Tag Archives: Aspiration

A weekend of work

After Thanksgiving Day off, cousin Steve dropped me off at the Wallingford train station where I caught the SEPTA train in to Market East Station and crossed the street to the bus station to catch my Greyhound Coach d’Elegance back to Manhattan.  As fellow passengers were boarding, the Indian woman behind me complained when I reclined my seat back a few inches.  “Oh, oh, please raise your seat, my knees are hurting!”  Irritated that a woman who couldn’t be taller than 5’4″ was complaining about her knees to someone a full foot taller than her, and resisting the urge to suggest she could pick out a different seat on the bus–preferably behind an unoccupied seat–I raised my seat a couple inches and rode the rest of the trip with this semi-comfortable compromise.

I took my first pediatric anesthesia long call on Friday.  I went in expecting to anesthetize a three-day-old neonate for a Norwood procedure (palliative surgery for hypoplastic left heart syndrome), only to find out the case was cancelled.  Instead I did a central line on a 1 year old and a pyloromyotomy on a 3 week-old, before helping with sedation for a 7 year-old in the MRI.  This child had “single ventricle physiology” having a hypoplastic left heart as well, now having undergone the Norwood, bidirectional Glenn, and Fontan procedures.

I then did brief afternoon rounds with the pediatric pain attending, as I was covering the “OUCH” pager that night.  Circling through the list before I left the hospital, everyone seemed comfortable enough, and I went home.  This is one of the few rotations where we can take home call, or “pager call.”

I was awakened by my pager at 0100.  There was a 7 year old with a ruptured eyeball, and the ophthalmologists wanted to take him to the operating room within the hour.  I quickly paged my attending to notify her of the case, dressed, and caught a cab to the hospital.  No telling how long I would have waited for the subway at that hour, and ten dollars seemed like a small price to pay to avoid the cold and get there quickly.

I was in scrubs and had the room set up by 0150. but the patient didn’t show up till nearly 0300 from the emergency room!  Somebody felt the need to order a CT scan before sending him up to the operating room.  Anesthetic concerns include the following:

  • This is a trauma, and thus may put the child at risk for aspiration of stomach contents during induction of anesthesia.  Pain and increased tone from the sympathetic nervous system delays gastric emptying, and aspiration can occur as a patient is anesthetized and loses protective airway reflexes.  Aspiration, though rare, has a high fatality.  In order to minimize the risk of aspiration, anesthesiologists frequently employ the “rapid sequence induction” technique.  This involves ample preoxygenation of the patient to build up as large a reserve of oxygen as possible in the lungs, and a quick administration of a sedative and a paralytic–usually succinylcholine because of its rapid onset.  As the medications are pushed, pressure is applied to the round cricoid cartilage in the neck to help close off the esophagus.  This pressure is continued until the placement of the breathing tube is confirmed.  The breathing tube with its inflatable cuff protects the lungs from aspiration.  In this case, the child had not eaten for more than 12 hours, so this risk was probably lower.
  • The eyeball (or “globe” in medical terms) is ruptured.  Succinylcholine can increase intraocular pressure, which could lead to greater extrusion of contents from the eye.  Most anesthesiologists get the willies when we think about jelly-like substances squirting out of an eye wound, so we prefer to avoid this.  Additionally, succinylcholine is avoided in children because of the risk of malignant hyperthermia (serious adverse reaction) in a child with an undiagnosed myopathy (muscle disorder).  Hence, we used rocuronium for our paralytic agent with an onset nearly as fast.
  • General anesthesia, and eyeball surgery in particular, can cause nausea, and wretching can increase pressures in the eye.  We would like to avoid this post-operatively as it could damage the surgical repair, so administering ondansetron (a powerful anti-emetic commonly used for severe gestational nausea or chemotherapy-related nausea) is a must.
  • Coughing and bucking on the endotracheal tube as a patient emerges from anesthesia is also suboptimal for the same reason.  We can treat patients with intravenous opioids and lidocaine to blunt airway reflexes, and we could topicalize the vocal cords with lidocaine, but in this case we opted for “deep extubation.”  This is a technique in which the patient is allowed to resume spontaneous ventilation, and the endotracheal tube is removed while the the patient is still anesthetized.  The airway is then supported and supplemental oxygen provided.  This provides for smoother wake-ups.

It was around 0600 when I dropped off the patient in the recovery room, leaving me enought time to check e-mail and change into street clothes before heading uptown for my moonlighting shift which began at 0700.  Thankfully, the day was as slow as it could be (not a single operating room case, epidural, cesarian section, or stat intubation) which meant I didn’t do much other than sleep, eat, and read.

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Maybe I should get a desk job…

Editor’s note: I wrote this post some time ago, but waited an unspecified length of time to post it to protect patient privacy.  It should be noted that the post portrays graphic medical situations in raw, unedited detail, so readers with a delicate constitution may wish to stop reading here.

Yesterday afternoon’s code was one of the…shall we say…earthiest I’ve ever been to.  My friend Jen, carrying the code pager for the day, had grabbed the orange “arrest bag” which was stocked with medicines, airway equipment, and gloves and was headed out of the anesthesia workroom.  “Code blue, sixth floor,” she said tersely, “Want to come?”  Given that I find participating in codes strangely rewarding, I tailed her.  It’s satisfying to make a huge difference in the acute trajectory of a patient’s health, and once an endotracheal tube is successfully placed, one can sense the rest of the medical team breathing a collective sigh of relief.  I’ve also noticed that walking into a crowded room, assessing the situation, and taking charge and communicating effectively seem to restore a bit of order to the chaos.  It’s good practice for learning to function well in highly stressful situations.

As Jen and I rounded the corner, we saw a small gaggle of medical students clustered around a door near the nurses’ station.  They talked quietly in intense conversation among themselves, their short white coats’ pockets bulging with reflex hammers, pocket references, and “to do” lists.  We immediately headed toward that door.

We strode into the room that was packed with physicians, nurses, pharmacists, respiratory technicians, and the code cart.  Being nearly 6’4″, I had a decent view of the situation, but rather than seeing a patient, all I saw were white coats clustered around the bed amid a flurry of syringes and beeping.

“Anesthesia,” I announced loudly.  “Who’s the primary team?”

“Anesthesia, get in here and intubate this patient!” one of the surgery seniors commanded me.  A little taken aback by his tone, many thoughts quickly crossed my mind.  Why else were we here?  Tea and crumpets?  Of course we were going to intubate the patient, in the quickest and safest manner possible.  Jen and I were working our way to the head of the bed.

Rather than replying, “Can you communicate with me rather than barking orders at me?” I simply asked in a voice that carried across the crowded room, “Does he have any cardiac history?”  The surgeon didn’t seem to know.  Instead, in a more neutral tone, he said, “He aspirated.  He needs intubated.”  Aspiration is the medical term for when acidic stomach contents enter into the trachea (windpipe) and potentially cause grave damage to the lungs.  Most people who aspirate end up with in the ICU with lung injury; many die.

By this time, through the tight ring of white coats, I was able to see the patient at last.  They were doing chest compressions.  I looked at Jen and said, “Compressions.  We need to intubate.”  A true code–that is, a cardiac arrest–makes our job fairly simple.  No medicines are needed.  Just a laryngoscope and endotracheal tube.  And there’s really nothing worse than being already dead, so we don’t have to worry much about hurting the patient.  I’ve never heard of a patient saying, “Hey Doc, I wanted to thank you for saving my life, but I think you may have cut my lip in the process.”

The “fairly simple” task, however, became a bit more complicated as I got a better view.  The bed was only about two feet off the floor, making it more difficult to get a close view.  The patient had a huge stomach, which is usually associated with a thick neck and a difficult time performing adequate laryngoscopy.  In addition, he had a full beard.

“Move the bed out,” I ordered.  As the bed rolled forward, I noticed not puddles, but small lakes of brown liquid covering the floor at the head of the bed.  The white sheets covering the mattress were saturated with particulate brown fluid.  Donning gloves, I scarcely had time to process it before the respiratory therapist told me, “I’m having trouble moving air.”  With that, she removed the ambu bag and I saw the source of the effluvium.  It was erupting from the patient’s mouth with every compression of his chest.

“This’ll be tough, Jen,” I said, looking at my fellow senior resident.  “Do you want to do this?”  She shook her head no as I removed the head board and grabbed the suction tubing with the Yankauer tip.  This attachment quickly clogged with the particulate matter, so I removed it and placed the larger tubing directly in the patient’s mouth while the internists continued compression and rounds of epinephrine and atropine.

After thirty seconds, I realized that whatever I suctioned out was being replaced with more fluid from deep, deep inside this poor patient.  His mouth was like a storm sewer overflowing after an afternoon deluge.  If we didn’t get oxygen into his lungs soon, there would be no hope of resuscitating him.  I tried to think about my options: a fiberoptic scope would be useless with all the liquid, and it was downstairs anyway.  A laryngeal mask airway might help get oxygen in, but it wouldn’t prevent more fluid from entering the lungs.  I don’t feel qualified to do a slash-tracheotomy, and a needle cricoidotomy would be silly in this setting.  He needed a definitive airway–an endotracheal tube–and our main way of placing it–by direct sight–was impossible with the copious runny stool being forced up by the impossibly large gut.  My sense of smell, taste, and hearing didn’t seem to help me here.  This left me with one obvious answer.

“Jen, could you hand me a bougie?”  This somewhat rigid yet flexible tool saves lives daily in the operating room.  Its curved tip is designed to bounce on the cartilaginous tracheal rings, providing tactile confirmation that the bougie is within the trachea and not the esophagus.  Once in, an endotracheal tube can be slid over the bougie, the cuff inflated, and the bougie removed.

I grabbed the laryngoscope and pried open the patient’s mouth, while brown chunks seeped out the corners of the lips.  Advancing the laryngoscope by feel rather than sight, I knew that it would help me by lifting soft tissue out of the way, rather than providing a line of sight.  I took the bougie in my right hand and plunged it into the small pool in the patient’s mouth.  It met some resistance as I advanced, so I twisted and redirected a couple times before it finally sped forward.  I felt a subtle bump or two, suggesting tracheal rings.

Raising my eyebrows at Jen, I steadied the bougie while she advanced the endotracheal tube over it.  With deft hands, we inflated the cuff, pulled out the bougie, attached the carbon-dioxide sensor, and applied a few breaths with the ambu bag within seconds.  The sensor turned a reassuring yellow, and one of the keen internists called out, “Bilateral breath sounds!”  The tube was miraculously in place.

I called for a soft suction catheter, knowing if the patient stood any chance of survival I’d have to remove as much fluid as possible from the lungs.  As I removed the ambu bag, however, I didn’t anticipate the geyser of fluid pumped from the lungs, up the tube, and out onto Jen’s scrubs and a nearby internist’s white coat as another medicine doc continued forcible compressions.  We quickly suctioned and continued ventilating while rounds of epinephrine, atropine, lidocaine, and calicium were poured into the femoral line.

The story ends, sadly, as many codes do.  We were unable to restore a heart rhythm.  The code was “called” as no pulse was attained.  The room emptied in what seemed like seconds leaving Jen and me, with spinning heads, alone with the patient and our orange bag.  We wandered back downstairs to change scrubs and sit down for a few minutes of peace to restore our sanity.

In retrospect, I cannot think of much we’d do differently.  Attempting mask ventilation can force more fluid into the lungs in a patient with such copious gastrointestinal regurgitation.  We should have put on masks with face shields first thing for our own protection.  But in reality, I knew that our chances of bringing this fellow back were next to nothing with such massive aspiration.  Here is a situation where the patient is clearly objectified, as he should be in that moment.  He becomes a task, a problem, a challenge.  We solved it.  And even if saving his life was practically impossible, by restoring oxygen to the lungs, we at least gave a sense of closure to the medical professionals.  Everything that could be done had been done.

Images of those minutes kept coming into my mind during the remainder of the afternoon and as I tried to go to sleep last night.  Nearly every sense was saturated with input: slippery floors, shouted orders, red blood & brown stool, ringing pages, splatters, needles, cracking ribs.  And I wondered, “What kind of job do I have?  What would it be like to sit behind a desk, sip coffee, and sort through e-mail and messages?”  In medicine, we tweak the inner workings of an amazing machine, our finesse guided by thousands of years of experience, by the scientific method, by love, by art.  But in the crucial times, practicing medicine rams together the raw, animalistic, sloppy, dirt-under-your-nails sort of gritty survival instinct with placid, cerebral, transcendent rationalism.  And I marvel that this is all starting to become normal.

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