Anatomy of the Emergent Airway

We (that is, young anesthesiologists like me) sometimes dream of the heroic emergency rescue: a man allergic to peanuts runs afoul of the legume and we rush over, pulling an endotracheal tube, laryngoscope, and syringe of epinephrine out of our pocket, saving his life. This, I guarantee, is not the day-to-day life of the anesthesiologist. The older crowd likes to avoid excitement; the good day is one in which everything is calm, planned, straightforward. My attendings remind me that we don't aim to have situations worthy of TV sitcoms. So perhaps it is only the emergency doctor or physician bystander who gets to make the dashing, daring, and frightfully decisive saves.

In the past two days, upon arriving at the hospital at 5:45am, I've been called for an airway emergency. I walk over to see the patient, planning in my head the absolute minimum I would need if that person needed to be intubated right then. But luckily, that was not the case. Much as I would have loved to be the TV show star, I knew the safest thing, the anesthesiologist way, was to plan everything out.

Both patients were in extremis; they were breathing at forty breaths a minute (try doing it, and see how long you can keep it up). But they were oxygenating and ventilating, which meant I had some time - whether five minutes or thirty minutes, I didn't know, so I dared not venture far from the room. But I examined the chart, looked at old intubation records, looked into the patient's mouth, and called my attending. We situated the room so that everything was available and ergonomic. Instead of having just the bare minimum, I set up every possible tool I could use, from a line of oral airways to the fiberoptic bronchoscope. This is a mantra in anesthesia: if you are prepared, nothing goes wrong. If you aren't prepared, you'll wish you were.

In both cases, despite rapidly decompensating patients, we kept our cool. We called a time-out. We prepared medications for every possible scenario. I took a look with a laryngoscope and intubated them smoothly. We brought the patients to the ICU and started the process of diagnosis and treatment. There were none of the frantic yelps and breath-holding crowds and sighs of relief of the heroic intubation. But I realized I don't need that.