ADULT TRAUMA CODE 1, FIVE MINUTES OUT BY AIR.
A young man was riding his motorcycle, swerved to miss a log in the road, and was flung headfirst into a concrete barrier. He was acting funny when the medics arrived on scene and quickly became so combative that they had to sedate him for safe transport to the hospital.
This is a telltale story for a head injury, and one that can be terrifying for the medic ground crew. It often takes multiple paramedics and firefighters to restrain these patients so that an IV can be placed and sedative medications can be given. In this case, he rapidly decompensated and required a breathing tube.
Intubation is not an easy procedure in the best of circumstances. Anatomically, the human airway is positioned above the esophagus, requiring specialized instrumentation to provide clean line of sight. The airway itself can be unbelievably hard to visualize; so much so that the field of emergency medicine has devoted entire lectures, conferences, and books to airway management.
The paramedic was unable to place an endotracheal tube; always a bad sign. He placed a specialized oxygen mask on the patient, flipped on his lights and sirens, and sped to the hospital as quickly as possible.
And thus, I find myself staring at the most difficult airway I've ever seen. The patient weighs about 280 pounds. His tongue is so swollen that I'm not even convinced I can get a laryngoscope past it. Vomit is everywhere, obscuring my view. Blood pressure is dropping, heart rate escalating. An entire trauma team is standing around with scalpels, waiting to cut into his neck in morbid anticipation of my failure.
Always pause, gather yourself. Ten seconds to focus.
Primary airway equipment ready, the backup in case it goes wrong, the backup for the backup. The room goes quiet. All eyes on you. It's an odd feeling, holding a life in your hands. This man is not breathing and you need to help him. Fail and he dies.
Things speed up as you grab the laryngoscope. The surgeons crowd around the neck, like bloodthirsty sharks waiting to take bites of flesh. They know that if you can't get the tube in place, they'll need to slice down to the windpipe to place it directly. It's a last resort.
Primary equipment fails. You switch to secondary. It feels like minutes but only seconds have passed. Your arm is shaking; he's a big guy and it takes muscle to lift things into alignment.
Secondary equipment fails. The surgeons prepare for the cutting; a messy, bloody procedure that leaves a jagged scar. Voices rise, a chaotic, frantic cacophony. You grab your third and last option. Your mouth is dry, your heart pounding. Suddenly, a small view of the trachea.
Tube to my hand, please, I can see the airway.
The room goes silent. Someone puts the endotracheal tube in your hand and you place it gently in position. You straighten up and realize 20 people are watching you. Your hands are shaking from the adrenalin. He's alive.
A glance at the clock. Only 1 minute has elapsed.