology, when ventilation is possible, and a surgeon/anesthsia are less than 10 minutes away (at which time a controlled, definitive, airway can be obtained), is mistaken...and dangerous.

just because you know how to do a procedure (that's maybe performed once or twice a year) doesn't make you a good doctor. it's knowing WHEN to do said procedure...and when it's more beneficial to step aside and allow other people who are more specialized to intervene.

SAFE er doctors aren't too arrogant or allow their big egos to interfere with calling for help if help is available. that, my friend, is what really compromises patient care (less so than being 'extra careful' in the risk management area)...and should not be encouraged or applauded by anyone in the business of providing quality patient care.

i'd guess that you're the type of guy who never pulls over and asks for directions ;o)

Path201X said...

Great post as usual ER Doc. And I LOVE how you stand up for yourself too!!

Toni Brayer MD said...

Amazing post and great save after using all the tools in your shed (including begging, bribing and just plain not giving up)!

I find the critical comments here a bit annoying. Monday morning quarterback after the crisis...go get em.

Bostonian in NY said...

EM Phys-
Good on ya for putting the anon posters without a clue in their place.

As far as the post goes, it's nothing but good, clean, conservative medicine on a pretty scary case. You covered your ass and got a better outcome for a patient than having to live with an unnecessary cric and all of the associated risks/morbidities that come with it in the ICU.

The story absolutely underscores the medical-legal-financial issues that are preventing consultants from taking ED cases. It's unsettling to think that you could end up needing assistance on an airway but because the anesthesiologist has a bug up his ass that night, you're stuck with his CNA who may or may not be able to help the situation. And then your surgeon on call "can't do trachs"??? Why the hell not and why does he have a medical license still? And there's no ENT on call...good thing you found someone to drag out of bed.

Oh man, the realities of EM get scarier every day...and you're the safety net!! It's a scary time to be a patient my friends.

ERP said...

I can't believe those Anon comments and CRNA posters. I mean, what the hell? Our CRNA's in our hospital can't do anything more than we can in the ER - ie they don't routinely do crichs or even use the fibreoptic scope. They are generally useless in a really difficult airway situation. Luckily we have attending anaethesiologists available almost all the time. I RARELY call them - maybe once or twice a year - and when I do, it is for a shitshow that they have trouble with as well. As for the crichs, I have done several and in a thin with good landmarks they are easy - but in a fat guy with a bull neck - no easy task. The last crich-trach we did in the ER was almost impossible for the ENT to do himself! He basically butchered the lady's neck and found the trachea at the last second! We as ER doc's can't just do these things willynilly - in fact no one can. Not ethical and not medically-legally safe either. I would like to see any of those critics at the bedside trying to handle a difficult airway like that and watch them implode. Assholes.

E said...

great story, great job.

DHS said...

my real question is: what sort of general surgeon doesn't do trach? it seems to be general surgical bread and butter.

mcd7m said...

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ER doctor said...

Had to eliminate some more comments. Let's keep in mind that this is just a story...
...created by me...

...to make a point. So let's just change it a bit:

***

So...okay, the guy couldn't be intubated awake b/c he was decompensating too quickly and something had to be done...and anesthesia wasn't "available."

The medical management wasn't effective. And he couldn't be transferred to see ENT until his airway was secure.

We can even change the story and say...the anesthesiologist came *right down* but couldn't do an awake scope because the patient became altered secondary to hypoxia/hypercapnea. In the setting of such rapid/profound decompensation, the procedure was unsuccessful...
...and the 'modified BVM' was working well as a temporizing method.

Anesthesia called for the surgeon...but the surgeon was in the OR trying to put Humpty Dumpty together again...

...and the rest of the story stands as originally written. :o)

How about that? See how easy it is to 'make up a story?'

Geez.

H said...

Dude,

If you're going to be an ER doc, you gotta grow some brass Cajones and cric that patient when the situation dictates! Begging the anesthesiologists and the ENT folks, who will only agree with you that this patient needs a surgical airway, just makes you and your EM colleagues look WEAK. You've done the procedure before. You know how to do it. For crying out loud the patient is dying right before your eyes. Damn it, are you an ER doc or are you not??! Who is the best damn doctor to handle a critical life or death situation such as this? Cric 'em Dano!

Here's a real ER doc who is unflappable:
http://fingersandtubesineveryorifice.blogspot.com/2006/07/is-for-airway.html

chuckr44 said...

Just a shot in the dark here, but I guess insect bite or sting. Was it 60 Minutes that found 40% of New York hotels, luxury or otherwise, had bedbugs? I've read of cases where people are sensitive to bedbug bites, but no cases where their throat actually swelled up.

Also, it's possible for it to be a wasp sting. Some people have a high tolerance to pain. My theory is he was sleeping, got stung, didn't notice it, then had a reaction to the sting.

Rachael C. said...

BTW, yesterday a medical show on NBC, I think, called "The Doctors" which features an ER physician and a couple private practice physicians, was in brief instructing how to give an emergency bronchiotracheotomy in the case of foreign object blockage in the trachea (when the Heimlich doesn't work), only I thought they forget to mention a couple of important things: 1)What about using alcohol wipes or gel to sanitize the knife, straw/empty pen, and incision area 2)Shouldn't emergency trachs be only preformed under the guidance of an emergency phone operator or personel, seeing the risks? What are your thoughts on lay persons preforming emergency trachs?

Christina said...

Very nicely delivered story. All too often, we're unable to find the physicians and other personnel we need in the middle of the night. If this is a true case, kudos to the ENT doc for coming in and kudos to you for calling him and begging.

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