“Doctor! Come quickly! This girl is having difficulty breathing.”
I am in OPD and it is coming up to midnight. I have just been seeing a group of three babies with gastroenteritis. I keep getting them mixed up – they all look the same (despite what their mothers would claim), all have basically the same symptoms, and the nurses have put them all in the same cubicle.
I follow the nurse’s voice. They are supporting a teenage girl who has an immensely swollen face and dragging her to the resus room. I had spotted her in the waiting area half an hour before and she looked fine then.
They lie her on a trolley. “What happened?” The nurses translate for the mother. Apparently she was well earlier today but during dinner her face began to swell, her lips, and then her eyelids. I ask whether there were any new foods, or insect bites, or stings? No. None at all. Has this happened before? Yes, a couple of times a year ever since she was 6 years old. Can they think of anything that sets it off. No, they cannot.
She is conscious but distressed and drooling because she cannot swallow her own saliva. Her airway is clearly as swollen as her face and she is danger of suffocating in front of me.
“Can I have some adrenaline please!” The nurses run around in circles looking – the night staff are not always as familiar with the layout of the place as the day. I take advantage of the delay to check the dose in my British National Formulary – it is so long since I have done this it is embarrassing. We also give her a nebuliser. She appears to settle a little but her face is still swelling and this is only going to end one way unless we do something. She is beginning to have stridor (a haunting gasping noise that one can emulate by breathing whilst compressing your own trachea – do not try this at home), an indicator that her airway is close to obstructing completely. She is looking exhausted and drowsy. She is on 100% oxygen and the monitors confirm she is well oxygenated but things will change quickly.
I take a deep breath. “OK – we are going to have to sedate her and paralyse and ventilate her.” The nurses all stop. They haven’t done this before. But that is fine because I haven’t either.
I ask for the drugs I need (quickly looking up the doses in my trusty BNF). They all look at each other. “I will phone Sister Nene on High Care. She will know where they are,” says the Matron. They move with commendable speed and Sister Nene arrives with the drugs within (several) minutes. They explain to the patient what we are about to do.
I start praying – if this goes wrong I will have killed her. I ask Matron injects the sedative and once she is unconscious I paralyse her with the second drug. I grab the laryngoscope – the device that lets me see down the throat to the vocal cords, through which I need to pass the breathing tube to protect the airway. I pass it over her tongue. I cannot see anything – everything is swollen up. I have intubated several times before but never in this situation. I beginning praying under my breath. I insert it again. And again, trying to get oriented and find landmarks that will show me where the cords are. I cannot even see the epiglottis – or perhaps that enormous swollen thing is the epiglottis. In which case are those the cords? They cannot be – normally the cords are thin and widely apart leaving a clear black hole that leads to the lungs. These white things are completely stuck together. There is no space for a tube.
“Pass me that wire please,” I say tersely not moving my gaze from the laryngoscope view. They pass me a long piece of rigid wire that was clearly a coat hanger in a previous life. I carefully push it down the throat and probe at the line that divides the white lump in two. On the second go it parts slightly, admitting the wire. “The tube,” I bark. I can hear the tone of the oxygen monitor dropping in pitch as the girl’s oxygen levels begin to fall. They pass me an intravenous giving set. “Not that tube, the other tube.” They pass me an oxygen tube. “Not that, that!” The pitch of the oxygen monitor is falling quickly now. They pass me the endotracheal tube. I thread it over the wire, pushing it down the throat. It stops at the cords. I push harder and twist. Suddenly there is a give and it passes down. We attach a breathing bag to the tube and I listen with a stethoscope as a nurse squeezes air into the lungs – there is clear air entry in both sides. I let out an involuntary “Hallelujah, thank you Jesus,” which the nurses enjoy.
Suddenly, I need the lavatory.
I am in OPD and it is coming up to midnight. I have just been seeing a group of three babies with gastroenteritis. I keep getting them mixed up – they all look the same (despite what their mothers would claim), all have basically the same symptoms, and the nurses have put them all in the same cubicle.
I follow the nurse’s voice. They are supporting a teenage girl who has an immensely swollen face and dragging her to the resus room. I had spotted her in the waiting area half an hour before and she looked fine then.
They lie her on a trolley. “What happened?” The nurses translate for the mother. Apparently she was well earlier today but during dinner her face began to swell, her lips, and then her eyelids. I ask whether there were any new foods, or insect bites, or stings? No. None at all. Has this happened before? Yes, a couple of times a year ever since she was 6 years old. Can they think of anything that sets it off. No, they cannot.
She is conscious but distressed and drooling because she cannot swallow her own saliva. Her airway is clearly as swollen as her face and she is danger of suffocating in front of me.
“Can I have some adrenaline please!” The nurses run around in circles looking – the night staff are not always as familiar with the layout of the place as the day. I take advantage of the delay to check the dose in my British National Formulary – it is so long since I have done this it is embarrassing. We also give her a nebuliser. She appears to settle a little but her face is still swelling and this is only going to end one way unless we do something. She is beginning to have stridor (a haunting gasping noise that one can emulate by breathing whilst compressing your own trachea – do not try this at home), an indicator that her airway is close to obstructing completely. She is looking exhausted and drowsy. She is on 100% oxygen and the monitors confirm she is well oxygenated but things will change quickly.
I take a deep breath. “OK – we are going to have to sedate her and paralyse and ventilate her.” The nurses all stop. They haven’t done this before. But that is fine because I haven’t either.
I ask for the drugs I need (quickly looking up the doses in my trusty BNF). They all look at each other. “I will phone Sister Nene on High Care. She will know where they are,” says the Matron. They move with commendable speed and Sister Nene arrives with the drugs within (several) minutes. They explain to the patient what we are about to do.
I start praying – if this goes wrong I will have killed her. I ask Matron injects the sedative and once she is unconscious I paralyse her with the second drug. I grab the laryngoscope – the device that lets me see down the throat to the vocal cords, through which I need to pass the breathing tube to protect the airway. I pass it over her tongue. I cannot see anything – everything is swollen up. I have intubated several times before but never in this situation. I beginning praying under my breath. I insert it again. And again, trying to get oriented and find landmarks that will show me where the cords are. I cannot even see the epiglottis – or perhaps that enormous swollen thing is the epiglottis. In which case are those the cords? They cannot be – normally the cords are thin and widely apart leaving a clear black hole that leads to the lungs. These white things are completely stuck together. There is no space for a tube.
“Pass me that wire please,” I say tersely not moving my gaze from the laryngoscope view. They pass me a long piece of rigid wire that was clearly a coat hanger in a previous life. I carefully push it down the throat and probe at the line that divides the white lump in two. On the second go it parts slightly, admitting the wire. “The tube,” I bark. I can hear the tone of the oxygen monitor dropping in pitch as the girl’s oxygen levels begin to fall. They pass me an intravenous giving set. “Not that tube, the other tube.” They pass me an oxygen tube. “Not that, that!” The pitch of the oxygen monitor is falling quickly now. They pass me the endotracheal tube. I thread it over the wire, pushing it down the throat. It stops at the cords. I push harder and twist. Suddenly there is a give and it passes down. We attach a breathing bag to the tube and I listen with a stethoscope as a nurse squeezes air into the lungs – there is clear air entry in both sides. I let out an involuntary “Hallelujah, thank you Jesus,” which the nurses enjoy.
Suddenly, I need the lavatory.
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