My pager went off at 0030 the other night. I’d just fallen asleep thirty minutes earlier, so I was rather disoriented when the team captain told me they’d need my help in the pediatric hospital. As the pain night float resident, I’m also back-up for the adult hospital, pediatric hospital, and labor & delivery floor. On a good night, I’m not called to any of those services.
I stumbled downstairs and over to the pediatric OR desk. The attending and fellow were already there; the fellow was going to start a heart transplant. My case was a child who’d ingested a foreign body. In common speak, the kid had swollowed a penny.
This x-ray is a similar one I found on the internet. The penny is oriented side to side (i.e., in the coronal plane) because it’s in the esophagus, pressed against the flat tissue of the neighboring trachea. If the coin were in the airway, it would usually be rotated 90 degrees, in the sagittal plane. In the real x-rays, the coin was much higher, in a place where it could potentially flip forward and obstruct the larynx, leading to acute respiratory failure and imminent death unless immediate action were taken. In a panic, we threw up our hands and ran around the stretcher a few times, screaming as we went.
And then, without too much fanfare, we took the kid to the operating room, preoxygenated him after putting on monitors, and put him to sleep with intravenous medication. I had some Magill forceps handy in case I saw the coin when I intubated. It was nowhere in sight, so the surgery fellow took a look with his rigid bronchocope and nabbed the coin with little grabbers. That was it. We woke up the child, extubated, and brought him to the recovery room.
I helped out a bit with the heart transplant which was just getting off the ground, but was back in bed by 0230, having done an interesting case and now looking forward to a few hours of sleep.
Below is an x-ray of a sword-swollower, just for fun.
So it was in the airway? I’m assuming that it was if they got it out that way using a bronchoscope for visualization and not an esophagoscope……tracheal FBs are a little more complicated than esophageal. Is surgery (pediatric?) called for these typically in your hospital instead of ENT???
The coin was in the esophagus. On the x-ray, it looked like it was at the level of the larynx (more or less), but perhaps it had shifted caudad by the time we got him to the operating room.
Maybe it was an esophagoscope. I just assumed it was a rigid bronchocope, but I don’t recall them telling me the name of the instrument. In either case, I intubated first, and then they retrieved the coin with the rigid instrument.
I’m not sure the usual protocol for ENT versus pediatric surgery. In this case, the pediatric surgeons were there.
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