Worst Airway I’ve seen in a long time

[Noyac]

---

Members do not see this ad.

Yea, worked great. And it certainly was the right choice. That being said, I was disappointed at the lost opportunity.

I agree. Sounds like your attending was worried enough that s/he just wanted to get the case done without teaching. Must have been a nasty one.

 

[Noyac]

If you can’t do a trans tracheal injection, ENT’s going to have a problem with a slash trach as well. If things were impossible, and you couldn’t do a fiber for some reason, awake trach seems like the only option.


--
Il Destriero

Except that it wasn’t really an option. I couldn’t even get in there to do a transtracheal injection. There was no way you were going to get instruments in there.

 

[Noyac]

Retrograde wire wasn’t even an option.

My thoughts were, if I can’t get the tube then we cancel the case and refer to tertiary center with CPB/ECMO capabilities.

 

[Noyac]

My only concerns with. Continuous spinal is that most of these pts have Ankylosing Spondylitis and you may not even be able to place a spinal.

That’s just another reason why this wouldn’t fly on the boards.

 

[Noyac]

Except that it wasn’t really an option. I couldn’t even get in there to do a transtracheal injection. There was no way you were going to get instruments in there.

I just thought of something. Maybe I could have gotten in there to do a transtracheal with a spinal needle!

 

[deleted59964]

Well of course. But this pt had a recent staph infection which was treated. And the plan was to go to ICU post-op intubated at least overnight. I wanted to attempt an oral airway in order to avoid a possible sinus infection if for some reason she remained intubated for a few days.

well done and well played sir.

I've thought about this for a while now ... great case.

I guess if nasal looked easier I'd probably have done nasal.

At the end of surgery hopefully her neck is in a more favourable alignment maybe it'd be possible to put a tube exchange catheter down the nasal tube, then oral asleep fibre optic ... once you get a view of the cords with the scope withdraw the nasal tube over the tube exchange catheter just far enough so it's out of the way. then pass your scope through the cords before withdrawing your tube exchange catheter and then railroad your oral tube over the scope.

 

[2Fast2Des]

that is messed up. ridiculous. was this one of those states that allow CRNA to practice independently?

Unfortunately due to billing, optimization of supervising ratios and CRNAs complaining that residents get preference for the good cases leads to situations...

 

[Psai]

Unfortunately due to billing, optimization of supervising ratios and CRNAs complaining that residents get preference for the good cases leads to situations...

Residents should always get preference wtf are they smoking?

 

[Man o War]

That crap would never fly anywhere I’ve trained or worked. Not even in the .mil


--
Il Destriero

Me neither- I’ve never seen some s@@t like this!
Which is why they look at you like a deer in headlights in the real world when they get a less than optimal airway.

 

[IlDestriero]

Unfortunately due to billing, optimization of supervising ratios and CRNAs complaining that residents get preference for the good cases leads to situations...

That shows weak leadership. The squeaky wheel doesn’t get the grease to the detriment of resident training.
Where I am the CRNAs do get some good cases, because there are so many decent cases and not enough fellows in the ORs. They even may get assigned to one over a resident, but a resident doesn’t need to know how to do some of those cases anyway. They’re not going to be at a Childrens Hospital doing crazy cases without a fellowship. That’s different from the above noted situation.


--
Il Destriero

 

[pgg]

Unfortunately due to billing, optimization of supervising ratios and CRNAs complaining that residents get preference for the good cases leads to situations...

Not OK.

This is something ACGME ought to hear about in program reviews.

 

[Noyac]

Pre and post images.

 

[deleted162650]

That must have been a fun spinal cord stim placement.

I’m diggin the glasses in the post-op film. 😎

 

[Noyac]

That must have been a fun spinal cord stim placement.

I’m diggin the glasses in the post-op film. 😎

Dude, WTF!
Nothing gets bye you.

 

[frosted2]

How long was the surgery?
I'd **** a brick if I saw an airway like this on the ambo

 

[Noyac]

How long was the surgery?
I'd **** a brick if I saw an airway like this on the ambo

About 8 hrs


Which brings up another discussion, how would yo7 do this case after the pt survived the intubation of course.

 

[Noyac]

That must have been a fun spinal cord stim placement.

I’m diggin the glasses in the post-op film. 😎

The spinal cord stimulator May have been the cause. It was after the placement that the pt had shooting pain with cervical extension. So she never extended her neck and eventually became frozen in that position.

 

[frosted2]

About 8 hrs


Which brings up another discussion, how would yo7 do this case after the pt survived the intubation of course.

Me personally? On the ambulance? I'd go for a nasal tube. If that was unsuccessful, I'd use a bougie to try and snake a tube in (both orally and nasally). If neither of those things worked, I start praying to the one above and haul on to the ER and have anesthesia ready when we got there.

That'd be a bad day on the bus.

 

[chocomorsel]

The spinal cord stimulator May have been the cause. It was after the placement that the pt had shooting pain with cervical extension. So she never extended her neck and eventually became frozen in that position.

That sucks.

I can't believe they wouldn't remove that stimulator before she became frozen. I have been around in removing a few pain stimulators.

I do remember patients having these weird motor/seizure like activity associated with pain immediately after placement from one of our surgeons. We ended up removing the stimulators thinking that the patients had a "weird" reactions to them.

Come to find out, the reps had them dialed up all the way to the most stimulating settings in the OR and left them there instead of turning them down. Don't remember the exact details, but......

It was totally weird to see them doing these weird contortions and writhing in pain right after surgery. Immediate take back.

 

[chocomorsel]

About 8 hrs


Which brings up another discussion, how would yo7 do this case after the pt survived the intubation of course.

Propofol and Sufenta infusion with whatever little gas I was allowed to give for SSEPs/Motors. Steroids.

Keep them intubated post op, but you said that was the plan. Blood/FFP in the room with known available platelets. A- line and two big Peripheral lines. Lots of bleeding in these cases sometimes. Mostly, if not much blood loss, it's a lot of twiddling your thumbs and trying to stay awake. I remember starting some of these long ass spine cases as 2pm in my old job. Sucked a lot.

That's all I remember.

 

[deleted162650]

About 8 hrs


Which brings up another discussion, how would yo7 do this case after the pt survived the intubation of course.

I’m not sure the case is much different than any other big fusion once you get the tube in. I’m curious how you positioned her though?? I’m thinking pins is the only way to do it.

Please tell me you went full rockstar and extubated on the table.

 

[MirrorTodd]

Pre and post images.

JFC!

 

[Noyac]

I’m not sure the case is much different than any other big fusion once you get the tube in. I’m curious how you positioned her though?? I’m thinking pins is the only way to do it.

Please tell me you went full rockstar and extubated on the table.

Yep, went full RockStar. I pulled the tube as we rolled her supine all in one motion just to show my stuff. But then I slipped it back in with a MAC3 grade 1 view before taking her to the ICU for further recovery. 😉

 

[chocomorsel]

Yep, went full RockStar. I pulled the tube as we rolled her supine all in one motion just to show my stuff. But then I slipped it back in with a MAC3 grade 1 view before taking her to the ICU for further recovery. 😉

Cowboy!!!
Go ahead, with your bad self!!!

 

[2Fast2Des]

Residents should always get preference wtf are they smoking?

Depends on who is doing the scheduling, if the attending assigned cares enough. The other option is having to scout cases every day to request to be in, but doing that every day for 4 years can be tiresome and since cases get moved around won't always work