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