Wrestling With The Reaper

It's not too often that I am in a life and death struggle for a patient within a few seconds of a call. The other night was an exception.

Walking from one department to another at about 2am, I was innocently thinking about what part of my "lunch" I would eat once I got there. My wife had packed my favorite salt and vinegar chips, and my mouth instantly started watering for them. As soon as I walked into the empty surgery staff lounge, the local overhead paging system broadcast what sounded like a pretty stressed out nurse, asking for my help by name in OR #4 STAT!

What struck me as odd was the fact that I had just randomly walked onto the unit, and seconds ago would not have heard the page. I had no time to wonder about the coincidence, however, since this was most definitively a very serious problem. A couple of things about that page lead me to think the proverbial shit has hit the proverbial fan.

One, I am the OB PA at night, and everyone working at the hospital knows my position is dedicated to emergent C-sections. They can happen at any time and must often be done in minutes. Therefore I am not permitted to scrub on regular surgery. This may sound strange, but I can't be dedicated to two department's possible emergencies. I can't be stuck in an "emergency" appendectomy while a woman is crashing who needs a section. The surgical team leader must give any scrubbed-in member of the surgical team verbal permission to break scrub. Doing so without permission (say, out of anger or exhaustion) is not only grounds for termination, but grounds for losing your job license. It's a legal offense that is considered abandonment (of the patient's care). So I knew that requesting me to come into an OR for a case STAT must be for a pretty damn good reason since it is technically against my job description and could land me in trouble with administration.

Two, the 1st call surgical PA, Janeen, who was called in from home to actually do the case, was new and on her first night working solo with a surgeon. This meant what was going on in there was pretty dicey, and not within the skill set of a rookie assistant.

Three, my pagers starting lighting up, and the hospital wide overhead speakers called for the OB PA to report to OR #4 as I was putting on my mask. This to me meant that whoever called out for me initially then decided to use every possible method of summoning my assistance.

There are really only three things that warrant a distress call like that - the A's, the B's and the C's. Airway, Breathing and Circulation. A patient must have these three things or they are going to die relatively quickly. Typically in surgery the C is the culprit, so I fully expected an uncontrolled bleed as I ran into the room, or a coding patient. It wasn't.

As soon as I ran in, I realized the patient wasn't moving air. There were the signs that a struggle had taken place. Usually the start of a case looks pretty orderly, with the team members at their designated positions, arms folded, standing still around the OR table like some macabre ceremony with a lit up body on the altar. This time the routine had been broken for some reason. The 5 team members were visibly panting and in various poses as the patient lay there on the table squirming, and the surgeon was using his scalpel to cut down to the trachea cartilage. The anesthesiologist was masking him with one hand, and squeezing the bag with the other, but the air-filled mask was just cheek farting as the much needed O2 was meeting a dead end somewhere in the patient's mouth or throat, and slipping out the sides. The tech was draped over the legs, which incidentally were half off the table, keeping him from squirming. The rookie PA was holding one of his hands away from his neck while ineffectively retracting the site for the surgeon.

He had been admitted for a drainage of a pharyngeal abscess (throat infection gone bad), and had been acting strange at home. Good thing the ENT surgeon sensed something wasn't right, and decided to do it in the OR and not the ER as usual.

Apparently, I later learned, this 280lb linebacker of a man had suddenly seized as soon as they got him onto the OR table from the gurney (which was still in the room, tipped over on the floor). The circulator RN had somehow been scissored between his legs off the end of the table as he was seizing, and it took some strong-arming from the rest of the team to break her free. She then staggered to the phone and called out for me. Her two words for me when I barged in were, "GLOVES!! HELP!!", as she pointed to the surgical site. These words were actually all she needed to say.

I just put on some nonsterile gloves and took over for Janeen, who was understandably a little stunned and out of breath. The Anesthesiologist kept saying, "I don't know what happened! I don't know what happened!", and was pushing Diprovan into the IV as fast as he could. The patient, I should mention, did not appear conscious or reactive to the pain of surgery, but still had positive (and strong) muscle tone. It was pretty obvious he was in laryngospasm, where the muscles that can close off the top of the windpipe decide to clamp shut, just as if you were drowning. He was trying very hard to breath on his own to no avail, as the chest and abdomen kept contracting violently.

I asked the tech for another retractor, and pulled the hole wider for the surgeon. I had one L-shaped retractor called an Army/Navy in the hole on one side and another Army/Navy on the other side. The distance from the skin surface to what we were hoping would be the trachea was about 2.5 inches deep, and about an inch and a half in diameter. Needless to say we were working on a big fat neck in a little deep hole. It kept filling up with blood, too. Working with the surgeon and giving Janeen a few instructions on what to hold, we finally got a relatively clear view of the bright white tracheal cartilage. I am not sure the surgeon knew exactly where we were on the trachea, but it wasn't the time to explore. His pulse ox (a finger monitor that measures oxygen saturation in the bloodstream) had stopped it's baritone beeping and gone silent.

He asked if we were ready and I instinctively crouched to the side of the patient while still holding exposure, and waiting for the stab. Judging by this guy's thoracic retractions, I anticipated some pretty forceful breaths coming out of that little hole once the trachea was cut. As I got as low as I could while holding the two retractors, I came face to face with the patient's shoulder tattoo. In plain black ink on his massive shoulder was drawn a sinister image of the Grim Reaper, with skull face, black hood and scythe. How coincidental, I thought, that this man was currently dying, and all I really know about his history was that once upon a time he decided to have death scarred into his left shoulder.

As I thought about that, there came a surprisingly loud hissing and spurting sound from the surgical field. I glanced up to see a fine pink mist geysering up from the man's neck, with drops of more blood flying to the ceiling. The face of the surgeon was covered in little red polka dots and his eyes squinted through the red haze. Janeen had her head turned, but every surface with an unobstructed line to the the surgical site was hit with bloody splatter. My bare forearms got hit, and the vaporized blood formed a pink fuzzy coating on all of my arm hairs.

With the sudden rush of oxygen, the patient's muscles sprang to life again. I had to forcefully resist the squirming man's neck in order to allow the surgeon good visibility. The tired circulator had to get back into the game and start keeping the patient still.

The sound was impressive. We had to talk at a yell in order to be heard over the loud whistling and hissing coming from the new little hole in the trachea. With every massive inhalation, there was the snake-like hiss, and every exhale there came the rough whistling, interrupted by violent spasms of coughing and sputtering; the blood from the incision trickled into the new tracheostomy and then ejected into the air as droplets and mist. At some point during the case, the cartilaginous tissue of the trachea began to actually honk under the forceful passage of air. It was sort of like cutting a slit into a reed or a piece of thin bamboo then blowing as hard as you possibly can through it, making a loud and offensive goose call. It was a barrage of honking, hissing and whistling.

We eventually had to use a little pediatric tracheotomy tube since the adult size wouldn't go in despite the surgeon's best effort to mash it into place. I remember there was a point when it didn't look like a tube was going to fit, and the case sort of hit a standstill. We weren't getting anywhere in our efforts and were starting to genuinely fatigue, but the RN produced a little pediatric tube, and things started to work. Once the tracheotomy tube was in place, things were able to calm down considerably. I took that moment to get out of there. The patient was getting good general anesthesia, and the tube just had to be sutured into place - I left Janeen to assist.

After attending my duties elsewhere that night, I learned that the patient spazzed out again on wake up. He shot up like a jack-in-the-box and immediately thrashed about, clawing at his throat. This time the Anesthesiologist was ready, and sedated him well enough for an uneventful recovery.

When younger people start to circle the drain, they usually do so with effort. It's almost like a 100% attempt to die, or perhaps 0% effort to fight - so drastic things must be done to save them. You don't see that with old people. Old people fade into death, often times surprising health care workers in their prolonged descent despite horrendous numbers that seem impossible. I knew somebody quite close to me who lived on for 6 good months at 10% ejection fraction. Our hearts empty 60% (if I remember correctly) of its blood volume with every beat, and the books say anything below 15% is noncompatible with life. But the body adjusts to survive if given enough time.

We still don't know why this guy seized the way he did, but he certainly seemed like he had a mission to die. Everything the anesthesiologist did was to no avail, every attempt to keep him still was met with forceful resistance, and the surgical site was a messy, hazardous combat zone with sharp instruments and blood on the field and in the air. When I left the room, I glanced back to see the weary circulator nurse tucking his huge tattooed left arm back onto the table at his side while the team worked - it had of course broken free and was laying limp over the edge for a while.

That's the last I saw of that patient - an ugly tattoo of the Grim Reaper himself, complete with the scythe and the black hood. In the space of ten minutes I had become sweaty, bloody, tired and stunned. And that hideous, grinning skull was staring back at me with empty eyes as I walked out of the room.