Back in the GOR

I'm back in the general operating rooms, which we fondly call the "GOR." They've recently renamed this to the "multispecialty division" to sound less gory, but the name sticks with the residents. I've had the usual hernia repairs, cholecystectomies, appendectomies, and gastric bypasses, but I wanted to write about the difficult airway.

We learn all the risk factors for a difficult intubation: obesity, short neck, poor Mallampati score, unusual incisors, large tongue, etc. But occasionally a patient without these risk factors presents with a difficult airway. Two patients, a thin older gentleman undergoing a cholecystectomy, and a young woman having an endoscopy, surprised me with unexpected trouble. These are the cases where prior to induction of anesthesia, I'm humming to myself, not too worried. Yet when I take my first look with a laryngoscope, I know it will be tough.

This reminds me why we spend so much time in training. For the routine, the easy and smooth, we don't need 4 years of undergrad, 4 years of medical school, and 3-7 years of residency. For the patient with chronic back pain needing refills or the child with sniffles or the pap smear, we don't use the breadth of our skill sets. Our knowledge, skills, and thinking as physicians are really tested in the unusual, unexpected, emergent, and scary moments of medicine.

In both circumstances, the patients did fine. I reminded myself to stay calm. I communicated with my attending; we continued to ventilate the patient with a mask and discuss our options. Both of us were unable to intubate using standard direct laryngoscopy, and so for one patient, we placed a laryngeal mask airway and then used a fiberoptic scope with an Aintree catheter to guide ourselves through the vocal cords. For the other patient, we actually used the gastroenterologist's endoscope to see the back of the oropharynx and intubate the patient under direct visualization. Remaining calm and in control of these situations is the most important thing; communication and rational thinking allows us to move on from what is not working to our backup strategies.