Field Notes: One of the Toughest Airways of My Career

Earlier this year, I cared for a critically ill patient in the emergency department. He was essentially unconscious. He needed intensive care, which we initiated. He needed a breathing tube — that is, I was going to have to temporarily paralyze him, prop open his mouth, and place a plastic tube down into his trachea, which we would then connect to a ventilation machine to breathe for him.

My initial assessment was that intubating him would be routine. There’s no such thing as an “easy airway,” but there were no red flags screaming that this would be unusually difficult.

And yet…

Prepare for the Worst

Whenever I intubate a patient, I always assume it’s going to be a chaotic situation. That way, if it’s not, it’s smooth sailing, and if it is, I’m ready.

Emergency medicine training prepares doctors like me to suss out tricky airways before we start the intubation procedure. There are mnemonics that remind us of things to look out for, both in terms of anatomy and physiology.

If anything from those checklists jumps out, I’ll verbalize that to my colleagues so that everyone knows to adjust accordingly. For example, if I know the patient has had trauma to the head and neck, I might anticipate a hematoma (an enclosed collection of blood) in the airway, which could block our tube, or worse, become a landmine and blow up in our face. An airway that is full of blood is just about the worst-case scenario during this procedure.

Bring Your ‘A-Game’ to Every Case

Even if my assessment is that the case seems routine, I still prepare for challenges. That means a few things:

Using video. In the old days, we’d intubate using equipment that didn’t have fiberoptic video. I actually trained both ways (with and without) and for a long time preferred non-video intubation, because I preferred to “own the airway.” When everyone can see what’s going on from a video screen, a lot of unsolicited advice starts flying. I don’t love it. But the medical literature says that using video first is better. So, I have changed my practice. I am not above the data. There are still times when the video view of the airway is actually worse than using the naked eye, but I start with the video-enhanced equipment these days.

Assume I’ll need the elastic bougie. What’s an elastic bougie (pronounced BOO-zhee)? It’s a long thin piece of plastic with a curved tip. It’s much thinner than the hollow breathing tube and easier to manipulate. We basically put the bougie where the breathing tube will go. Once it’s in place, we railroad the breathing tube over it. Imagine the breathing tube is like a big flimsy drinking straw. The bougie is like a chopstick. Once the chopstick is in place, you can slide the straw over it. Once it’s in place, you remove the chopstick. It’s like a guide wire.

Now, I do not use the bougie automatically even though it probably increases success rates overall. Why? Because it adds steps, which add time. But I always have it right next to me, ready to use. That way I get the benefits without delay.

Setting up. I almost always intubate with the patient’s bed at a 30° angle or so, not flat. This helps in a number of ways that I won’t get into, but it takes time to set up properly. Sometimes I can feel my collaborating teammates getting impatient with this, but it’s worth it. It’s actually one of the major “hacks” that turn seemingly difficult airways into easier ones.

You know how you play tennis, chess, or whatever it is you do better when your opponent is good? I feel the same way about airways. I’m at my best when things are at their worst. So, the cognitive trick is to try to make myself that good on the routine cases — bringing my A-game to every airway.

When Things Go Badly

In this case, I had set up everything as if it were going to be a challenging airway, even though nothing seemed unusual.

Right before we began, the nurse tested the IV line, as always. It “flushed” well. She then administered the sedative and paralytic drugs. I waited for the paralytic to take effect. You can tell when the paralytic is working because the patient stops breathing. That moment is always a little bit exhilarating (it’s “go time”) and terrifying; the second we take away the oxygen mask so I can get into the airway, the clock is ticking, because the patient is no longer getting oxygen.

The paralytic can take 15-30 seconds (or longer) to work. These are long seconds, I’ll tell you. In this case, something was wrong. He kept breathing. The paralytic was not working. This is, I should mention, physically impossible. Once the paralytic medication is in your bloodstream, it only takes that short time for the skeletal muscle in your diaphragm to be absolutely blocked from contracting.

“Why the hell is he still breathing?” I thought. I asked the respiratory therapist to put the oxygen mask back on the patient, buying some time while we ran a checklist.

• Had the nurse given the right medication? Yes.
• Had the nurse flushed the line after giving the paralytic (to make sure the drug is in the body, not the tubing)? Yes.
• Had we given the right dose? Yes.

I didn’t have an answer to our riddle. “Okay, we can intubate without a paralytic. So, maybe we should just proceed,” I said. After all, this was an otherwise routine airway. I’ve intubated without paralytics many times, albeit usually during CPR. I was about to proceed when I thought better of it. Maybe the paralytic was in the body, but not in the right place. Maybe the IV was not actually in a vein, even though it felt that way to the nurse. That can happen when a patient has an unusual amount of soft tissue. The fluid feels like it is flowing freely into a vein, when in reality, it’s just diffusing easily into soft tissue of the arm (usually we feel a lot of resistance on the syringe when this happens, but not always).

“Actually, let’s pause.” I said. “Let’s get a new IV placed and start over.”

I asked for an ultrasound machine, which I used to look at the area beneath the original IV. I pushed 10cc of saline into that IV and looked at the vein. It didn’t “light up” the way it would if the IV were in the vein. Instead, the saline could be seen expanding into the soft tissue around that vein. Indeed, the paralytic was in the patient’s body, but not in the vein. It was sitting there among ligaments, muscle, and fat.

That meant that the paralytic would eventually work once it was absorbed into microscopic blood vessels, but not for many minutes. I asked the pharmacist if a second full dose would be harmful — because 20 minutes later, the patient would indeed effectively have received a double dose in that case. It was okay to do, she said.

The nurse got a second IV started. We confirmed it was in the vein. She gave another dose of the paralytic. The patient stopped breathing immediately. I moved forward with the procedure.

What I found when I reached the epiglottis — the border where the airway and the GI tract split into two — was totally unexpected. This patient’s airway anatomy was going to be extremely challenging to navigate. The most difficult I’d seen in years. Getting the breathing tube through the vocal cords was going to be like threading a needle — with outstretched arms, at a funky angle, with time pressure and an audience.

I grabbed the bougie and managed to guide it right between the vocal cords and into the trachea — even that was not easy, but I got it done. After that, I slid the breathing tube over the bougie, and connected the patient onto the breathing machine.

Mission accomplished. The respiratory technician gave me a very nice compliment. I can’t remember exactly what was said, but that was a great feeling. Those folks know from crazy airways.

Fast Is Slow and Slow Is Fast

One of my mentors, Scott Weingart, MD, always says that “fast is slow and slow is fast.” What he means is that if you try to hurry something, you’ll end up making a mistake that costs more time than you saved. And, taking the time to back up and start over might feel painfully slow, but actually saves time.

I think if I’d gone ahead with the intubation without stopping the procedure to have the nurse place a new IV, the patient’s breathing (and any other movement — he was not entirely unconscious), would have made getting the breathing tube into that trachea nearly impossible. It would have increased his time without oxygen, which has obvious consequences.

What had initially appeared to be a routine procedure nearly turned into an impossible one. Fortunately, we handled it well. The difference was not any technical prowess, but rather, a cognitive process. I believe this is common, not just in medicine but in many challenging situations in almost all demanding fields.

Have you thought your way out of sticky situations in your work? Please share your best moments in the comments below!

This post originally appeared in Inside Medicine.

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