Some situations in medicine end up sticking with you, no matter how hard you try and shake them off. For me, this is one of them. it has been firmly planted into my memory and I occasionally have flashbacks, not in some detrimental dramatic way, but in a thoughtful and introspective one.
Like most of the stories I tell, it usually starts with a 24-hour call and this situation was no different. I presented myself to my call and attended the handover diligently, waiting to suss out the pre-call patient situation. I waited for the day team to handover the overnight work for the ward patients.
I smiled. Today was going to be a good one. Somehow, I felt it in my toes. I hydrated, took my morning supplements, had a fairly okay work day and now at 4pm, I would start my call that would progress smoothly, fizzle off with hopefully no further admissions and ample time to twiddle my thumbs.
The day team escorted me to the next patient’s bedside and that’s when I felt it. Dread. Utter and pure dread. When I saw the little human grunting, I knew this would be the downfall to my earlier hopefulness which lasted all but 5 minutes. He looked so tiny for a 2-month-old. Not that 2-month-old are large anyway. Scrawny and pale. He didn’t cry, squeal or fight, he just grunted and grunted away.
His eyes fixed forward, his head bobbing with each grunt. The nasal prongs planted snuggly into his nostrils, his eyes wide, pupils dilated, a warped shocked expression. His mother tried earnestly to comfort him, fix his blanket, position his neck, soothe him somehow. His only response was more grunting.
I could see his chest wall tire with each breath. His neck muscles took over when his abdominal muscles couldn’t cope. His sternum heaving with all its tiny might. If “severe respiratory distress” needed a picture, he was perfect.
I saw my on-call consultant walk in and my nerves calmed just a little. I was comforted by her presence because I knew a decision could be made early. This baby needed ventilation. And as much as I hate sticking tubes down baby’s throats, I would hate for it to happen at some ridiculous hour when I was alone.
She did a thorough examination and concluded the same.
Get the vent ready!
We scrambled quickly. We were ready in no time.
At this point, I wish I knew then what I know now.
Difficult airways are a reality and there’s really no way to predict when it may happen and to whom, especially in a child.
Laryngospasm is death himself, spitting in your face, watching you struggle and panic, with a stupid grin on his face.
I did what I always do, I looked for the vocal cords. No biggie. I have done this more times than I can count. I can do it at 3am in the morning before I have brushed my teeth. My fingers know the grip the laryngoscope handle, my eyes know how to maneuver past a flickering blade light. I know how to position it ‘just right’ when the batteries are at the end of its life and need careful placement to make the light shine as bright as the sun. I have learned how to overcome panic and be ever so gentle and calm, focusing as to not Knick gums in the process. my fingers know the shape of a McGill’s forceps. I know the base of the tongue can sometimes try to sabotage you. I’ve learned how to give cricoid with the gentle touch of a fairy princess. I’ve learned how to dodge outbound secretions and blood.
I have looked in so many throats, questing for the vocal cords. Man, I have searched and searched and searched.
This wasn’t supposed to be a difficult intubation/airway/ventilation. But then again, which is?
I tried twice; the vocal cords looked completely shut closed. A big fat NO-ENTRY sign in my face.
Tube out, we bagged.
I was so grateful to have the consultant around. Just knowing there are more experienced hands in the room, put most fears to rest. My hands were still shaking from my intubation attempts, I felt my gastric mucosa burn from stress gastritis.
She sussed the airway out.
“looks like laryngospasm”. I shifted nervously.
She obviously had dealt with these situations many a time and knew precisely what she was doing.
“we may have to call anesthetics and ENT in the interim”
She skillfully maneuvered the tube around, trying to get passed the spasm, no luck.
Tube out, we bagged.
In we go again, I could see the focus of a true pediatrician on her face.
If it wasn’t for the adrenaline pumping and the throbbing in my ears, I would have collapsed.
All I know is, I wanted to cry and die at the same time.
The consultant, like the true lady she is, made no fuss and moved on quickly.
Difficult airways are a reality and they happen more often than we would like them to.
More than anything, this was a teachable moment for me. Aside from the difficult airway, it was how to behave in a tricky situation when all you feel is pure panic and dread. A true leader didn’t focus on the problem but searched for the solution in spite of the pressure of a life-and-death situation. I learned more about panic management in that moment than I did in my entire exam-riddled life.
“Call anesthetics”. And we did. They dig some throat digging without success.
“Call ENT”. And we did.
Laryngospasm spat back, knocking each specialty in its path.
ENT arrived, like glory on a good summer’s day. They marched in with their suitcase of fancy equipment capable of the smack down laryngospasm deserved.
We were in theatre in no time. Me, on the edge of my seat, chewing my subcutaneous lip fat, hoping for no further trouble. The ENTs managed to get the endotracheal tube in with minimal hassle. They made it look so easy and smooth.
There was no time for egotistical nonsense. We were happy the tube was in and the baby was stable on the ventilator. The repeat chest Xray looked better barring the pneumonia filled lungs.
When the patient had left with the ambulance to the pediatric ICU, I breathed a long sigh of relief.
My only hope was never to meet laryngospasm again.
Obviously, I did…
But that’s a story for another day.