We are such stuff
As dreams are made on; and our little life
Is rounded with a sleep.
Shakespeare, The Tempest Act IV, sc. 1, 156-158
I imagine a “rounded” sleep is a smooth and easy one, devoid of rough awakenings. It would be nice if my dreams were “rounded with a sleep,” but mine are jagged ones. And, more often than not, they are about my work. It is the particularly stressful operating room cases I revisit again and again in recursive loops of dread late into the night.
I am an anesthesiologist practicing in San Francisco, providing care at several hospitals and surgery centers. It was at the old Children’s Hospital that this terrifying tale of a pediatric airway emergency took place.
New Dr. Salber‘s Review Notes appear at the end of the story.
To this day, I dream of this case even though it happened many years ago. The memory of it will startle me awake. It troubles my thoughts and makes my heart race. My breaths come sharp and quick until I calm myself and sink into my pillow. Then, I try to go back to sleep before the morning arrives far too early and far too soon.
The well-run operating room
The buzz of activity of a well-run operating room is a sight to behold. Wheeled carts laden with packs of instruments wrapped in sterile blue paper are delivered by attendants straight from the autoclave. Machines and monitors, X-Ray C-arms, and operating microscopes are ferried from one room to another.
Surgeons, nurses, and scrub techs walk briskly and purposefully down the corridors dressed in blue-green scrubs and cover-gowns in a coordinated and efficient dance. Patients come and go, shepherded safely from awake to asleep to awake again in precise fashion by the anesthesiologists at the head of each OR bed.
On this particularly busy day in the middle of the afternoon, the operating rooms were in full swing, filled with the usual variety of elective cases. In Room 1, there were urology cases. Rooms 6 and 7 were booked with orthopedics, and Room 9 held a long list of breast biopsies. I was in Room 2 doing pediatric ENT cases – ear tubes, adenoids, and tonsillectomies. In my dreams, I am transported back to that room…
The list of elective surgeries diminishes as one after another is completed and erased from the master schedule-board. It is a smooth human assembly line as patients walk over from Admitting and are ushered into the holding area. They wait, dressed only in their paper, ill-fitting Bair-Hugger gowns1, to be seen by the circulating nurses and the anesthesiologists before entering the OR.
The gowns are ugly but effective, and they are disposable. They are a distinct improvement over the traditional tied-in-the-back, thin cotton gowns. These are designed to allow hot air from an external blower to circulate throughout the gown in built-in baffles, enveloping the patient in warmth to ward off the cold exposure of the operating room.
A pediatric airway emergency is on the way
Late in the afternoon, the smooth routine of my day is disrupted. A call comes from the
emergency room that immediately puts a hold on my next scheduled case. A one-year-old child is being rushed directly from the ambulance bay to the OR for a foreign body airway obstruction.
This is unusual – I typically go down to the emergency room to evaluate the children first, but I am told that I don’t have time, as this one is in severe distress and already on the elevator.
With a sinking feeling, I run back to my room to prepare for the case. Beyond what I have just heard, I know nothing else. I don’t know what the child may have swallowed or how long he has been in trouble.
Even though I have been well trained for this exact situation, my stomach twists, my chest tightens, and I breathe a little faster, fearful that this may end badly.
My greatest fear was my children choking
Pediatric airway obstructions are emergencies of the highest order. Ask any anesthesiologist who is also a parent to pick their greatest fear while raising their young children. Mine was choking.
Despite an outward appearance of being calm and efficiently competent in emergencies, I can be a fairly anxious individual, especially where my family is concerned. They have had to endure countless lectures from me on the “forbidden” foods of childhood.
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No raw carrots, peanuts, apples, hot dogs, steak, hard candy, and so forth, until the back molars are established, or the child has graduated from college, whatever comes last. And, definitely, no talking, laughing, singing, running, or walking around while eating.
Once at a birthday party for a friend of my eldest son, Henry, the other parents watched with both shock and embarrassment for me as I put a dramatic, hyperventilating, immediate end to a game of “Chubby Bunny.”2 If you have never heard of this game, consider yourself lucky. Chubby Bunny is a contest where the children compete to stuff as many marshmallows as possible in their mouth, one by one, and repeat the words “Chubby Bunny” three times.
To me, this game is tantamount to attempted child homicide. It is a prima facie example of gross parental neglect, justifying a call to Child Protective Services.
After startling all of the kids silent due to my sudden and very dramatic outburst, I made them immediately spit out the sticky gobs of marshmallow that were distending their cheeks like chipmunks.
I sarcastically and angrily asked the stunned host mother, “How about a game of
William Tell, or knife-throwing next? Do you have any Lawn Darts handy? Or let’s just tie up the kids and toss them in the pool to see which one can hold his breath the longest?” Obviously, it took a long time for me to be invited back to birthday parties after that.
Pediatric anesthesiology mantra: Airway, Airway, Airway
From day one of residency, anesthesiologists are taught a simple algorithm: “ABC – Airway, Breathing, Circulation.” In pediatric anesthesiology, we are taught an even more succinct
algorithm: “AAA – Airway, Airway, Airway.”
It doesn’t take long to suffocate when the airway is obstructed. An adult has about three to four minutes after cessation of breathing room air before suffering irreversible brain damage. A toddler may have even less time due to the nature of their more rapid metabolism and high demand of the developing brain for oxygen.
This is why the importance of maintaining a patent airway in order to breathe is drilled into us before we even get to touch our first patient. A great deal of our knowledge and equipment is tailored to achieve this goal.
We learn how to assess an airway preoperatively to judge the potential risk of losing it once an anesthetic begins and the patient is rendered unconscious and unable to breathe unaided.
We know how to manipulate the jaw to tighten the neck muscles to support the pharyngeal structures and facilitate breathing.
And we know many ways to re-establish an airway once it’s lost, including performing an emergency cricothyroidotomy,3 literally cutting a hole in the neck. Mostly, we know how to do these things in a logical sequence, as rapidly as possible. Time is of the utmost essence.
Treating airway obstruction
Treatment of an airway obstructed by a foreign body can range from a simple slap on the back to a Heimlich maneuver or even a manual extraction of the offending agent with a finger. The latter, however, can potentially make things worse by further pushing whatever is causing the blockage deeper into the larynx, cutting off the small amount of air that is getting through.
Sometimes anesthesiologists use a special type of curved grasper called a Magill Forceps4 to pluck an object from the back of the throat after using another instrument called a laryngoscope,5 a lighted retractor that holds down the tongue, thus allowing us an unobstructed view of the larynx and vocal cords. We use laryngoscopes to “intubate” patients – that is, passing a tube through the vocal cords into the trachea to establish a secure channel through which we deliver oxygen and anesthetic gases.
Face to face with a full-on emergency airway obstruction
As the elevator doors open, I see the huddle of doctors and nurses surrounding the crib of this small child being manually ventilated with oxygen, a clear plastic mask covering his mouth and nose. I can hear the awful high-pitched squeal and wheeze of the oxygen escaping around the edges of the mask rather than being delivered to the lungs. I am afraid that this will not be one of those quick and lucky situations.
The child is decidedly blue, pale around the mouth and eyes. His small, fragile body is slack, without muscle tone. We rush into the operating room and place him on the table. The anesthesia tech quickly transfers the cables from the transport monitor to my machine. Then, I take over the task of attempting ventilation.
I look up at the monitor that measures the percent oxygen saturation of circulating hemoglobin, the molecule that carries oxygen so efficiently to the rest of the body. I see a number alarmingly in the low twenties. It should be in the high nineties.
The lower the number, the lower the pitch the machine makes with each beat of the heart. This pitch portends doom. The heart rate is also steadily decreasing, an ominous sign that this child is about to have a full cardiac arrest.
The child is about to have a cardiac arrest
I inject atropine and then epinephrine into the IV already established by a skilled EMT on the way to the hospital. Then, I quickly look inside his mouth and throat with my laryngoscope and see nothing but mucus and blood. It appears that someone had looked before and stirred up a mess.
As the oximeter’s pitch drops even lower, I tell the nurse to begin chest compressions. And, I ask the surgeon to prepare to cut the neck to try and establish a surgical airway. This is difficult when the patient is an adult, but it is much harder when it is a small child. I force myself to breathe slowly and stop my hands from shaking.
–One more quick look
As a desperate last effort, I decided to take one more quick look inside the pharynx with my laryngoscope. This time I see something different. There’s a small glint, silver and shiny, reflected in the bright fiber-optic light from the tip of my laryngoscope blade. It is the thinnest visible edge of a dime.
The rest of it is buried in the swollen tissue, mucus, and blood obstructing the vocal
cords. It is wedged tightly by its serrated edge. I can understand why the paramedics and maybe the ER doctor missed it. Taking the pediatric Magill forceps in my free right hand, I fix my gaze on the tiny crescent moon of the edge of the dime. I don’t want to lose sight of it.
Above the background noise, I hear the pulse oximeter’s tone bottoming out, past the point where the numbers are even accurate. The child is purple and mottled. A full arrest is seconds away.
–A rush of stale air
I’ve stopped shaking, and my hands are surprisingly steady. I aim for the small, barely perceptible glint and feel the solid metal between the jaws of the forceps. Gently and carefully, I pull it out. A rush of stale air follows.
The small coin had acted as a one-way valve, trapping the depleted air behind it. Now that it is gone, I can freely ventilate the lungs with pure oxygen.
After an agonizing number of seconds, I hear the oximeter’s pulse and pitch recover along with the oxygen saturation. The pallid limp child finally and mercifully becomes pink with life-giving, fully oxygenated blood. He begins to cry.
The memory of this pediatric airway emergency brings back feelings of dread
To this day, even awake, I cannot think about this case without feeling the familiar tightness in my chest, as well as a stomach-dropping sense of dread. Even though I know that this child made a miraculous full and symptom-free recovery, and even though I have had the opposite experience of having patients die in the operating room who were critically ill or traumatically injured and not expected to make it, this was the closest I have ever come to losing someone… a child, like this.
Working as we do in this environment, at the edge of the precipice, one never knows if the next elevator will be the one that opens to replay the nightmare over again.
My children are grown up now and no longer live with me. But, when they were younger and still in the safe embrace of my old house in their bedrooms down the hall, I couldn’t help myself. I would awaken, startled from my restless dreams in the deep hours of the night, sit up and listen intently, staring into the dark.
I’d swing my stiff legs out of bed and walk as quietly as I could down the hall to my daughter’s room. Pausing, I stand at her door for a moment, hovering, watching her uncertainly. Then softly, I go to sit on her bed and gently cup my hand near her mouth, reassured. Slowly, deliberately, I would count each warm breath as I stroked her precious face. One…two…three…four…
Health Resources for Pediatric Airway Emergencies
- Pediatric Choking Emergency Management6
- Pediatric Advanced Life Support and CPR7
- Heimlich Maneuver on Toddlers and Children (Video)8
- Poison Center Information9
- 3MTM, Science Applied to Life – Bair Hugger Patient Warming Gowns
- Wikipedia, Chubby bunny – https://en.wikipedia.org/wiki/Chubby_bunny
- John C Sakles, MD, Emergency cricothyrotomy, UpToDate, https://www.uptodate.com/contents/emergency-cricothyrotomy-cricothyroidotomy
- Wikipedia, Magill forceps – https://en.wikipedia.org/wiki/Magill_forceps
- Wikipedia, Laryngoscopy is endoscopy of the larynx – https://en.wikipedia.org/wiki/Laryngoscopy
- Stanford Children’s Health, How to Help a Choking Child – https://www.stanfordchildrens.org/en/topic/default?id=how-to-help-a-choking-child-1-197
- American Heart Association, CPR & First Aid Emergency Cardiovascular Care,AHA Pediatric Training for Healthcare Providers https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/pediatric
Performing the Heimlich Maneuver on a Child or Infant, YouTube Video – https://www.youtube.com/watch?v=aXaLc-AwX2g
- Health Resources and Service Center (HRSC), Poison Centers – https://poisonhelp.hrsa.gov/poison-centers
Medical Reviewer Notes by Dr. Salber
Dr. Swisher captures exactly the rapid transition from calm to terror that happens when even the most highly trained and experienced doctor is faced with a dire emergency, such as a pediatric airway emergency, that requires immediate intervention. I know because that was my life too when I practiced emergency medicine at a very busy ER in San Francisco.
One minute I could be joking with the nurses while moving from one routine case to another. Colds, flu, lacerations, sprains, infections…all things that could be dealt with without breaking into a sweat.
But the sudden arrival of a toddler in acute distress and my heart would race and my breathing quicken – just like it’s described in this story. In fact, when I first read this story, my pulse got fast, and I experienced a sense of foreboding. It was like being in the ER again. For those of you who haven’t had this experience, I can promise that this kind of work is exciting and rewarding. It is also the stuff of nightmares.