First I flattened her tongue with a tongue depressor and sprayed the back of her throat with Xylocaine. A minute later I instructed her to lie down. I then slid the laryngoscope blade to the back of her throat and sprayed the zone between the posterior throat and the voice box. This caused her to cough and splutter so much I had to withdraw the scope and give her a minute to recover. On the next attempt I was able to get the blade a bit further down, but when I began spraying she reached up and tried to grab my hand. Not good. I removed the scope again.

“Are you okay?” I inquired.

“Yes. Sorry about that – it was just a reflex,” she panted.

I turned to the nurse and whispered: “This looks like it’ll be a tough intubation. I’m going to want to give her the thiopental and sux to sedate and paralyze her as soon as the tube’s in place so she doesn’t pull it out.”

“Okay, I’ll have them both ready.”

I went in again. This time I saw a sliver of the epiglottis, which is the lid of the voice box. The vocal cords lie directly beneath it. When I squirted the epiglottis with Xylocaine she started coughing violently. She then began twisting and rolling around on the bed. I withdrew the scope and waited for her to settle. When she calmed down I asked, “Are you okay?” No answer. “Miss Pickwick?” Silence. Something was wack. Was it just my imagination, or did she appear to be unnaturally still?

“Hey, wait a minute – how come she’s not breathing anymore?”

The nurse checked the patient’s IV line and gasped.

“I inserted the loaded syringes of thiopental and succinylcholine into her IV port and left them there so we’d be able to inject as soon as you got the tube in! Both syringes are completely empty – she must have self-injected just now when she rolled over!” Yikes!

Her oxygen sats entered free fall. I asked the nurse to apply firm pressure to the patient’s cricoid cartilage to reduce her risk of aspirating stomach contents. In the meantime I attempted to ventilate her lungs with the Ambu bag. Even using both hands I couldn’t get a good seal with the mask. Her sats hit 70 percent. I put the laryngoscope back down her throat and hunted for her vocal cords. I could barely see the epiglottis, never mind the cords.

“O2 sat 60 percent!” shouted the nurse. A multitude of monitor alarms started beeping simultaneously. I went into Hulk mode and pulled on the laryngoscope so hard, it’s a wonder the patient’s entire body didn’t lift off the bed. Miraculously, her vocal cords popped into view. I vaguely recall my hands trembling a little as I guided the ET tube home.

Miss Pickwick went on to a complete recovery.

Let Me Help You With That, Doctor

A while back I was called to the medical floor to see a patient who was developing pulmonary edema, or fluid on the lungs. Despite aggressive medical therapy and BiPAP she was becoming increasingly short of breath. She needed to be tubed and put on a ventilator. I set out my equipment and assessed her airway. Her anatomy was favourable and there was nothing to suggest she’d be a difficult intubation. The only wrinkle was that if I knocked her out with thiopental, her already-lowish blood pressure could bottom out completely. I elected to sedate her lightly with midazolam, paralyze her with succinylcholine and then slip the endotracheal tube in. Once the tube was in place I’d sedate her more heavily. I explained the game plan to her and she gave me the green light to proceed.

I injected 3 mg of midazolam and 100 mg of succinylcholine into her IV port. Succinylcholine usually effects paralysis within a minute or so. After a minute of cricoid pressure and bagging I put the laryngoscope in her mouth. I could see her vocal cords clearly. My ET tube was on a sterile towel next to the patient’s head. I didn’t want to lose sight of my target, so I said, “Could somebody please pass me the tube?” The patient picked it up and handed it to me. I almost quailed. “Hey! Aren’t you supposed to be paralyzed?” I asked.

“Am I? I guess it didn’t work,” she mumbled around the laryngoscope blade in her mouth. “Are you almost finished? This is kind of uncomfortable.”

I removed the scope and inspected the bottle of succinylcholine. It was nowhere near its expiry date. I checked the patient’s IV line. It was patent. What the hell?

“Ms. Selwyn, we’re going to try that again.”

“Okay, doctor.”

I gave her a touch more midazolam plus another 150 mg of succinylcholine and waited for her to go limp. Nothing happened.

“Aren’t you paralyzed yet?”

“Sorry, no.”

I sprayed her throat and upper airway with Xylocaine and tried to do an awake intubation, but when the ET tube reached her vocal cords she started thrashing about. Attempting to pass the tube was like trying to hit a moving target. I was worried about traumatizing her epiglottis and cords, so I pulled the laryngoscope out.

Before I could work out a Plan C, her oxygen sats fell off a cliff. I gave her a ton of midazolam plus a whopping 200 mg of succinylcholine. She still wasn’t paralyzed, but at least she was adequately drowsy. When I put the laryngoscope back in her mouth I nearly gagged. It looked as if a tiny grenade had just exploded at the base of her throat. The trauma of the preceding intubation attempt had caused the soft tissues of her upper airway to swell so grotesquely, I couldn’t spot anything even remotely recognizable. More and more alarms bleeped as her oxygen sats continued to tank. I was on the verge of asking for the cricothyroidotomy tray and a scalpel when a tiny air bubble appeared on the surface of one of the bruised lumps of flesh at the back of her throat. That bubble must have just exited the trachea! I aimed for it and pushed firmly. The tube slid underneath her distorted epiglottis and lodged neatly in the windpipe. Bingo!

A few months later I attended an advanced airway management course. One of the instructors informed us that once in a blue moon you run across a bottle of succinylcholine that simply doesn’t work. Apparently the anaesthetists call it “Bad Sux.” The solution? Toss it out and open a new bottle!

In my next life I’m hoping to come back as a librarian. I can’t handle all this excitement!

Koyaanisqatsi (Life Out of Balance)

“ Things fall apart; the center cannot hold;

Mere anarchy is loosed upon the world…  .”

– William Butler Yeats, The Second Coming

Remember that high school science experiment with the tin can? Allow me to refresh your memory. You took a large tin can, sucked all the air out of it with a vacuum pump and then resealed the lid. Within seconds the can caved in, crushed by the surrounding atmospheric pressure. Kids applauded, your science teacher bowed theatrically and the jocks loitering at the back of the class rained an apocalypse of spitballs down on the hapless geeks in the front row. Ladies and gentlemen, I present to you Exhibit A, the Human Tin Can. Watch carefully as the pressure generated by running a busy medical practice while simultaneously attempting to be an involved parent, an attentive spouse and a dutiful son threatens to crush him like a bug. Will he implode? Place your bets, everyone, place your bets!

I, Carnival Duck (Apologies to I, Claudius)

I’m on call for our ER every Wednesday night, so I usually take Thursday mornings off. Or at least, I try to. In theory it makes sense – if I give myself a chance to repay my sleep debt, maybe I’ll be able to avoid premature flameout. In reality, though, it doesn’t always work out that way. Yesterday was Thursday. Here’s how the morning went.