Tuesday, February 13, 2007

disaster on disaster

recently i was involved in a case which i want to talk about on so many levels. therefore this posting is probably going to be very disjointed. a peripheral hospital sent us a patient that they said had severe stridor (an inspiratory noise usually denoting an upper airway obstruction) what they didn't tell us was that the guy could hardly breathe at all. he arrived and my medical officer quickly made the evaluation that a tracheostomy needed to be done and immediately. he phoned me. i was not on call or even standby, but he told me he couldn't get hold of the other guy. my mo had assisted in a tracheostomy recently and i told him to go for it (see one do one teach one principle). he said he would, but i could hear he was a bit nervous so i came in. in theater the man was in severe distress. he could only breathe if he sat up and leant forward. i injected his neck in this position with local. (you don't want to put this type of patient to sleep unless you're sure of getting an airway or he might asphixiate and die.) i then started the procedure with him in almost a sitting position. i decided to do this one because of the distress of the patient and i'd be able to work faster than the mo.

i dug into the neck as fast as possible. but i couldn't find the trachea in it's normal position. where it should have been was a transverse pulsating artery about the size of my little finger. in retrospect i think it was an aberant right carotid artery which ran anterior to the trachea, but i'm not sure. i reflected it inferiorly and much deeper down and travelling in the wrong direction (the trachea is usually more or less parallel to the skin, with a slight slant posteriorly. this one dropped posteriorly almost at right angles at the level of the abnormal artery) was the comforting corrugated feeling of the trachea below my finger.

at about this stage the patient became disorientated due to hypoxia (lack of oxygen) and started fighting. fighting for his life as he saw it. the anaesthetists had no choice but to put him to sleep. i continued my endeavour while they tried to intubate him from above. i heard them saying they could see a pedunculated tumor at the base of his tongue that formed a ball and socket valve over his airway. the cause of all his problems.

with much sweating and swearing i finally got the tracheostomy pipe in, casually asking the medical officer why he didn't do this one alone (a joke, just in case i get flamed). we sent him to the ward. it was the most challenging (surgical talk for difficult) tracheostomy i've ever done.

i felt my adrenals slowly recover, shrinking back to only twice the normal size. i went home and had a beer.

about 3 hours later, the same medical officer phoned me. he started with an apology that once again he couldn't get hold of the other guy, but the patient had removed his tracheostomy pipe and he couldn't get it back in again. immediately i headed off to the hospital. i went straight to theater. there i found a very pale man. the patient also looked off colour, but he was blue. the pale medical officer told me surgery was not for him. if i didn't think he'd take it badly i would have laughed. the patient seemed to almost be in exitus. not good!

to be continued.......

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