A Basic Procedure Goes Awry
We walked over and looked at the scan on a monitor. I was stunned. There was a huge mass, the size and shape of a small cantaloupe, in Steve’s upper chest. It was compressing the area where the trachea splits into two smaller tubes, called the main-stem bronchi. The right main-stem bronchus was obliterated, and the left was only about half its normal diameter.
“This explains why he wants to lean forward,” I said. “It takes pressure off his airway.”
“What do you think it is?” the emergency room resident asked.
“I don’t know,” I said, “but a lymphoma has to be high on the list.” A tumor originating from the white blood cells of the immune system, lymphoma represents almost 15 percent of all cancer diagnoses in young adults. Steve’s symptoms had come on quickly, and of the tumors that can occur in this area of the chest, lymphoma is one of the fastest.
We took Steve to the operating room to biopsy the mass. The staff surgeon asked me to have the anesthesiologist insert the breathing tube into the patient’s airway while he was awake and sitting upright. Although patients are usually sedated and paralyzed during this procedure, the surgeon worried that if Steve were relaxed and lying down, the tumor could press on the airway so firmly that the anesthesiologist would be unable to pass the breathing tube at all—what we term “losing the airway.”
As I walked into the OR, the anesthesiologist was lowering Steve from a sitting to a lying position, counter to the surgeon’s instructions.
“We think you should intubate him awake and upright,” I said hurriedly, “due to the tumor’s location.”
“I don’t think that is necessary,” he replied, and immediately injected Steve with the intravenous anesthetic.
Over the next several seconds, I watched in horror as the anesthesiologist tried five times to pass the tube, only to have it stop halfway down: The tumor had slammed the trachea shut.
“Dammit!” the anesthesiologist said, “it won’t go!” His face was red, and his hands trembled from anxiety.
I ran over to the bedside and barked at the circulating nurse: “Get the rigid bronchoscope, stat!”
Unlike the thinner and flexible breathing tube, the rigid bronchoscope is not much more than a metal tube about half an inch in diameter with a lighted fiber optic shaft. We occasionally use this device to remove foreign bodies or to biopsy airway tumors. It can also be used to ventilate a patient when the more flexible breathing tube cannot be inserted.
As the nurse ran out of the room, I looked over at Steve’s oxygen saturation monitor, which displays the amount of oxygen being carried by the red blood cells to the tissues of the body. The monitor both displays a number and beeps with each heartbeat; the beeping tone gets lower as the numbers go down.
Over the next several seconds, I watched in horror as the anesthesiologist tried five times to pass the tube, only to have it stop halfway down.
A normal blood saturation level is between 95 and 100 percent. Anything lower than 80 percent for more than a few minutes can damage the brain and other organs and possibly result in death. With no oxygen reaching Steve’s lungs, I listened and watched helplessly as the numbers got smaller and the beeping tone went lower: 90… 70… 52… Steve’s heartbeat began to slow and became irregular.
“We’re losing him!” I yelled. I knew that CPR would be futile—it pushes oxygen through the airway, and the airway was closed.
The nurse wheeled a cart into the room. I grabbed a rigid bronchoscope and attached the light cord as the anesthesiologist moved out of the way. I placed the scope in Steve’s mouth, identified the larynx, and shoved the metal scope past the vocal cords. I felt a bump as it slid past the tumor and down the left main-stem bronchus. I heaved a sigh of relief. We could deliver enough oxygen to one side to sustain him. Now I just needed tubing to hook the bronchoscope to the ventilator.
“Hand me the ventilator tubing,” I told the anesthesiologist.
“Thank God!” he said, handing me the tubing.
I froze. The tubing, retrieved in haste by the nurse, was the wrong size and lacked the connective hardware the device required. “Get me a connector!” I yelled. The nurse ran out of the room again.