Weekends and Difficult Airways

Anesthesiologists plan for worst case scenarios. I've written about this a lot in this blog, but our concerns don't revolve around cases that go smoothly; we worry about that exceedingly rare case that goes bad. In these situations, anticipation, planning, resource management, and crisis response can make the difference between life and death. During weekdays, we have a lot of resources at our disposal. There are a lot of anesthesiologists, technicians, nurses, pharmacists, surgeons, and other providers who can help out in an emergency. But on nights and weekends, the operating rooms can feel like a ghost town. What happens if something goes bad, and you're the only provider around? Your nearest help may be the ICU or code team or ED, physicians that are unfamiliar with the operating room environment. I think about this, and my setup differs whether I'm on call at night or doing routine cases during the daytime.

One Saturday call, I had a patient with a bad tooth abscess causing an infection of the floor of the mouth. She could barely open her mouth, was having trouble breathing, and drooled uncontrollably (as any pediatrician can tell you, this kind of drooling doesn't bode well). I wanted to secure her airway while she was awake, a task that is simple enough when it goes well but can go horribly wrong if she stops breathing. On a weekend, I asked for and set up my difficult airway cart and multiple backup supplies. I walked my attending, nurse, and technician through what I would do in every imaginable situation; if she was not sedated enough, if she was too sedated, if she became agitated, if her oxygen dropped, if her vocal cords closed. I prepared myself and the team more thoroughly than I normally do because I knew that in an emergency, these would be all the players, and I depended on them. The case went very smoothly, and we all had a lesson in what happens if you never brush your teeth.

The following case was an emergency eyeball. A patient with retinal detachment needed immediate eye surgery to preserve vision. Nothing on the pre-operative evaluation clued me in that this would be a difficult intubation. I planned my anesthetic, tailoring my medications to protect the eye. But when I put the patient to sleep, I couldn't see the vocal cords. I calmly tried a different laryngoscope blade and couldn't see anything again. But I was stuck; most of my difficult airway supplies were being cleaned and turned over by our technician because they were taken out for the previous case. I asked the nurse to call for a video laryngoscope, but because it would take time to arrive, I decided to attempt a blind intubation. I knew where the vocal cords should be, and without seeing them, I gently snuck the endotracheal tube in. I was a little surprised when it worked out, and when the technician rushed my video laryngoscope into the room, I didn't need it.

Early on in my residency, I had situations where I couldn't see vocal cords, and I would immediately hand the case over to my attending. They would inevitably sneak the tube or an exchange stylet in. Occasionally, when I asked what they saw, they would say, "Very little" or "Nothing." That validated my laryngoscopy technique, but I was always impressed. How do you intubate someone blindly? Although experience, practice, knowledge of anatomy, and a delicate feel all contribute, the attending would say that when you have to secure an airway, you do it. The buck stops with the anesthesiologist. When my back is against the wall, the motivation is that if I don't breathe for the patient, he will arrest. Anesthesiology is about planning for and avoiding these situations, but they will happen, and when they do, you step up. For this patient, I knew exactly how that felt, and that's how I managed a blind intubation. My heart was pounding. Of course I could have handed it over to my attending, but then I wouldn't have progressed from the junior resident I was two years ago and I wouldn't be ready for independent practice in a few months.