In surgery, as in many fields of endeavor, it is never a good idea to panic. We strive for equanimity, the ability to remain calm and effective despite surprising or difficult circumstances. We never curse or say “Oops” after cutting the wrong structure or getting sprayed in the face by an unanticipated fountain of blood, for instance. The well trained surgeon merely says, “Well, that’s interesting,” or something similar. (Anesthesiologists know that when the surgeon says that something is interesting, it’s time to start transfusing blood pretty rapidly.) This particular personality trait was drilled into me throughout my surgical training, but never so effectively as by my senior resident and mentor, Ben Jeffries. Ben at the time was new to our program, having been tossed out of the Johns Hopkins surgery residency as part of the pyramid system they use and because he wasn’t a dick. You gotta be a dick if you’re going to succeed in the Hopkins surgery program. Fact. Anyway, Ben was a skilled surgeon and a positive influence in our program after he joined us in his third year of training. We still stay in touch.
A lot of what we do in surgery is done because that’s the way we do it. Of course, what we do is based upon careful scientific research. How we do it, however, is often done because we do it that way. Not always the best way, as it turns out.
The surgical procedure of tracheostomy is frequently performed upon critically ill patients in the intensive care unit who require long term support on a ventilator. It is dangerous and uncomfortable to maintain a breathing tube down the patient’s throat for longer than a week or two, so the patient is eventually scheduled to undergo the routine procedure of making a surgical opening in the windpipe, the trachea, and inserting a special tracheostomy tube. This tube is much more comfortable for the patient and is less prone to becoming blocked or dislodged. Research has proven over and over again that it is a valuable surgical procedure.
Research has not clearly addressed just how this valuable procedure is to be accomplished, however. A couple of options are available to the surgeon about to embark upon the procedure of tracheostomy. The safest and most enjoyable manner for all concerned, surgeon and patient, is to perform the tracheostomy in the operating room. Everything is more fun in the OR. In the OR, the surgeon is surrounded by skilled, helpful personnel, a trained anesthesiologist is carefully managing the critically ill patient’s respirations and sedation, the lighting is optimal, and every tool one can possibly need is readily available. So, of course, we often don’t do tracheostomies in the OR. We frequently perform this surgical procedure in the patient’s bed in the ICU. This is much more efficient–which means, it’s much cheaper. Can’t honestly think of any other reason.
As part of my surgical training, I rotated through a very busy community hospital. This hospital had a large, pleasant Pulmonary Intensive Care Unit, the PICU, which cared for patients who required ventilator support because of emphysema, lung surgery, or other severe pulmonary illness. These patients often required tracheostomy. On this occasion, I was a second year resident, having been a doctor for about eighteen months. My service was consulted to perform a “trach” on an elderly, robust man who had been requiring high levels of ventilator support for over a month. He was overdue for the procedure and our attending, an ebullient thoracic surgeon named “Tex” Dallas, felt we should get this done ASAP. Tex was a skilled, flamboyant thoracic surgeon, who had the practice of wearing a cowboy hat while doing hospital rounds. Nobody knew why he had to leave Texas, but he cut a loud and colorful swath through the Midwestern surgical society while he was here. Tex told Ben, my senior resident, to get the trach done “today” in the PICU and he’d staff the procedure. Which meant that Tex would be flirting with the PICU nurses (one of whom would go on to become a skilled physician and my wife) while we did the procedure at the bedside.
Ben and I prepared the patient for his tracheostomy by setting up the instruments that we borrowed from the OR. We recruited the Respiratory Therapist to help, as there comes a point in the operation when the tube already in the trachea and supporting the patient’s respirations, called the endotracheal tube, needs to be removed from the patient’s mouth so that the surgeon can put in the new tracheostomy tube. This role is usually filled by a trained anesthesiologist or anesthetist in the OR, of course. We, as I mentioned, weren’t in the OR. But the Respiratory Therapist was enthusiastic and anxious to help, especially since she’d never seen this done before. Ben and I instructed her on when and how we’d like her to remove the tube when we said so. She nodded enthusiastically. This was exciting.
Ben and I got started. The patient was cooperative as we had given him a small dose of sedative, his breathing being entirely supported by the ventilator anyway. The operation started well, with Ben letting me do everything while he held the tissue out of the way with retractors. This was critical, as the patient had a bull like neck and the hole to reach his trachea was therefore deep and narrow. And since we weren’t in the OR with all the special lighting, a little dark, as well. Tex was sitting at the nursing station, which was around the corner from where we were working, watching the patient’s vitals on the monitor and trying to convince the stunningly beautiful nurse to join him at lunch after the procedure. (Did I mention that I married the woman about a year later?) The operation was going smoothly and we had the surface of the trachea cleanly exposed in the depths of the wound. Ben turned to the Respiratory Therapist standing at the patient’s head, watching with fascination. “Ready to remove the tube?” he asked her. She nodded enthusiastically.
At this point, it is necessary to carefully cut into the trachea and create a small window in which to insert the new tube. As I began this maneuver, Ben suggested that I take care to avoid the small blood vessel just adjacent to the point we had picked for our window. While it wasn’t a conscious decision (in the dark depths of the wound I couldn’t see from my angle what he was referring to), I ignored his advice and instead severed the vessel just as I cut into the windpipe. The wound immediately filled with blood. “That’s interesting,” Ben said. I was speechless. “Okay, it’s out,” the Respiratory Therapist said. We both turned to look at her. She was smiling as she displayed the endotracheal tube she had removed from the patient. “Really?” was all Ben said.
Ben and I bravely suctioned and retracted in our efforts to expose the trachea so that we could get a tube into the patient. At this point, the patient was not receiving any oxygen or any type of respiratory support. He had, at best, a couple of minutes to live unless he was reconnected to the ventilator. The blood welling up from the wound became progressively darker as we struggled. Listening to the EKG monitor, we could hear the patient’s heart rate slowing as he lost oxygenation.
“You boys okay back there?” Tex called from around the corner, watching the pulse slow on the monitor at the nurse’s station.
“Just fine, Dr. Dallas,” Ben called back. We were not fine. We were completely fucked, actually. The wound was so deep that we needed two hands to hold the tissue out of the way, leaving only two hands to suction the bleeding and operate–about two hands short of what we needed. We couldn’t see shit. The patient was rapidly deteriorating. The Respiratory Therapist was looking over, fascinated. “That’s a lot of blood,” she commented helpfully. The patient’s heart rate continued to slow.
“Boys?” Tex called from the desk.
The patient’s heart stopped. He was in arrest. I looked up at the monitor. Flatline. Ben took the tracheostomy tube from me and jabbed it blindly into the wound. “Ho-ly Shit!” we heard Tex shout from around the corner. Ben hooked the tube up to the ventilator, having no idea whether the tube was actually in. It must have been in place, however, because in the next few seconds the patient’s heartbeat reappeared and quickly came up to normal. Tex came skittering around the corner and pulled up short at the foot of the bed, looking at the monitor.
“That’s pretty weird,” Tex said, scratching his head. “Poor bastard was looking a little dead there for a bit. That monitor must be fucked up. You boys all good here?”
“No problem,” Ben said. “All good.”
Tex bent down to pick up his hat that had flown off as he ran around the corner. As he bent down, he noticed the half-inch deep puddle of blood under the bed and lapping at our shoes.
He straightened up, smiling. “Nice job, boys, nice job. Now don’t make that pretty young nurse have to clean up after you boys now, you hear?”
“Of course not, Dr. Dallas. We’re better than that.” Ben smiled at him.
Not much better, though.