planning to fail…intubating patients

Monday, June 11, 2012

There is always a backup plan in baseball. It may be the on-field fundamentals, like the catcher who backs up first base on each infield throw or it may be overall strategy when the relief pitcher walks to the mound or the pinch hitter comes to bat. There is always planning that occurs before the pitch, as different scenarios and options are considered in advance. The “what if” thought process is a big part of being manager and it turns out that everyday life is also filled with people contemplating their options. Life gets complicated when the number of options becomes smaller and smaller.

In medicine, not considering alternatives or forgetting the “what ifs” is not a viable option, especially in critical situations. This is especially true when the patient has difficulty breathing and the decision to intubate them has been made. Putting a tube in the trachea or windpipe seems like an easy procedure; all you have to do is open the mouth wide, look for the vocal cords where the trachea begins and shove a tube in between the two cords. Whatever could possibly go wrong, other than you can’t see the cords, the tube won’t go where you aim it and the patient is biting down on your hand. There is never enough equipment at the bedside or extra people to help when bad things happen.

Regardless of the reason a patient would need help breathing, from becoming too weak to breathe because of pneumonia or COPD or an overdose that turns off the breathing centers in the brain or a major trauma, bad things can happen when a doctor rushes in unprepared. The patient may be combative and may need to be paralyzed and sedated. They may be vomiting or bleeding, making it hard to see. They may have unusual anatomy that puts things where they aren’t supposed to be.

The key to good outcomes in situations where the patient is crashing begins with taking a deep breath and slowing down. Elite athletes use visualization, getting their mind’s eye to practice future actions. They also talk about how the game slows down as they make their decisions. Having practiced intubating repeatedly allows the world to slow down when the next emergency presents itself. That said, athletes and doctors don’t always share the philosophy of a bad outcome. Striking out at the plate or throwing a wild pitch isn’t life and death, except for the diehard fan. Being unable to secure an airway and getting the patient to breathe most certainly is. For the player there will be another game; for the patient, maybe not. Having the backup plan in place is a forgone conclusion.

Usually intubations go pretty well and they happen routinely in the OR for elective surgery. The patient has an empty stomach, their vital signs are stable, they are cooperative and their anatomy is pretty well known beforehand. That’s why the anesthesiologist came by to visit. In emergencies, all that is thrown out. The patient may be violent or combative, there may be vomit and blood everywhere making it too tough to see any anatomy landmarks. Even if everything is otherwise reasonably okay, the patient may have a small mouth, a big tongue, a receding jaw line or any number of issues that can turn getting the tube where it belongs into a potential nightmare. Fortunately, there are plenty of options available, usually a whole intubation cart filled with suction tubes, fiber optic lights, tubes of various sizes and shapes, guide wires and even more toys to help. But even with the most experienced doctor can fail, even with all those toys. Then what? There’s always a surgical alternative, cutting a hole in the neck and getting the tube into the trachea below the vocal cords. A cricothyroidotomy or tracheostomy may be the only way to go to save a life but few doctors have ever seen one, never mind done one.

In baseball, it’s routine to substitute and that luxury sometimes exists in a large hospital where many doctors and specialists might be available but in many parts of the country and the world, there is no relief pitcher warming up in the bullpen. In the end, it’s one on one, with the doctor and tube against the patient and trachea. Fortunately, the winning percentage very much favors the doctor and as it turns out, that makes the patient a winner too.

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