Blueberries!
People say that anesthesia is 98% boring, but I just encountered the other 2% for the first time yesterday. There’s nothing like watching your patient turn blue in a matter of seconds, but to have it happen 3 times in one day is pretty ridiculous. I guess it is true that when bad things happen, it comes in waves.
My first patient was an older guy who was morbidly obese and had some underlying cardiovascular disease with a baseline heart rate in the 50s (not because he was healthy). He was intubated and was lying on his side for a couple of hours for his back surgery. He was a difficult intubation so the plan was to take him to recovery still intubated and wait until he was fully awake before extubating him. When it was time to flip him back on his back at the end of surgery, I disconnected the machine from his breathing tube (so that it won’t accidentally be pulled out during the move). It took the team, maybe, 4 seconds to flip him on his back. I immediately hooked him back to the machine. Within 2 seconds, he turned dusky blue and the oxygen saturation on the monitor read 72 (normal should be >97). I immediately pulled him off the vent and started pushing air in manually but I could not squeeze air in no matter how hard I tried. His sats continued to drop. I had asked the nurse to call my attending immediately and within seconds he was in the room, took him 5 seconds to do a first assessment and immediately called for backup (the patient’s heart rate was now in the 40s and we thought he was going to code). Before I knew it, I had 3 attendings in my room. From then on, it was just a whirlwind of controlled chaos as we tried to break the patient’s bronchospasm so that he could breathe again. We finally managed to break the bronchospasm, his vital signs stabilized, and we took him to recovery still intubated. We waited until he was fully awake before we extubated him and he did well afterwards. Actually, he went home today.
My second patient was a young guy who was overweight and has been a heavy smoker for half his life, started in his teens. Other than that, he seemed pretty healthy. He was having surgery on his neck so I decided to intubate him using a device that has a camera at the end so I can visualize his airway anatomy and watch the breathing tube go into the trachea. He had a lot of secretions (smokers!) but I easily got the tube into the trachea. I manually pushed air through the tube and waited for the return of carbon dioxide to confirm that I am in the trachea (even though I watched it go in). There was no return of carbon dioxide. My attending and I decided the tube must have slipped out for some reason and ended up in the esophagus. So we pulled the tube out and tried again. Looking through the camera the second time, there was yet more secretion but again, we watched the tube go into the trachea. This time, we made sure that the tube did not move. Again, I tried to squeeze air in and waited for the return of carbon dioxide. Again, nothing. In fact, it was quite difficult to squeeze the bag. By now, we watched his oxygen saturation steadily drop…100…99…98…97…92…90…88. Geez, not again! Indeed, he developed bronchospasm where his airways just clamped down so neither oxygen can get in nor can carbon dioxide get out. We had to turn up our pressures and gases on our machine to break through the spasm. Eventually his airway relaxed, and we were able to ventilate normally. His surgery went smoothly. At the end of surgery, I called my attending to let him know the patient is about to wake up and be ready for extubation. The patient, again, had a lot of secretions in his mouth and I suctioned all of it out as he was waking up. He started bucking and coughing because the breathing tube was bothering him. I assessed if he was ready for extubation. He was already breathing on his own. When I asked him to open his eyes, he somewhat followed my instructions and fluttered his eyelids. When I asked him to squeeze my hand, he squeezed it hard (meaning he was not still paralyzed). He continued to buck on the tube. Knowing that he just had neck surgery, the increased pressure from him bucking and coughing may cause further trauma to his incision site. Weighing the possibility of this happening, I decided the right decision was to extubate him. I was wrong. Immediately after I took the breathing tube out, he clamped down with his teeth. If I hadn’t put in a soft bite block at the beginning of the surgery, he would have bit off his tongue. He started jerking around on the bed, his teeth still clamped together, and he started turning dusky blue while the alarms on my anesthesia machine started going off because his oxygen saturation was dropping (noticing a trend here?). I immediately threw a breathing mask on his face, pushed it down to get a good seal and tried to push oxygen into his lungs. By this time, my attending was already in the room. As I was doing this, he again called for backup. This time, it was not because we thought his heart would stop but because we have no access to his airway. If the patient continues to clamp down, it would be very difficult to pry his teeth open to even intubate. Within seconds, help was there. I continued to push the mask down on his face to get air in while my attendings started drawing up drugs and getting everything set up for immediate intubation. After I pushed a paralytic, my attending pried the patient’s mouth open and stuck the scope in. Looking on the screen, we couldn’t see anything but secretions. After suctioning, we finally saw a little tiny hole that was to be the trachea. We successfully placed a breathing tube into the trachea. Even after that, the patient’s oxygen saturations continued to be low. We had to completely deepen him with anesthetic gases and took him to recovery to be placed on a vent. While in recovery, he continued to have low saturations as he woke up. We were concerned that he may have developed fluid in his lungs or actually popped a lung. Clinical evaluation was not consistent with either of those problems, but he continued to have intermittent desaturations. Ultimately, we decided we could not safely extubate him and admitted him to the ICU sedated. I checked on him today. After being intubated overnight, he was finally extubated this morning and is doing well.
So I am not going to go into the reasons why this happened to both my patients. If you really want the pathophysiology behind it, you can ask me. It was a terrible day but also the most exciting as I learned a lot yesterday. Like everybody else in training, I have read a lot about bronchospasm and laryngospasm in all my textbooks, but I didn’t really appreciate the severity of it until yesterday. There is an absolute difference between reading about the causes and symptoms and treatment of bronchospasm and then witnessing it in patients that have multiple other health problems that needs to be addressed as well. Everything just happened within seconds. But like I said earlier, it was controlled chaos. I didn’t even have time to panic; I just did what I needed to do. It was as if my brain and body went on auto-pilot and just did things to manage the situation. Not until the patient was stabilized in the recovery room before my adrenaline slowed down and my hands started shaking as I started thinking about how much worse it could have been (like if I didn’t put in that soft bite block and he chewed off his tongue or if we couldn’t re-intubate him).
And as I talked about it over dinner that night, I realized how much I have grown in the past 6 months. Reflecting back to the first day in the OR, I was terrified and unsure of myself. I was hesitant to push large quantities of medications, I was scared that I would prematurely wake my patient up if I turned my gases too low. And I would have freaked out if my patient started bucking on the vent. I don’t know when I started feeling more comfortable being in the OR by myself, and I absolutely don’t know when I started developing this sense of control over adverse situations. But over the last 6 months, it has happened and certain things has now become second-nature to me. This is what it means to be in residency, to endure all those long workdays and unlimited hours of studying. It is days like yesterday that proves to me that all that hard work has been worth it as it has made me into a more competent physician.
