Saturday, December 20, 2008

Candy Cane Time

The one time I don't mind being on-call overnight at the hospital is during a blizzard. Everyone scurries around frantically trying to leave early, to avoid having to drive in the snow storm, but the person on-call isn't going anywhere. With any luck, the busy work dies down early and you can ensconce yourself in the doctor's lounge with a mug of something warm to drink (unless you're at a trauma center, in which case you might not sit down all night).

St. Boonie's is not a trauma center, but it does admit a lot of very sick patients, and the busy work did not die down so early on my last blizzard call. A PACU patient went into respiratory distress and was found to have a highly unexpected pneumothorax. The O.R. ran non-stop all day and into the night, though I did take a late afternoon break to have a yogurt and a couple of Lavender-scented Shortbread Nuggets. That night Bubba had to bring a patient back to the O.R. to control some bleeding. The ICU moonlighter called not once but twice to ask if I could perform a couple of after-midnight intubations for some really ailing, failing patients. There was a steady stream of work, but it was good work in a warm place.

The real gift of the day was the chance to help a colleague manage a really tough situation. While I was finishing my lavender-infused butter cookie in the break room, one of the nurses came in and said, "Do you think you could come and help Alex out? He's having trouble intubating this woman. He's been trying for almost half an hour."

"Half an hour?!" I got up and started walking back to the O.R. with her.

"It's a woman we've had a hard time with before. The last time this patient was here Jinny took four tries before she could get the tube in." Jinny's been practicing anesthesia for almost as long as I've been alive.

"Well, if Jinny had a tough time, and Alex is having a tough time, I don't imagine it's going to be any easier for me." Alex had done a fellowship in cardiac anesthesia at a prestigious heart center after his residency, so technically he had had even more anesthesia training than the rest of us.

When I walked in Alex had the situation under control with a temporary airway device, but we still had to find a way to get an actual breathing tube into the patient's trachea. "I had no view with a Miller blade," Alex said. "Tried twice. Then I tried a blind nasal - no luck. I thought I'd wake her up and do a fiberoptic next."

"Have you tried an intubating LMA?"

"No. We could do that first. Or you can have a look if you want."

We got the LMA and the fiberoptic scope ready and positioned our assistants. I got a tube and different laryngoscope blade ready, then I went to the head of the bed to take a look, expecting a very unpromising view.

I was right. No vocal cords to be seen. Not even arytenoids. But I did find the tip of the epiglottis, which Alex had had a hard time even visualizing. I asked Alex to apply some external pressure on the patient's cricoid cartilage, passed the tip of the breathing tube behind the epiglottis, and asked the nurse to remove the stylet from the breathing tube slowly while I advanced the tube. The patient coughed weakly. That was actually a good sign.

Alex's eyes lit up, almost not daring to hope. He hooked the breathing tube up to the ventilator. I squeezed the ventilator bag. The patient's chest rose. Our eyes swerved toward the carbon dioxide monitor to see if there was indeed a waveform indicating exhaled carbon dioxide. The electronic line appeared, drawing the exact curve we were looking for. Alex put his stethoscope on the patient's chest. "Good sounds on the right. Pull back a little...okay, good sounds on the left. We're in!"

Alex, the nurse, and I all breathed a sigh of relief. Then Alex turned to me and asked, "How did you DO that?"

"I think I got lucky," I said, "but I can show you what I was trying to do once we're all set here."

Alex set about securing the tube and positioning the patient while I cleaned up syringes and wrote a note in the chart. When he had gotten everything settled, I showed him how I had inserted a stylet into the breathing tube and curved the whole contraption into a letter J or, as I told him in the spirit of the season, an upside-down candy cane. Then I had him position his hand as a kind of epiglottis and showed him what happend to the tube as the stylet was being removed slowly. Because of the candy cane shape, the tube was propelled first vertically upwards before snaking horizontally into the glottic opening - a movement demonstrated to me during residency by an anesthesiologist I had had the chance to work with only a few times.

Had I not spent that particular day with that particular teacher and had a patient with a challenging, "anterior" airway, he might never have had occasion or taken the time to pass on this particular tip. It was a maneuver that had gotten me out of many, many sticky situations, when an airway threatened to be difficult and I didn't have much around in the way of extra hands or fancy technology. It's these seemingly simple, low-tech options that sometimes save lives in the field, during ICU intubations, or when you're the only attending anesthesiologist around for miles in a rural hospital in the middle of dairy farms. I thought of Dr. R, the man who gave me the courage and ability to try this little technique, and thought, "What an incredible gift you've given me. How many patients have I been able to help, because you taught me this one small thing? Thank you!" I wrote him to tell him so that night.

Teaching each other is truly one of those "gifts that keep on giving." It reminds me of something Will Smith said recently on TV, about the kind of work we should all be doing: "If you're not making someone else's life better in some way, then you're wasting your time." When I have been on the receiving end of an eye-opening, helpful lesson, I feel a small rush of excitement and happiness at having been given something truly constructive, valuable, and ultra-cool. When I've had the privilege of teaching others helpful things that my teachers have taught me, the feeling is doubled: I feel my own excitement and that of the person to whom I've passed on what I know, as well as a resurgence of gratitude to the teacher who gave me the initial knowledge or ability.

Alex and I felt like celebrating after we were able to secure his patient's airway, not only because we were relieved to have done so at last, but also because he was so excited to have acquired a new option for his store of airway-management techniques. So thanks, Dr. R, for showing me that candy cane maneuver, and giving me the chance to help not just patients and students but also fellow-physicians. I owe you one.


QuietusLeo said...

This technique sounds similar to using an elastic gum bougie. Have you ever used one?

rlbates said...

T, I think you "paid" Dr R back by passing on the tip. :)

T. said...

QuietusLeo - yes, I most certainly have. The bougie, too, has gotten me out of some tachycardia-inducing situations.

Ramona - I hope so. I feel like the "debts" for those valuable little pointers you carry with you every day for use in times of trouble are almost un-payable; all we can do is pass them on as much as possible! I guess much of what is most valuable about each of our lives lies in the good we pass on to those who come after us.

PaedsRN said...

The Candy Cane intubation! What a perfect Christmas gift. Nice one :)

medaholic said...

Education is a gift that just keeps on giving. It builds on our previous knowledge and inspires our current students to teach.