Debriefing

A woman in a car accident several days ago now has symptoms of a new stroke. The neurosurgeons would like to do intra-arterial tPA. Tissue plasminogen activator (tPA) is one of the miracle drugs of the last few decades. Most strokes are due to clots (the remainder are due to bleeds). tPA is a so-called "clot buster," and can reverse the devastating symptoms of a stroke if given early. There is a specific window of time in which it can be given, but if a patient is out of the window for IV tPA, then intra-arterial (IA) tPA may be considered. Furthermore, given this patient's recent history of a car accident, the risks and benefits of IV or IA tPA must be considered carefully because clot-busting can increase bleeding at other sites. After discussing these issues with the patient, the neurosurgeons decided to proceed with IA tPA.

The patient was brought into the room. She was 250 lbs and in a C-collar, which stabilizes the neck. Both of these concerned me because they make intubation much more difficult. I set up for a difficult airway with a fiberoptic laryngoscope and a fiberoptic bronchoscope. I induced the patient with general anesthesia and took a look with the fiberoptic laryngoscope. All I could see was epiglottis; it wasn't enough for me to identify vocal cords. At that moment, blood obscured my camera and I couldn't see anything. My attending took over but was unable to visualize things as well. When unable to intubate, we went to mask ventilation. However, the patient's body habitus prevented us from ventilating, even with an oral airway and a laryngeal mask airway. This was alarming. The incidence of "cannot-ventilate, cannot-intubate" patients is incredibly low, but when it happens, it means we cannot oxygenate the patient. This is even more important given that the patient was having a stroke. But after manipulation of the laryngeal mask airway, we were able to ventilate the patient, and her oxygen saturations came back up to normal. Finally, we used a fiberoptic bronchoscope and an exchange catheter to intubate the patient while ventilating them with the airway. In the end, we were able to place the endotracheal tube, but it was a harrowing experience.

I write about this not because of its severity, but because these situations require debriefing. They happen to every anesthesiologist and it is part of the consent I do when I speak to patients about the risks of anesthesia. But during the experience, I was terrified. Afterwards, I was shell-shocked. Fortunately, my attending did the rare thing and sat down with me after the case to discuss what happened, what we did right, and what we could have done better. It allowed me to express my worries and concerns and feel a lot better.