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Clinical Case for Discussion: It is the conclusion of a craniotomy for a tumor resection on a 50-year-old, 80 kg woman. The operating room table is turned 180 degrees, you are the sole anesthesiologist. and you are at the patient’s feet. The nurse and scrub tech are applying the head dressing. The patient coughs, turns her head, and the endotracheal tube comes out above the vocal cords. What do you do?
Discussion: You have been peering intently at the monitors and the patient for the past 4 uneventful hours, seeking the perfect anesthetic, but now you have some urgent work to do.
The approach to acute medical care is always: Airway, Breathing, and Circulation.
In this case, the airway is distant from you and your equipment, because the surgeon needed full access to the head for the surgery. Your first move is to go to the head of the table, and attempt to push the endotracheal tube (ETT) back into the trachea. This is not successful. The oxygen saturation is 100%, so the patient is in no immediate danger. You unlock the OR table, and and rotate it back so that the patient’s head is next to the anesthesia equipment again. You remove the ETT, apply a mask to the patient, and manage the airway as the patient awakens from anesthesia.
What if the oxygen saturation had dropped below 90% when the ETT fell out?
The answer is the same. You take the time to turn the table so that the patient’s head is back adjacent to your airway equipment and anesthesia machine, and then you use mask ventilation to return the patient’s oxygenation to a safe level. To deliver continuous positive airway pressure (CPAP) or positive pressure ventilation to your patient, you need to be able to reach both the ventilation bag and hold the mask over the patient’s face. You can not do this if the table is turned 180 degrees. If the patient develops laryngospasm that you can not break with CPAP, a small dose of succinylcholine (10 – 20 mg) is recommended.
Any attempt to manage the airway problem with the table still turned 180 degrees, but relying on the surgeon or the circulating nurse to hand you drugs and equipment, or to squeeze the bag on the circle system, is not recommended by this author. Their skill level may not be what you were used to in your residency training, when you were sharing the responsibility with a second anesthesiologist.
What if, in a parallel universe, at the onset of this same scenario a different anesthesia provider inserted the laryngoscope into the patient’s mouth to attempt to replace the ETT. The patient bit down on the blade, and the anesthesiologist wrestled with a forceful laryngoscopy. The oxygen saturation dropped below 90%. He decided to inject succinylcholine to paralyze the patient, but his drugs and syringes were at the foot of the operating room table, six feet away and out of reach. He instructed the nurse to draw up and inject the drug for him, but this took over 60 seconds of valuable time, during which the patient was hypoxic. He finally inserted the ETT into the trachea, and was able to ventilate the lungs to increase the oxygen saturation to 100% again. But the blood pressure was now 180/110, the heart rate was 140 beats per minute, and the intracranial pressure was higher than the surgeon’s temper at this point.
Make a different choice: turn the head end of the operating room table back to where your equipment is.
Regarding the possibility of the ETT coming out during surgery, I anticipate comments like: “How could this happen? Why didn’t you use Benzoin to hold the ETT tape to the skin overlying the maxilla? Why did you tape the tube to the mandible instead of the mandible? You should hold the ETT yourself when you are awakening a patient and they are applying a head dressing. You should keep the patient anesthetized until the dressing is done,” etc.
Alas, despite experience and planning, unexpected events do occur. Your worth as a clinician will be proven and tested by how you handle the unexpected.
In sum: If you are working alone, and an airway problem occurs with the airway six feet away from your anesthesia equipment, I advise you to bring the airway back to your equipment.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: