Anecdotally Speaking

The superfluous, a very necessary thing. --voltaire

Thursday, April 12, 2007


Home Visit Code Blue

It was a quintessential moment, fitting for a rural medical practice. I was on my hands and knees in the dark cramped kitchen of a patient's home. The patient was sprawled across the floor in front of me. CPR was in progress.

I looked down at her face. It was devoid of even a vestige of color. Thin electric wires fastened to her chest made their way to an automatic defibrillator. A disembodied robotic voice from the device intoned, "Continue CPR." I prepared to provide her with an airway.

Moments before I was in my clinic seeing routine patients when my typically busy Friday morning was interrupted by the urgent call, "Code blue, patient down." I answered the call.

It wasn't far; she lived only a few blocks from the clinic. But then, in a small town, everyone lives only a few blocks from the clinic. I arrived at her house with the airway equipment in less than a minute.

While she was being ventilated and chest compressions were being delivered, I calmly prepared for what I needed. I checked the laryngoscope, inserted the batteries, attached the curved blade and checked the light bulb. Fourteen years ago, I was an ER doctor and I did this all the time. I was very good at it and fancy that I still am, even though I don't do it that much anymore.

I selected an ET tube, inserted the stylet, adjusted the stylet and shaped the curve of the ET tube just right, attached a ten cc syringe, inflated the balloon, checked it and then I was all set; I was ready.

I gently extended her head and inserted the blade of the laryngoscope along the side of her tongue, pushing the tongue out of the way. I was nearly laying flat on the floor, my head lowered down as low as I could go, to be at the best angle to see into the larynx.

Redundant folds of oral and pharyngeal structures obscured my view. I pulled up on the scope with my left hand and angled it to try to expose even just the smallest glimpse of the arytenoids or the vocal cords. I craned my neck. It was an awkward angle.

My bifocals couldn't quite bring into focus the minute area I needed to see, that particular teensy tiny little spot just beyond the tip of the epiglottis that I had to visualize in order to place the ET tube properly. I had to see it. I repositioned the blade and probed with the tip of the ET tube. I jiggled my glasses up and down.

For a flash of a moment it crossed my mind that maybe I wouldn't be able to do it. That it would be just too hard for me, that it had been too long since I had done this sort of thing and my eyesight was not good enough anymore. As I struggled within the diminutive space of my patient's gullet, stretched out as I was across the floor, it flickered through my mind for only a brief half of an instant that I should let the other doctor have a go.

Then I recalled that I am good at this. Really good. I used to do this all the time. I worked once in a busy ER full-time. I intubated people in code situations nearly every day. I am the best person for the job, I reminded myself. This patient needs me and by golly I am not giving up, I am doing what it takes to get this done.

So I pulled a little harder, angled a little bit more, got down a little closer to the floor, then I slid the tip of the ET tube up under the epiglottis and directed it anterior into the trachea. I removed the laryngoscope, inflated the balloon, attached the amboo bag, gave some breaths, watched the chest rise, fall and listened for breath sounds. It was a successful intubation.

Later on, ensconced again in my ordinary busy Friday clinic, I was still feeling warm inside from the glow of accomplishing something truly remarkable. I imagined that it might be like the feeling one might get from catching a game-winning touchdown pass or from winning a $10,000 Lottery Prize.

I wanted to share the feeling, so I said to my staff, to no one in particular, "You know, intubating somebody is always tricky, but it really is something doing it when you're in a cramped dark space laying flat on the floor."

No one in particular, replied, "Huh, huh, that's nice."

Hmmm, what do I expect? Anyway, I think I'll make an appointment to get my eyes checked. Maybe they can do something about that.

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