Tuesday, July 15, 2008

Why The O.R. is NOT a "Meat Market," Grey's Anatomy Notwithstanding; and, Looking a Patient in the Mouth: What's That About?

(West Side Story music intro blares - tararararum-tum-tum ta ra-ra):

"I feel pretty,
Oh, so pretty,
I feel pretty and witty and bright!
And I pity
Any girl who isn't me tonight..."


Now for some more prettiness.

I've been asked time and again by patients why I examine the interiors of their mouths. "What'd you do that for?" They say with puzzled, sometimes curious, expressions.

I'm doing a physical exam of the airway to determine its Mallampati Class - based on a classification system that allows anesthesiologists to assess and document visible landmarks and to communicate those findings with other anesthesiologists.

A "good" Mallampati class (Class I), however, does not always portend an easy intubation, nor is a disfavorable one (Class III) always a harbinger of airway trouble. I use the Mallampati classification in conjunction with other physical features that over the years have seemed to point to ease or difficulty of mask ventilating or intubating a particular airway.

I get a general idea of the amount of soft tissue around the face and neck as well as the quantity of facial hair.

I look at the size of the jaw - particularly the "thyromental distance" from, roughly, the tip of the chin to the neck, I specifically try to evaluate how "well" a person's tongue fits into the jaw interior, or the floor of the mouth, because that's where I'll be trying to tuck it with my laryngoscope when I put the breathing tube in.

I look at whether the front of the chin lies slightly in front of or behind the front teeth when examining someone from the side. I also try to get a general idea of the shape of someone's chin-to-neck profile.

I try to pick up on any unusual features like a high-arched palate, very prominent structures, loose teeth, etc.

When I was in school and thought I would be a medical geneticist, I studied pictures in a book entitled Smith's Recognizable Patterns of Human Malformation. It's at times an alarming and saddening volume. After getting to know that book fairly well I started to see genetic syndromes all around me, in people walking down the street or corridor, much as medical students learning about pathologic symptoms suddenly start to think they're coming down with every disease in the pathophysiology textbook.

Now I've narrowed down my scanning bias to four things that I can't help but notice about people almost immediately:

Good veins,

Bad veins,

Favorable airway (ok, I'll admit it - I just wanted an excuse to put Prince Caspian on this blog somewhere),


Scary airway.

I think it's interesting how different meanings can be assigned to external appearance. For some it's a suggestion of ethnic heritage, and all the assumptions, correct and incorrect, that can accompany the impression. For others it's a potential mating signal. For anesthesiologists in work mode, it comes down to the very basics, the crucial stuff: does what I see give me clues about whether I can protect your airway, and thus your very life? It may be a very narrow scope through which to focus on and view the world, but for those few hours when we're on duty, it's an important one.

So open wide, please. It helps us do our job.


Patty said...

Heh. So ... when you see the picture my daughter painted of my hands -- yes, they are veiny like that -- is that a good thing? :-)


I do know that they always have an especially easy time taking blood from me. And as wimpy as I am at the dentist I never worry about giving blood. Go figure.

T. said...

I think it's a good thing. I'm dying to stab them with an IV cannula right now. :)

Patty said...

Hmmm ... not sure about that, T. Sounds kind of deadly. IV cannula, eh?

I must say that when I had to be konked out for the "oscopies" getting stabbed prior to going under was awful ouchy. I guess that's fairly common, but I looked at her and said, "Gee, that hurt!" and I wanted her to say, "I'm sorry, you young thing. I didn't mean to hurt you."

She didn't even look at me. I wonder how many times someone says that to her with an injured little voice? I'm glad no one says that to me when I'm playing. (I do have one student who is so loud that it really does hurt sometimes, and I have to tell her she has to play softer or she's going to have hearing damage!)


(What would we do without all of you wonderful medical folk ... I'm in awe of what you do, and extremely thankful.)

Rhea said...

The scary airway reminds me of "This man has no neck!" a la "Rocky Horror Picture Show."

T. said...

Exactly! No neck, small/recessed chin, facial hair, lots of soft tissue...no fun!

nRT said...

Just found your blog and thanks for sharing. I am a MRI tech and I too look at people's veins. I don't do it intentionally but I look. I was once in a mirrored elevator and I looked down and saw 'my mother's hands(veins), to my surprise they were my hand. I am turning into my mother, slowly but surely.

Resident Anesthesiologist Guy (RAG) said...

I've been told that you shouldn't ask the patient to say "Ahhh" because it falsely makes their Mallampati more favorable - a 2 becomes a 1, a 3 a 2 or better, etc. Do you practice that way as well, or do, like many CRNAs and some MDAs I've seen, ask them to open up and say ah?

T. said...

Hi, RAG - it's true: the "correct" way to perform the Mallampati exam is to have the patients open WITHOUT saying "Ah."

That said, I sometimes ask someone with a Class III airway to say, "Ah." Why? Because an OB anesthesiologist once pointed out to me that sometimes the manuever can give you an idea of the movability of the anatomy. Perhaps it's voodoo, but I sometimes feel a little more hopeful if someone can get his or her own soft tissue out of the way simply by phonating rather than still being a Class III with laryngeal muscles doing some work. If I do do that, I'll document "Class III airway --> II with phonation." It's probably about as useful/predictive as doing a Mallampati exam at all...which is, if you do one in isolation, NOT super-predictive.

While you're in residency I'd play by the rules, and try to pick up from various attendings what their years of experience have shown them about the airway exam - what combination of features is valuable to consider as part of your airway gestalt. (Ask them about the "upper lip bite test...")With time you'll be able to look at someone walking down the road and say without going through every little step, "Oooooh, bad airway..."

Anonymous said...

Do you think that playing a wind instrument changes anything relevant about the accessibility of someone's airway? You would think that the hours wind musicians spend building up their embouchures and tonguing skills might make a difference.

gelci72 said...

Winrob - thanks for visiting! I look at my hands and find them weather-worn as well...much veinier than before.

Zoltania - what an interesting thought! I think wind players must have some finely developed muscles that non-windplayers don't even know how to use consciously, but when it comes down to it, we relax all those muscles completely before intubation, so I don't think they would come into play in terms of increasing or decreasing ease of intubation. Thanks for the comment!