intubation

Tuesday, January 16, 2018

Make a catch, miss a tackle. A miracle play or a disaster. The coming together of Stephon Diggs’ catch combined with the Maurice Williams’ missed tackle at the end of a playoff game made for one special play, instantly turning people’s emotions from Saint jubilation and Viking despair, to just the reverse. For fans, players, coaches and color commentators, it was life or death…but it was just a game. Real life and death happens in medicine when the ability to perform may make the difference in a patient’s survival. Not all medical moments or procedures are memorable, but the fear of being unable to intubate a patient makes for many an ER doc nightmare.

When a patient can’t breathe on their own, a tube needs to be placed into the trachea and air pumped into the lungs. In most situations, like surgery, intubations are planned. The patient hasn’t had anything to eat or drink, they have been evaluated by the anesthesiologist, and even if potential difficulties might exist, they are at least known and plans made. And then there is the rest of the world. Patients show up unannounced, or their condition unexpectedly deteriorates; their ability to breathe is compromised and nightmare scenarios rear their ugly heads. Be it heart attack, congestive heart failure, COPD, asthma, pneumonia, trauma, overdose, uncontrolled seizure, stroke …the list is long and each patient, with unknown pitfalls, makes placing that tube a journey into the potential unknown disaster.

 

The intubation procedure isn’t a difficult concept. With the patient on their back, and the intubator standing at the head of the bed, the laryngoscope, a lighted blade is used to sweep the tongue out of the way, while at the same time, lifting the jaw and allowing a clear view to the back of the throat, the epiglottis and the vocal cords, signalling the entrance to the trachea. The scope lifts the epiglottis that covers the vocal cords and a tube is passed through the cords, secured in placed and then usually hooked up to a ventilator to breathe for the patient. What could possibly go wrong?

 

    

Ideal conditions don’t always exist.

  • It is the rare patient who is unconscious, perfectly still and relaxed, and allows somebody to jam a tube down their throat. Often, a patient needs to be sedated or even paralyzed. Give those drugs and it’s game on. Don’t put the tube in the right place, breathe and supply oxygen for the patient and pretty soon, brain cells start to die.
  • Operating rooms and ERs have lots of extra hands to help when the patient’s condition goes south. Imagine the paramedic on the side of the road on a rainy, dark night trying to intubate a combative trauma patient? And imagine if there are family members hovering over your every move.
  • We’re not all the same size and a 4-week-old infant with RSV infection needs different techniques than an 80-year-old with congestive heart failure.
  • Not everybody is built the same and anatomy changes in trauma. With a face or neck injury, there can be blood everywhere and those vocal cords, the target for the tube, may not be able to be seen.
  • There can be other problems with seeing the cord, from vomit, to dentures being lodged in the back of the throat, to bullnecked patients whose mouths don’t open wide.
  • If there is tongue swelling, like in angioedema or a major allergic reaction, the tongue can fill the mount and there might not be room to slide the laryngoscope into place to see the vocal cords.
  • Don’t forget potential technique issues. In trauma, if there is the possibility of a neck fracture, don’t flex the neck in attempts to see the cords otherwise you might end up damaging the spinal cord. It’s also bad form to lever the laryngoscope and break off teeth.

Intubation seems easy in concept but it can be a tough skill to perfect. Most doctors don’t get enough practice and training to be proficient. Those with great skill still fear that one patient might show up who evokes nightmares. Presumably, if intubation were easy, there would not continuing education courses that teach management of the patient with a difficulty airway.

Most medical care is not witnessed by millions of people and procedures that do not go well are not seen repeatedly in slow motion on SportsCenter. Care providers go home and replay the events until they come to grips with the fact that sometimes best effort is not good enough. Maurice Williams missed a tackle that led to a final second touchdown. He needs to remember that it was just one play…in a game… and the next season will bring the opportunities for many more plays to be made. The life lesson to be learned from intubation is that in times of patient disaster, even with the best training, with the best effort and with the best care, that life and death moments often favor death.

 

 

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