R. Gu. Sixty-four-year-old Chinese man. Sepsis.
Richard, the night attending, was leading sign-out rounds. We stopped at Mr. Gu’s stretcher. Four other doctors--the admitting team--were already ministering to him, which meant, in theory, he would not be my responsibility.
Came in at 1 a.m. complaining of not feeling well. We counted two coats, two sweaters, a shirt, undershirt, and thermal underwear--and he was still shaking. Temp 104. Blood pressure 140 over 70. Okay so far. But he may be a sick cookie.
Mr. Gu registered no protest as a nurse poked his arms for more blood.
An hour later Mr. Gu’s cubicle was filled with the same bustling white coats.
Blood pressure just nose-dived, the doctor in charge told me. And he’s not breathing so well either.
If you need a hand intubating, be glad to help, I said, then left them alone. Mr. Gu needed fluids and medications to raise his blood pressure, and his doctors needed no distractions as they rode one of medicine’s most feared roller coasters: septic shock.
Sepsis is what can happen when bacteria invade the bloodstream. As they multiply in the blood, the immune system responds aggressively, releasing a cascade of chemicals to fend off the microbial onslaught. One effect of these chemicals is to open up blood vessels, a normal response that allows immune-system cells to move out of the bloodstream and into infected tissue. But in the case of sepsis, the response is nothing short of hysterical. The body can kill itself with its own defenses, by rendering blood vessels too leaky and flaccid to sustain blood pressure and vital organ function. This collapse is what we call shock, and when it occurs in the lungs, fluids can leak into the airways, swamping the lungs and suffocating the patient.
Mr. Gu was suddenly caught in such a cross fire.
A few minutes later the cry went up: Call anesthesia!
Mr. Gu needed to have a breathing tube slid down into his failing lungs so that more oxygen could be delivered to them through a ventilator. His team hadn’t so much spurned my offer of help as gone straight to the experts.
Intubation is the rescue of the airway, the life-giving conduit between atmosphere and lung. Patients whose lungs are failing from severe asthma, congestive heart failure, sepsis, or emphysema, or those whose throats suddenly swell shut from an allergic reaction, are literally at death’s door. If treatment with medication fails, they can be saved only by immediate and expert intubation. It is one of the most critical skills an emergency room physician can master.
In principle, it’s easy: all you need to do is slip a hollow plastic tube down the throat and into the windpipe, or trachea.
But anatomy is designed to thwart us. The throat does not open smoothly into the trachea but instead forks into two passages: the esophagus, the channel through which food enters the stomach, and the trachea. The trachea’s petal-like protector, the epiglottis, acts like a hair-trigger safety hatch. Every time we swallow, the epiglottis closes over the tracheal opening. If the smallest fleck of food sneaks past, we cough violently. Every throat reflex we have conspires to keep things out of the trachea, and a tube thrust blindly down the throat will almost always end up in the esophagus. To intubate, you must use an L-shaped laryngoscope--which consists of a handle and a self-lighting metal blade-- to maneuver between two rows of teeth, push away an often beefy tongue, avoid the ever-receptive esophagus, and make anatomic sense of a throat filled with misleading nooks and crannies until you reach a half-inch opening that is obscured by secretions or blood--all the while overcoming the patient’s very understandable resistance to the whole project.
Anesthesiologists are expert intubators because that’s what they do all day in the operating room. Moreover, they grow comfortable with a wide array of sedating and paralyzing drugs. In most cases, effective anesthesia means stilling both the mind and the muscles lest a patient remain fully conscious while paralyzed. Sedating drugs like Valium, Versed, and the barbiturates are used to induce sleep, thus blunting mental awareness; paralyzing drugs derived from curare--the substance South American Indians smear on their arrowheads to immobilize their prey--use molecular mimicry to block chemical signals from the nerves to the muscles, thus inducing muscular paralysis.
Within the minute, the anesthesiologist came down. Mr. Gu’s blood pressure was now stabilized at 100 over 70. He was still trying to breathe on his own and was quite conscious. I wondered what kind of drugs the anesthesiologist would choose for Mr. Gu. The most effective and humane way to intubate a patient is to sedate and paralyze him, so he can neither resist nor feel the procedure. But there is a terrifying downside: should you fail to create an airway in a paralyzed patient, he suffocates in four minutes. The fallback procedure is to force air into the patient’s lungs using a soft mask that fits over the nose and mouth and is connected to a large air-filled bladder, or ambu-bag. This can be squeezed by hand to force air into the breathing passages. When done methodically and well, bagging can keep a patient alive for as long as it takes to prepare for intubation.
Losing an airway is a heart-stopping nightmare. At one famous teaching hospital a young woman received a general anesthetic prior to cesarean section, paralyzing her respiratory muscles. The anesthesiologist couldn’t intubate. In the end, seven anesthesiologists, plus three or four surgeons, failed to secure her airway. Whether they tried to bag her while pondering their next move I don’t know, but in the end they lost her. Too many doctors getting in each other’s way? Too many half-measures? Most bewildering is that even with very difficult anatomy, an opening can be made just below the Adam’s apple, in the larynx, and a tube inserted there. Why this failed under ideal operating room conditions can only, unfortunately, be attributed to panic.
To my surprise, the anesthesiologist went ahead without sedating or paralyzing Mr. Gu. I shuddered as he inserted the curved laryngoscope blade between Mr. Gu’s teeth, into the throat, and then pulled up to clear the tongue. Mr. Gu writhed and his arms flailed weakly. The anesthesiologist pushed the endotracheal tube in with his free right hand but 15 seconds later pulled it out.
He tried again. Mr. Gu became more agitated, couldn’t help resisting.
The anesthesiologist got flustered. Then he decided he was done.
Call the surgeons. His anatomy’s awful. Needs a surgical airway.
After only two passes he wanted the surgeons to cut a hole in Mr. Gu’s neck.
But as I knew from the initial presentation, Mr. Gu’s platelet count--the blood component that plays a crucial role in clotting--was only 60,000. The normal count is more than 100,000, but sepsis unleashes an abnormal clotting cascade that consumes platelets, making them unavailable for normal clotting. A surgical airway would be a bloody mess.
Can I give it a try? I think I can do it, I said.
The anesthesiologist shrugged. Sure.
I moved to the head of Mr. Gu’s bed. As gently as I could, whispering I’m sorry, I pried his teeth apart, then used the laryngoscope blade to push his tongue over to the left. In the dark, moving depths of the throat, I could just make out the flaplike lid of the epiglottis. I lifted my blade to tease it out of the way and aimed the tip of the endotracheal tube at sheaths of white tissue that looked like vertical blinds pulled taut. These were the vocal cords, the trachea’s antechamber. The slender tube wouldn’t pass. I pulled everything out.
Bag him, I said softly while I got organized for a second pass. A clamp on Mr. Gu’s finger that monitored the oxygen content of his blood told me that, with bagging, Mr. Gu was getting enough air, despite his faltering breathing. We had time. No need to panic. I tried again. The tracheal opening stayed tantalizingly out of reach. I pushed and lifted as hard as I dared but couldn’t hit it. It was my turn to mutter, Damn.
By then the surgeons had arrived. A young resident measured Mr. Gu’s neck to plan his incision. But then he faltered. Backing off, he asked that the surgical attending--his boss--be called. Meanwhile we bagged Mr. Gu vigorously. His oxygen level and blood pressure stayed up. Three more surgery residents arrived and crammed into the cubicle. The anesthesiologist was packing his kit. Bad anatomy, he insisted.
I can see the vocal cords, I said. If we paralyze him, I think I can get it.
If we paralyze him, we’ll lose his airway, he snapped back. Better a poorly breathing patient, in other words, than a patient that can’t breathe at all.
Maybe, but his platelets are low, I countered. We’re not in an operating room, and opening his neck here could be a disaster.
The anesthesiologist wouldn’t budge. He needs a surgical airway. If you paralyze him, you’ll kill him. The assembled crowd nodded. Eight doctors in agreement. And besides, Mr. Gu wasn’t even my patient. The surgeons set out their gleaming tray of instruments.
Look, I reasoned with the attending physician, this patient has no platelets. Surgical airways are bloody enough as it is. What’s more, we’ve barely tried to intubate. We need to sedate and paralyze him.
But what if we lose the airway?
We’ve got the surgeons right here. As soon as they’re set up, I’ll try. If I miss, then it’s their ball game.
I can see the trachea, I reassured him. If we paralyze him, I’ll hit it.
And then, to put some oomph behind my argument, I announced, I will intubate this patient. Babe Ruth lifting his bat to the right-field bleachers.
I need one of Pavulon, three of Versed, and 100 of succinylcholine, I said. The first drug would begin the paralysis; the second would induce sleep; the third would complete the paralysis.
The er normally didn’t stock these medications, but I knew the anesthesiologist had them in his kit. He made no offer to lend them.
Someone run up to pharmacy, I requested, meanwhile thinking, Me and my big mouth.
A month earlier, I had made a startling discovery: after five years as a full-time er doctor and, I thought, a pretty fair intubator, I found I’d been doing it all wrong. A couple of near misses drove me back to the books, which, to my dismay, showed me I hadn’t been positioning patients’ heads correctly nor approaching them from the correct height. In short, I had been intubating instinctively for years (dropping on one knee instead of raising the stretcher, for instance) and getting away with it, until a truly tough one came along. I tried to think back to my training and couldn’t remember a clear, guiding hand. Mostly, as with probably too many doctors in today’s rushed teaching environment, I’d just taught myself.
But now I had no excuse.
While an intern ran upstairs to the pharmacy, I raised Mr. Gu’s stretcher, propped his head on a pad, and angled his neck back like a swan diver’s to align his trachea with my eye. Methodically, I showed my assistant how to press on Mr. Gu’s larynx from the outside to bring the trachea into view on the inside.
The intern rushed back in.
Pavulon one milligram iv, I ordered. Then the Versed, then we wait three minutes.
At three minutes we pushed the succinylcholine, the principal paralytic, into Mr. Gu’s vein.
Now give me a timed minute.
No one said a word. My assistant pressed down on Mr. Gu’s larynx. The surgeons hovered. The medical attending raised his hand.
The laryngoscope blade slid into Mr. Gu’s mouth. I could see his epiglottis, the pale, pleated vocal cords, and the smooth cartilage around the opening of the trachea. He still resisted a bit. I pushed the thin endotracheal tube home. My assistant bagged air through the tube but, listening through my stethoscope, I heard air in the stomach. My aim had not been true. The tube had found the esophagus.
Missed, I said, then pulled out the tube. I decided to try for a narrower tube.
Now the paralytics had achieved their full effect--Mr. Gu’s jaw dropped open. Holding my breath, I gently slipped the laryngoscope blade to the base of the epiglottis and pulled up. Like a reviving orchid, the epiglottis floated up to reveal the gateway to the vocal cords and trachea. It was my last try. I aimed the tip of the tube at the dark, glistening tunnel, then advanced my hand as if smoothly releasing a paper airplane. I felt the muffled clicking of plastic on the ring of cartilage surrounding the trachea, then knew.
It’s in, I said, straightening up. My stethoscope transmitted the sweet whoosh of the air being forced into Mr. Gu’s lungs. His airway was secure. He would have a fighting chance against his sepsis. Eight doctors stopped holding their own breath.
Not even Babe Ruth ever knew this feeling.