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.