Author: Scott Knappenberger M.D.
When first approached about the idea of a blog, I was reluctant. I am not a writer, not a philosopher, not an academician, nor a businessman. I have nothing to offer a blog but my humble experiences. I was planning to decline the opportunity. Then, however, this weekend happened.
I was on call, at home, enjoying a weekend with my family, playing with my daughter. The pager went off. Most of the time when the pager goes off, it is a parent concerned about the post tonsillectomy pain of their child, or a warfarin nosebleed, or the hospital calling in an unnecessary consult, (inpatient consult for rhinitis medicamentosa x 2 over the weekend). This time, however, the page was the ER, this time it was an airway.
Oral surgeon had already been consulted for the drainage of the mandibular abscess, but the abscess was displacing tissue medial and posteriorly, narrowing the airway, the patient had involvement of the pterygoid musculature and subsequent trismus. Bottom line, the patient could lose his airway at any time. I was consulted for an awake trach.
The tracheostomy procedure is one of the most conceptionally straight forward procedures in medicine. You take a curved rigid tube and place it in another relatively rigid tube. Unfortunately tracheostomy is rarely straight forward and is not a procedure that I take lightly. The depth of the trachea, the amount of adipose tissue in the neck, the venous return from the neck, the vascularity and thickness of the thyroid isthmus, the stiffness and position of the trachea, the coagulation status of the patient; all are variables that can turn this operation into a nightmare. Too much bleeding equals poor visualization, too much fat equals poor visualization, too many co-morbidities equals poor platelet function. Either iatrogenic or physiologic poor platelet function is an otolaryngologic nightmare. Bottom line, even the easiest trach sucks. Awake trachs really suck. I know what you are thinking, “aren’t you awake for all of your trachs?”, unfortunately, yes, but awake trach is when the patient is awake, aware, breathing on his own, with only narcotic on board. Typically, the patient is scared, coughing, (coughing out blood when the trachea is opened), and moving.
Why awake? Well, in the example of our patient waiting in the ER, if paralytics or deep sedatives are given, the airway will collapse and with the anatomical shift and the trismus, the patient would lose their airway and then a slash trach may be necessary. The patient awake allows him to protect his own airway.
When I arrived at the hospital, (I actually beat the oral surgeon there!), the patient was a thin male, sitting with no problems and a huge abscess pushing out from his face. He was talking with his mom, dad, and significant other. His breathing was fine. His trismus was severe. His CT looked like a nightmare.
I discussed with the patient the options. The patient was stable but scared. His family, however, was completely oblivious to his situation and how sick he was. The patient was right there with me as we were discussing the situation. His family, on the other hand, was interrupting me every four words to ask some inane question and to try to get me to laugh and show me how witty they were. Finally, after one of their laughter outbursts, the dad said “lighten up doc; he’s just got a tooth ache.” I retorted that “I don’t think this is very funny. Your son is very sick and if we don’t do things the right way, he could die.”
I always discuss with patients and especially families the 3% risk of death associated with the procedure. Bleeding, mucous plugging, dislodgement all are scary and catastrophic events and the nightmare of many a surgeon. Usually, I work up to the death risk discussion and gradually, like a crescendo, bring that to the forefront. My usual sequence is: “The risks are scarring, both inside and out; bleeding, mucous plugging, dislodgement, problems months to years down the road, and unfortunately a 3 in 100 risk of death.”
With every patient, we learn something. That is why I am writing this blog, because I am not a perfect doctor. I regret how I presented to that particular patient the risks of the procedure. I did it the way that I did because of how obnoxious his family was acting and to shut them up so that I could have a conversation with the patient, and not specifically for the patients benefit. In retrospect, I reflected on the situation and my lack of “aequanimitas” as Osler would have called it.
Fortunately, everything went well. The trach was avoided. In the OR, the airway was established with transnasal intubation, and the end result was as positive of an outcome as could be expected. However, as physicians, we should learn from each of our experiences in order to provide a higher quality of patient care.