Usually I get up about now but today I have been up for about an hour. It rained earlier, a short violent tropical rain that woke me. The air was refreshingly cool so I just lay in bed for a bit before rising to beat the morning crowd to the shower.
Around 1 AM last night, our anesthetist K. came into my room and woke me. She said that I needed to do an emergency tracheostomy. The patient was in the operating room. With that she was out the door, heading up to the OR a floor above the living quarters.
I swung my legs over the edge of the bed and pulled on some clothes and followed quickly, waking up as I walked past the ER staff on the stairway, bringing a bloody stretcher back down from the OR. In the OR I found a scene of controlled chaos. Our patient was squirming on the OR table, laying on his left side with his back toward me. K. was at the head of the bed. One of our nurse anesthetists was with her, making sure the IVs were working and drawing up syringes of medicine. G., our other surgeon who had just arrived the day before was by the patient’s head. Although he is an experienced surgeon in his own specialty, he had never done a tracheostomy which was why they had gotten me up on my night “off”.
R., one of our two OR nurses was directing the local staff to get set-up for a tracheostomy while S., our medical chief and ER doc was helping. There were 5 or 6 of the local staff, 2 working with R., the others standing around our patient, keeping him on the OR table.
I walked around the table to see how complicated this was going to be. Downstairs K. had said something about a grenade injury but there was just a single wound without surrounding shrapnel wounds, making it look more like a gunshot.
Single or multiple wounds, this one was impressive enough. Where his jaw should have been was just a hole opening up like a bloody flower with fragments of teeth and bone at the base.The tip of his tongue looked normal but flopped about loosely at an odd angle as if it weren’t quite attached.
There was blood everywhere but there weren’t any arterial pumpers that demanded immediate attention. He was laying somewhat still on his left side and his breathing was rapid but not panicked. It’s amazing how still someone with an acute airway problem will get once they can find a position that allows them to breathe. Conversely, that same person will fight you violently if you try to put them in a position where they can’t breathe. His neck was long and muscular without signs of external injuries. Long would make a tracheostomy easier. Muscular wouldn’t.
An elective tracheostomy is a fairly straightforward operation. The patient is already intubated with a secure airway, motionless from the anesthesia. You make a sideways incision in the skin, followed by a lengthwise incision between the so-called strap muscles of the neck, meticulously avoiding any bleeding that would make seeing the trachea difficult. You take your time. You make a controlled incision in the trachea and using special instruments, a three pronged retractor called a trach spreader and something that looks like a sharpened crochet needle called a trach hook, you place a short tube with a 90 degree bend through your hole in the trachea under direct vision and you are done. An emergency tracheostomy in an awake, moving patient is a bit more challenging.
K. and I had a 30 second discussion about the options.
Our patient clearly needed what in medical terminology is called a “secure airway”. I suggested she could try to intubate him in the standard fashion with a breathing tube down the mouth which can be surprisingly easy in cases of facial trauma. But K. was concerned about the possibility of a laryngeal injury. To intubate him would mean she would need to give him medicines that would temporarily paralyze his muscles. He was breathing on his own now but once he received those medicines he wouldn’t be.
Without any great options, we agreed on a plan. We would turn him on his back and I would perform an emergency tracheostomy under local anesthesia. If he didn’t tolerate being on his back, we would turn him back on his left side and try to do the tracheostomy with him in that position. If at any point things went downhill fast, he would need to be medically paralyzed and we try to get an airway, either by intubation or tracheostomy as quickly as possible.
I opened up the tracheostomy kit, making sure we had everything we needed. We went over the plan out loud so that everyone in the room knew what the plan was. Just before we turned the patient on his back, one of the local staff went over the plan with him in the local language, Sango. We are going to put some local anesthetic in the skin of your neck, then turn you on your back and put a tube in your neck to help you breath. We need you to help us by holding still but if you can’t, we’ll put you back on your side. With him still on his side I injected local anesthetic in the skin where the incision would be. And then we did it.
With him on his back, I made the skin incision with the scalpel down to the filmy tissue overlying the strap muscles of the neck. He was squirming and fighting us enough that we needed 4 people at his sides holding arms and legs and K. holding his head, but his oxygen saturation and vital signs remained unchanged so we kept moving ahead.
I imagine he was holding as still as he could.
With him moving so much, I switched from a scalpel to scissors to minimize the risk of cutting something I didn’t want to cut (including G. or myself) but the scissors were discouragingly dull, forcing me back to the scalpel until we were deeper in the neck.
Despite all the movement, I managed to stay in the midline and avoided major bleeding, largely going by feel. The trachea has a distinct feel, somewhat like a giant flexible straw. When I could feel we were down on the trachea, I placed the tips of the retractors in deeply and spread.
Much to my dismay, his thyroid was right in the way. At first I thought I had made my incision too high in the neck but then I realized he had an enlarged thyroid, a goiter. There are ways to split an enlarged thyroid for access to the trachea but they all risk bleeding, particularly in this setting.
I swept the thyroid north with a protective left index finger and holding the scalpel between thumb and index finger in my right hand, slid the blade down parallel to my finger and made an incision in the trachea. I was rewarded with air bubbles coming up from the wound, a sure sign we were in the trachea. With him still struggling and moving, I was afraid that I might tear the trachea if I grabbed it with an instrument like the spreader or the hook. Instead I put the the tip of my right index finger in the hole I had made in the trachea, pulling it forward and keeping my palm flat on his chest so that my hand would follow any of his movements and I wouldn’t tear the trachea. It actually has a name, the Utley maneuver. With my other hand I slid the tracheostomy tube down the back of my finger to just outside the hole in his trachea, then quickly removed my finger and slid the tube all the way in.
With the tracheostomy tube in, he was given anesthesia immediately and all the movements stopped. I secured the trach tube in place with sutures and a linen tape tied around the back of his neck, belt and suspenders, then stayed around to assist Dr. G. while he explored the wound, debriding pieces of bone and teeth and devitalized tissue.
The front part on the man’s jaw along with a fair amount of soft tissue going back under the base of his tongue was gone but his tongue was intact and there was enough skin left that we will probably be able to almost close the skin defect in a few days once the risk of infection decreases.
He will need significant reconstructive surgery to ever have anything near a normal appearance and be able to chew. It’s unlikely he will have the resources to get that done without the help of MSF or some other NGO. But that’s in the future and for tonight we had done as much for him as we can.
This morning it’s my turn to make ward rounds on the patients, then handle any new emergencies that come our way. If the weather stays cool and the ER stays quiet, I’ll try to grab a nap in the early afternoon.