Here's the scene:
I'm 1st call. I inherit some long wreck of a case when I come in at 3pm. Crani for tumor resection, aneurysm, something long and painful. Things are actually running pretty smoothly in the ORs. I get the 2nd call guy out around 730 and have a fellow in the head case and a resident in an ORIF. The other resident is seeing preops somewhere. The crani finishes up and we're just arriving in the PICU when my phone goes off. The OR desk calling me on my phone can only mean 2 things, the resident just assassinated my ORIF or something REALLY BAD is on the way in.
"Dr. D, the ENT fellow just called and there is an 8 year old with dog bite to the neck that will be going emergently to the OR, ETA 10 minutes." Awesome.
I tell them to page the resident back from pre op duty, and send the fellow back down to set up the difficult airway cart and the fiber. I tuck the patient in the PICU with not much more report than stable for the last 13 hours and here's the record. The neurosurgery fellow was there to pick up the slack.
A little pause for some background. Prior to going back to fellowship I was an attending at a small hospital for a few years, alone and unafraid. We were by no means a trauma center, but we saw some crazy s h it in the ED. I had taken care of a few failed suicide attempts where they had blown their faces off, conveniently failing to actually kill themselves, apparently it is pretty common. I had done a couple of surgical cricothyroidotomies myself in the ED and watched the ED MDs place a couple of the emergency cric. kits. I had also intubated a few bad airways emergently that the ED MDs had failed to secure. When I was a resident I strolled down to the ED trauma bay one day and saw a dude with his trachea transected by a stab wound to the neck. The tube went right in the proximal half after the succs. Sorry no etomidate for you since you're bleeding to death and barely conscious anyway. My attending showed up 5 min later and said "Good job dude" and made a rapid exit while I was sewing it in place. He didn't make it to the OR. In this case, there was an ENT attending (but not an "airway" guy), fellow and resident available. Nothing to fear?
Kid hits the door, normal, healthy, happy, until a visit by Mr. Cujo the giant German Shepard. He strolled up to her, bit her in the neck and tried to drag her off, like Roy of Seigfreid and Roy and his tiger. Grandma beat him off with a rock.
Nuts.
She has a C collar on, poorly, with a huge dressing on her neck. She had a little morphine somewhere along the line, either in her 5 min in the ED or on route, so she was calm. Monitors on. 1st assessment. Not bad, no bloodbath, awake, vitals were OK, spont ventilation. She is coughing up pink/bloody sputum. ENT guys want to do a flexible and/or rigid bronch with spont vent to assess cord function if possible as by report, there was air leaking from her bite. I give her some versed, prop and succs in line and they take down the dressing. The dog bit her right across the neck, I have no idea how he didn't hit one or more of the big red tubes in there. Just than, she coughs and a clot blasts out of one of the large jagged (canine tooth) wounds. "OK guys, enough of this s h it, time to get started and get a tube in there." The resident covers the hole with a tegaderm and we mask her down. Suctioned bloody secretions, ENT's nasal fiber shows that the trachea was crushed and the cords avulsed, but she has a fairly patent airway. A canine tooth went in right above the thyroid cartilage and ripped everything up. Things are oozing, so I again remind them that time is not necessarily on our side, as the several minute flexible fiber continues. We throw our fiber, with tube, in the mouth and guide it through the mess down to the carina. Tube in, gently and with extra lube. Suction airway and clear out some more bloody secretions. Big win for the home team. Call comes into the OR, the cops told the OR front desk that they shot the dog. Awesome.
They powwow and decide urgent tracheostomy, minimal airway reconstruction, inspection and washout of the other wounds and a post op CT scan to make sure that there was no hidden vascular injury, or cervical fracture. A few hours later and I'm on my way home, she's on the vent in the PICU. She's going to live, but a singing career is definitely out.
Key points:
-If she's stable and spontaneously ventilating, it's probably a good idea to continue that plan until the tube is going in.
-use the fiber to make sure that the tube doesn't go in a false passage and you make things a lot worse. A couple of liters or more of air in the mediastinum is not going to do you any favors. The ENT attending wanted to just put the tube in directly, I said hell no, I have the fiber all set up right here. I'll do it.
-Have a plan B and C ready to go before you start. (fiber, diff airway cart, trach kit, retrograde wire, etc.)
-Don't F around too long without securing the airway, or you may not be able to. They would have spent 10 more minutes looking around. If she had a vascular injury, coughed and blew out a clot, the airway might have become impossible.
-I ordered emergency release blood into the OR, just in case, when they called and said she was on route.
-Don't forget about a possible yet to be discovered vascular injury or cervical fracture.
-if you don't necessarily like what the ENT, or whoever, is about to do, say something. They can be so focused on what they are doing, they might forget something important about the patient.
Tons of fun. It could have been far worse, but we were ready for anything!
"So in conclusion, thank you, Dean Martin and members of the graduating class, I have only one thing to say to you today. It's a jungle out there. You gotta look out for number one. But don't step in number two. And so, to all you graduates... as you go out into the world my advice to you is... don't go! It's rough out there. Move back with your parents! Let them worry about it!!!"
