a rude awakening & the parting of the red sea

no one likes to be woken up at 3am. esp if you have just gone to bed at 2am. i was put in that unenviable dilemma recently. well, actually it wasn't a dilemma - i was on-call & i had to answer the phone.

the emergency dept (ED) medical officer (MO) was desparate. he has a middle-aged man who had surgery for cancer of the thyroid followed through with radiation therapy to the neck. he was recently discharged from hospital but has come back because of breathing difficulty. the MO attempted to intubate (medic-speak for inserting a tube into the mouth & passing it down the windpipe to maintain an airway & to assist respiration) but he couldn't identify any of the structures in the throat to facilitate the procedure. ah, this is not good - i'm half awake, a difficult problem has cropped up & this could be life-threatening.

by the time i got to the ED, sleep has worn off & the adrenaline was in control. the MO heaved a huge sigh of relief - 2 heads are better than 1, right? the gentleman was obviously in distress - he was panting like he's just done a sprint & his lips had a sickly bluish shade, indicating he's not getting enough oxygen into his lungs. & i seriously thought he was a goner. i mean, he's got cancer that has breached the original boundaries & now, obstructing his respiration. & i'm getting flashbacks of darth vader breathing down my own neck.

ok, i definitely won't be thinking of curing his cancer, i thought, but i'm going to try to pull him through the night, at least. so here goes........

endotracheal tube - checked!
laryngoscope - checked!
oxygen - checked!suction - checked!
tissue paper (for mopping my forehead) - checked!
intestinal fortitude - err, checked, i think....

using the laryngoscope to look into the throat, i can confirm what the good MO saw - it's a war zone in there. i cannot recognise the usual anatomical landmarks other than a deformed epiglottis, which resembles a flap overhanging the opening into the windpipe, through which i must insert the tube. except that there was no opening where one should be!! zero. zilch. the devastation of the spreading cancer & the rages of subsequent radiotherapy had altered the landscape altogether.

on to plan B, & this comes with experience. seriously. (young ED MOs, before you hit the panic button & yell for the ENT consultant - & face his wrath - at such unearthly hours, you might want to consider this.) i inserted the tube just behind the epiglottis because theoretically, this is where the opening should be. as i gently prodded at the fleshy tissues with the tip of the tube, they gradually gave way to reveal the hidden orifice. suddenly i felt like moses at the parting of the red sea.

with the tube well-secured in the windpipe, oxygen breathed life into the patient, who was then transferred to the ICU for assisted mechanical ventilation. 2 days later, a tracheostomy (an artificial orifice surgically created through windpipe) was performed & he was able to breathe on his own without further mechanical assistance. after another course of radiotherapy, he was well enough to go home. i had earlier thought he was a goner, but he lived another day to dote on his grandchildren. & i love a happy ending.



"many are the plans in a man's heart, but it is the Lord's purpose that prevails." proverbs 19:21