Out With the Bad Air
Solstice at Gainesway, Ryan Martin, King of Trees
Can fear ever be a trusted guide? Do you, like me, have fears that shape you by guiding you along paths away from imagined dangers?
Yesterday, I had a case in the ER that will certainly shape my memory of this career in my old age should I be lucky enough to have one. To forestall any unnecessary apprehension, I will tell you that it ultimately went well. I am not writing this as a story to entertain but to explore the experience and share it; to extract the universal from the unique.
In any emergency medical training, it is generally taught that attending to a person’s airway is the first priority. Without first ensuring the movement of gases to and from our blood, few other interventions can be useful. Breath is the foundation of resuscitation. Early in my training I heard an attending physician say “When you decide to take someone’s airway…” as a way of talking about intubating someone, or placing a breathing tube into between their vocal cords and attaching the other end to a ventilator. The phrasing initially struck me as paternalistic and arrogant. But there is often a great deal of compassion underlying the militaristic expressions and dark humor that pervades ERs, and I have come to see “taking someone’s airway” as very succinct way of placing one’s self in charge of defending a person’s most vital treasure, their breath.
As an EMT, I learned CPR, and mouth to mouth resuscitation is visceral way of sharing breath, but crude and poorly effective. It is, however, almost satisfyingly primitive in its approach to empathy; the sharing of breath. From that beginning, I have learned increasingly sophisticated ways of safeguarding another person’s breath and I increasingly feel the weight of doing it well. In the smaller size ERs that I have always worked in, I am the person to whom this responsibility is delegated. I am the one who decides when to become responsible for the breath of another. Committing to that task means committing to succeeding because there is only one possible consequence of failing.
The fear of failure at this taskhas kept me awake when I wanted to sleep. It has caused me to imagine scenario after scenario where things could go wrong and what I would do about it. It has caused me to mentally rehearse things I hope I never need to do but feel the need to be ready for. The fear is like a quiet animal that stirs at the sound of any patient who looks to be struggling for air. It forces me to imagine the worst and then imagine what to do about it.
In the 20 years that I have been doing this, I have become an expert at the required skills and the process of thinking about them in an organized way. In the past, I had imagined that expertise would yield confidence. But it has also taught me how many different ways that things can go wrong.
There are two scenarios that I fear when it comes to needing to assume the responsibility of breathing for someone else. First, is any condition that causes the tissues in the mouth and throat to swell, making it difficult or impossible to see into the airway or to place the necessary equipment. We have incredibly fancy tools for looking down throats, but the best flashlight in the world won’t get you to the end of a collapsed tunnel. Second, is any patient who is so sick that their blood has become acidotic. These patients have to breath very fast to blow of carbon dioxide as a way of trying to adjust their pH; they are hyperventilating in order to survive. If they stop breathing for very long at all the increasing acidity of their blood can cause their heart to stop. This means that placing them on a ventilator must happen very quickly and in some very specific ways. Both of these situations terrify me. In the first case, it could become necessary to cut a hole in the front of their throat to access their lungs and in the second it could mean trying to do CPR on someone who is already gravely ill while continuing to try to protect their airway.
I have mentally rehearsed both of these scenarios, studied approaches to them and practiced techniques on cadavers and mannikins. Yesterday, I had a patient with both of these things happening at once. In other words, he was critically ill from complications of diabetes and simultaneously had rapidly progressive swelling involving the entire airway.
The patient had been officially admitted to the hospital hours earlier, but because of bed shortages, he remained in the ER. I checked on him intermittently and when I realized what was happening, my fear uncoiled and stood to its full height. There was little time to prepare, but while I asked various members of my team to assemble the required supplies I went and peed. I have learned that if at all possible, you should never face an emergency with a full bladder. I also took five deep slow breaths started mentally walking through every way the situation could go wrong and what we could need if it did. I work with some amazing nurses and respiratory therapists and the focused teamwork that this sort of situation creates gives as much meaning to my career as anything else. We rehearsed the plan, the ways it could go wrong and what we would do in each scenario. Humans can work together to make things better no matter their differences. It really is possible and you can’t convince me otherwise.
Placing a person on a ventilator involves giving them a medicine to sedate them and then giving them a medicine to paralyze all of their muscles. Once this paralytic is given, the patient can no longer breath on their own because the muscles for breathing can’t contract. But this is necessary to prevent them from gagging and vomiting and also to relax the airway tissues so that the tube for the breathing machine, or ventilator, can be placed. Once the patient is sedated and paralyzed, we use a laryngoscope which is a combination of flashlight and camera. With this tool in one hand to look down the throat, we use the other hand to slide a plastic tube with an inflatable cuff through the vocal cords into the lungs.
In this case, despite some fancy trickery with meds and technique, we would only have seconds to do this task without making the patient too acidotic to live, but we also knew that the swelling in his airway would make finding the vocal cords and having enough room to pass a tube very difficult.
At this point, I am at the head of the bed near the patient’s head with a table of supplies next to be and a room full of nurses and respiratory therapists ready to help with any complications. I had marked the patients neck with a surgical marker at the site I would need to cut if everything else failed.
After giving the sedative and doing some things to help prevent worsening acidosis, we administered the paralytic. From this point on, we are committed to getting a tube into the patients lungs or they will likely die. I quickly placed my laryngoscope deep into his mouth; it has a curved blade with a camera tip that allows me to see around the bend in the back of the throat. I alternated my gaze between the patient’s pharynx and the tiny screen near my hand to try to find the vocal cords amidst the swollen tissues. Accidentally placing the tube in the esophagus is disastrous. I was unable to see the vocal cords due to swelling but could see one of the bumps that lies at the bottom of them. There was clearly not enough room to get both the camera and the tube in. This led me to my second plan which was to place a thin plastic rod into where I thought the vocal cords should be. This rod gives you tactile feedback as it slides across the bumpy ridges of the inside of trachea when you cant actually see it. I could then slide the breathing tube over this rod into the lungs and then remove the rod. Thankfully, this worked and took less than 45 seconds. But with the flood of adrenaline, it felt like moving through cool amber over several minutes. The time distortion of adrenalin fascinates me; the 5 minutes of involuntary shivers that comes 30 minutes later does not.
With the tube in place we were able to use the ventilator to improve the patient’s acidosis by breathing faster and deeper for him than he could breath on his own. It also meant that we could begin to treat the swelling without concern for the patient suffocating.
This was one of the most frightening airway cases that I have been responsible for. I felt relief at succeeding but also profoundly shaken by the experience of being so directly responsible for deciding to do something that could have gone so poorly. I feel comfortable that taking his airway was necessary and I feel deeply thankful for the attending physicians who not only trained me to do this work but also trained me how to keep getting better at it through mental rehearsal and simulations.
I talked to the patient’s family and the doctors that would be taking care of him in the ICU. This all occurred at the end of my shift which meant that I was in my car headed home to play board games with my family about 30 minutes later. The shivers got to me in the car well as a flood of thoughts about how easily things could have gone wrong. Over the years I have gotten better at going from life and death situations to, say, a plate of French fries at a dinner party, but I’ve also learned that failing to process these sort of events just leads to really poor mental health. Usually, exercise is my way of letting my body release stress through movement but this particular day I had a foot injury that was going to keep me from running for a couple of days. I have found that rolling down the windows at interstate speeds and yelling and grunting like a constipated weightlifter seems to help. I try not to do this when I’m right next to another car. But you just have to get things out somehow. These fight or flight systems that we have inherited are not designed for the rapid changes of scenery and environments that modern life creates. Being fully adrenalized in your living room is disregulating.
That night, after some interstate screaming and a few minutes in a comfy chair just adjusting to being home, I played a board game with my family where you defend a castle from attacking monsters. In my son’s mind, there are practical skills to be learned from this game and maybe I agree. Know what you want to protect. Know what your strengths are. Don’t give up until you have to. Chance favors the prepared mind.
After a night of fitful sleep and waking up several times with thoughts about things I could have done better, I returned to work the next day and had time to check on my patient before starting my shift. He was still sedated and on the ventilator but improving and his labs looked much better.
I had to call a couple of ER friends and tell them about the case. I’m lucky to have people that I can talk to who can appreciate the fears and after effects of case like this. It’s a weird job and sharing the load around makes a big difference. Sometimes working in the ER feels like skipping through a minefield and it can be hard not to think that you’ve only got so much luck before you land on the wrong patch of ground. Most doctors can tell you about a piece or two of themselves that’s missing thanks to their career.
But what I find myself thinking about the most, is how do we show up for our fears in life? If you spend a few seconds thinking about what truly scares you, then you realize what thing you hold dearest; what things you are most attached to. There is a doctor that I admire who has a background in philosophy and argues in favor of classic stoic approach to fear. He takes a few minutes each morning to imagine the worst possible things that could happen to him and what that would actually mean in his life. His belief is that this is an efficient approach to gratitude because it makes him appreciate routines and the many things that we take for granted in our daily life. Our bodies, our minds, and our environment are so fragile that occasionally contemplating their loss can be valuable. All life is short and each day that you wake up with choices is a day worth making the best of.
I also find myself surprised by the weird calm of middle age and am grateful for it. Young enough to still occasionally be clever or strong, old enough to know that sometimes neither is enough. Also old enough to know that if my best wasn’t enough, then the only thing I can do is get some sleep and try it again the next day.
For anyone interested in the medical specifics: It was an otherwise healthy patient with type 1 diabetes who had DKA and developed spontaneous angioedema. He had flown in from out of state and forgotten his insulin but was generally healthy with no other medical issues. His initial ph was 6.7 and after 2 liters NS and an insulin bolus/drip through a central line, the pH was 6.4. There were no evident precipitants of DKA. While boarding for an ICU bed, he developed anterior angioedema and quickly processed to posterior with extensive tongue and submandibular swelling over the course of 30 minutes. Subsequent CT just showed extensive soft tissue swelling and the labs just all went with DKA. We did delayed sequence intubation with ketamine and succinylcholine so we could blow of some CO2. We had a code cart, bougie, LMA, and cricothyrotomy kit at the bedside. We do not have anesthesia, ENT, or surgeons in house. We matched his vent rate to his respirations prior to intubation. I was using a macgrath video laryngoscope with a MAC 4 blade. I premarked the cricothryroid membrane with a surgical marker prior to intubation. Please email me if you have any suggestions or advice.
Details about the patient in this case have been changed/omitted to protect the patient’s privacy.