For Savannah Jones, it was not a great night for sleeping, far from it in fact. Savannah sat up straight in her bed in the Pediatric Intensive Care Unit, breathing fast and shallow like a frightened rabbit. She opened her eyes as I entered the room and looked at me wearily. Mist filled the mask over her mouth and nose and billowed with each breath; she was breathing at least forty times a minute, twice the normal rate. Her lungs sounded even worse than before – wheeze, wheeze, crackle, wheeze, crackle – and although her pulse oximetry reading held steady in the mid 90s, I feared it might not stay there for long.
“Crap,” I thought as she hurried out of the room, “this girl needs to be intubated, and soon.” I hustled to the nursing station and paged Dr. Connor. As I waited for the return call, I reviewed, as I had dozens and dozens of times before, the procedural steps of an intubation. Intubation, the technical name for placing a breathing tube in the windpipe, is without a doubt the most crucial hands-on skill that a novice emergency physician must learn. Since the first day of my residency, I had been taught that my job was to “own the airway.” When I first heard this phrase, “own the airway,” I thought it presumptuous – how could a physician “own” a patient’s airway as if it was a commodity? Surely, a person’s trachea was more innately his or her own than a moped or a surfboard? With time, however, I came to appreciate the phrase because it captured the mentality necessary to learn a critical skill. Training in emergency medicine emphasizes, above all else, the skill of airway management and with good reason; when a patient ceases to breathe immediate action is required. Bodily organs deprived of oxygen fare poorly and basic functions, such as the heartbeat, rapidly lose their verve. Depending on factors such as patient age and health, there might be minutes to spare, or maybe only seconds. And this is why the intubation process fills even a seasoned emergency physician with trepidation; because while the procedure is usually straightforward, if things go wrong, they can go very wrong.
“Ballard, I am on my way in,” Connor bellowed over the phone. “Get the airway equipment and drugs at the bedside and call the respiratory tech. Talk to Savannah’s mother, make sure she knows what we are up to. If Savannah crashes, you know what to do.”
“Yep,” I replied, surprised. I hadn’t told him a word about the situation. He just knew that this was going to happen. Obviously, he had been doing this for a lot longer than me, but experience alone didn’t allow an average physician to reliably predict future events. Connor was special.
Savannah’s mother nodded sadly. “Doctor, as I said before, do what you need to do. I trust you.”
She inhaled deeply. “How long? How long do you think she will need the breathing tube?”
“I don’t know. I am sorry, but your daughter’s infection is very serious. It could be a long road.”
“I see,” she muttered softly.
“We will get you as soon as the tube is in.” For a moment, Savannah mother’s worry weighed heavily on my soul, but I didn’t have the time to linger. Savannah’s respiratory rate was nearing 50.
“Okay,” I said to Savannah’s nurse, “we need to get this done now. Push the etomidate, eight
Milligrams. Follow that with the succ sixty milligrams.” I ran through my mental checklist one more time – tube with stylet, suction, syringe, bag and valve, color change detector.
Just after the medications had been pushed and Savannah’s eyes closed with a slight shudder, Connor strode into the room. He looked at me.
“Looks like we are doing this. Ballard, I hope your technique is cleaner than your hair-do.”
I chuckled. I hadn’t even considered my bed head. I was pretty legendary among my peers in my ability, in a short period of time, to get significant bed head. Just 15 minutes of lying in a bed could reliably cause a large puff of my hair to stand straight up. Thirty minutes in bed was guaranteed to leave pillow lines across my forehead. Usually, after I’d been paged in the middle of a nap, I would take a brief swing by a mirror and attempt to temper the follicular uprising. But, in this case, the urgency in Savannah’s nurse’s voice had caused me to skip the mirror. I was thankful that Savannah’s mother had focused her trust on my words and not on my appearance. Connor’s comment calmed my nerves and I focused on my task. We lowered the back of the bed so that Savannah was lying flat and I gently pushed the top of her head down, which popped her chin up slightly. I opened her mouth with my right hand and inserted the L-shaped blade at an angle with my left. I pushed her tongue to the side and the tip slid into the valleculla. I pushed up and out, at a steeper angle than normal, because of where I expected her young vocal cords to lie. And there they were, glistening and outlining the tunnel to a successful intubation.
“Tube,” I said.
I felt it in my right hand. “Steady now,” said Connor. “Keep your eyes on the pearly gates.”
The tube slid in smoothly, and although I didn’t see it pass the cords, I knew it was in.
Connor pushed the plunger on the syringe, filling the balloon. The respiratory tech connected a color detector and a respiratory bag, after a large squeeze, the detector glowed yellow. I listened to the breath sounds – still wheezing and crackling, but present. I listened over the abdomen to be sure and was reassured because I didn’t hear the hollow sound of air blowing into Savannah’s stomach. The respiratory tech began to tape the tube into place and connect Savannah to the ventilator. The nurse prepared to slip a tube into her nose down to her stomach. I looked at the monitor, Savannah’s pulse oximetry was creeping back up, now in the mid 90s.
“Good job, Ballard.” Connor gave me a slap on the shoulder. “Now, let’s find you a comb.”
I laughed in relief and headed towards the call room and then stopped.
“How did you know?” I asked Connor. He smiled. “Simple really, you weren’t the only one who got a call from Savannah’s nurse. We don’t let you rookies have too much latitude. C’mon, let’s get some rest.”