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I was over in the surgery forums and they posted that ENT's are the "airway experts" in the hospital. Do you agree with that? I always thought that you guys were the ones to call when there was a difficult airway.
http://gasforums.studentdoctor.net/showthread.php?t=450299
http://gasforums.studentdoctor.net/showthread.php?t=450299
An otolaryngologist is THE airway specialist in the hospital. The ENT is at least as good at intubating as is the anesthesiologist--and often better. He is far better with surgical airways than is the general surgeon or the emergency physician. He is better at instrumenting the airway than the pulmonologist as well.
No one should be more adept at the airway in your hospital other than maybe another ENT.
You can intubate a 500lb heffer with retrognathia and a malampati IV oral airway, slash trach an epiglottitis in less than 45 seconds, bronch an 18 month old and remove the pistachio they aspirated within a minute or two if needed when your an ENT.
You are the airway expert. All else pales in comparison.
At least 8 times in my 3 years since residency I have been asked to be in the OR when anesthesia was intubating a difficult patient. Usually a severely fat dude with OSA. They want me there to do the trach if they can't get in. Of those 8 times, I've performed the intubation after anesthesia failed 4 times. Never have I had to do a slash trach on these patients.
Anesthesiologists are trained to evaluate the airway differently than ENT's. Whereas I almost always see them put the pt's head on a pillow, I never do. I'll even sometimes put a shoulder roll under the big ones. For the airway, I'm not interested in comfort, I'm interested in safety. I'm interested in creating as straight of a line from the mouth to the carina as I can. Anesthesia is trained to create a straight line from the mouth to the glottis--they don't use rigid bronchs and don't have a need for the severe positioning we do.
Anyway, that's just one example of the difference. Another would be fiberoptic intubation. At least 3 times, anesthesia has failed to perform a transnasal fiberoptic intubation while I was in the room. In each case they stood above the patient's head which creates an unusual curve in the scope making it harder to maneuver. I put the patient in a sitting position, scope them from in front like we do in the clinic, and have yet to fail placing a fiberoptically guided nasal intubation this way. Simple stuff, but we just have more experience and more refined technique.
Another example, I was called for a 2yo kid who started to desaturate in the OR while getting a revision circumcision. When I arrived in the OR, his sats had been in the 60's for 3 1/2 minutes and there were 3 anesthesiologists in the room. When they failed to improve the airway, I simply took the direct laryngoscope and saw that the tube was in the esophagus. I reintubated, pt did fine. That was a silly case where panic on the anesthesiologist part prevented them from running through an appropriate algorithm. They kept pumping in albuterol for bronchospasm because they swore that they heard breath sounds and wheezes with them, but never took the time to just look at positioning. That should have been one of the first 3 things they did. Also, they didn't trust the CO2 monitor which was reporting no CO2 return (another failure on their part).
Next case, called to the OR to help with a patient who was supposed to get a lap chole. The anesthesia resident was having a tough time masking the patient and like a genius decided to push succ (for presumed larygnospasm) instead of considering that he may just be a big ole fatty who was obstructing because of his hypopharynx. Well, when the succ got pushed, the patient crumped. Sats went to the 30's. Pt was blue. That's when I got called in. I yelled for a trach set. The general surgeon said no. He wasn't going to let this patient get trach'd. He instead wanted to do a retrograde intubation. He tried, but never was able to find the wire after inserting a percutaneous angiocath into the upper trachea (or that's where he thought it was). He started to do the trach, but actually took time to tie of superficial vessels while the pt cont to sat in the 30's and was now starting to significantly brady. I pushed him out of the way and did an emergency trach. Pt's airway responded, but neurologically he took a hit. The general surgeon was pissed initially but admitted later he was wrong.
Next one. Homeless guy seen eating a hoagie on the side of the road. Witnessed aspiration and choking. EMT's were driving by at that very moment. Pulled over and tried heimlich, no success. Pt went LOC and they started CPR but did not get good air movement. EMT's then intubated him--in effect cramming a piece of meat into a saddle obstruction of B primary bronchi. Pt transferred to level I ED only 5 minutes away. My jr resident was in ER and heard the call come in. He immediately called me in even before the pt arrived. I lived 8 min away when breaking laws to get there fast. Which I did. Surgery resident in charge at ED wouldn't let my jr resident do an emergency bronch. Instead he wanted to pass a fogarty cath past the meat, inflate, and then pull it back. Didn't work obviously. When I arrived jr resident had a bronch in the airway and was just pulling bits out of the mass of shredded beef. I arrived, grabbed the bronch and looked with a scope. It was clear that the mass was too big and friable to remove with the bronch. I pulled the bronch out. Did a DL and blindly stuck alligators down the airway using only tactile feedback. I felt the meat, clamped the jaws down, and pulled out an 8cm hunk of shredded beef. Pt was down too long, however, support was withdrawn 72hrs later.
