Saturday, April 03, 2010

high-pressure job

Reading this story (from the book "Source of Power: How People Make Decisions) makes me glad that I'm not a doctor, and gives me newfound respect for doctors.

Norman Berlinger (1996), a physician, describes a case in which a fetus was diagnosed as having a large cystic hygroma, a tangled mass of lymph vessels, on the side of his neck. The sonogram suggested that the hygroma had grown inside the neck, wrapping around the trachea. If that were indeed the case, without emergency treatment the infant would die shortly after delivery because his air passage was blocked. As long as the fetus was in the uterus, receiving oxygen from the umbilical cord, he was safe. A cesarean section was scheduled for the following day.

During the delivery, Berlinger was going to determine if the baby was able to breathe on his own. If he could not, Berlinger's strategy was to intubate the infant, guiding a slender tube down his throat to clear a breathing passage. But that might be impossible if the hygroma had grown so large as to obscure the opening of the windpipe. In that case, it might be necessary to do a tracheostomy—piercing the trachea and inserting the breathing tube into it. That would also be difficult. A tracheostomy is easy with an adult, but an infant's trachea is less than a quarter-inch wide, and soft and spongy. It is difficult to find. And other complications were likely. The incision would probably cut into the hygroma, possibly leading to infection of the lymphatic cysts and serious problems with abscesses in his chest. Moreover, the tracheostomy would have to be done under crisis conditions. It would be a last resort.

Upon delivery the infant gave a cry, suggesting a clear breathing passage. But then the passage sealed up. The infant could not even grunt. One of the nurses suctioned the infant's mouth and nose and placed him in front of Berlinger. Berlinger remembered an earlier situation, when he had been called in to operate on a young man who had run his snowmobile into a strand of barbed wire strung above the ground to discourage trespassers. The wire had jumbled the victim's neck tissue into sausage-like chunks. On that occasion, when Berlinger arrived, he found that the emergency technician had already inserted a breathing tube, and Berlinger had wondered how this was done. The technician later explained that he stuck the tube where he saw bubbles. Bubbles meant air coming out.

So in the delivery room, Berlinger looked into the mouth of the infant for bubbles. All he saw was a mass of yellow cysts, completely obscuring the air passage. No bubbles. Berlinger placed his palm on the infant's chest and pressed down, to force the last bit of air out of the infant's lungs. Berlinger saw a few tiny bubbles of saliva between some of the cysts and maneuvered the tube into that area. The laryngoscope has a miniature light on its tip, and Berlinger was able to guide it past the vocal cords, into the trachea. The infant quickly changed color from blue to a reassuring pink. The procedure had worked.

I can only imagine being handed a tiny infant who is dying from suffocation, and having to figure out how to insert a breathing tube into a quarter-inch area.


ArC said...

If you like this story, you might also like "Walk on Water" by Michael Ruhlman, about an elite pediatric heart surgery unit. (I found the topic too difficult to get through, personally.)

Wanda said...

I've done plenty of tracheotomies on mice, and their tracheas are slightly smaller. It's not hard to do- I could probably teach you to do it. But of course those are healthy mice in non-crisis conditions.

Niniane said...

The thought of being taught how to perform a tracheotomy is frightening.

Btw, poor mice! They didn't do anything, and suddenly they're just given a tracheotomy? Aww.

Blake said...

I was talking to a vascular surgeon a while back, who mentioned that he once had to perform an emergency tracheotomy with hollow tube of a ball-point pen. The patient lived. Talk about true grit...

s said...

I think I may have nightmares about neck tissue being jumbled into sausage-like chunks. How does that even work? I could understand ground pork, but sausage...?