Teachable moment strikes a ‘cord’

I still feel guilty about the first time I intubated somebody.

I was an ICU intern. My patient was crashing and needed a breathing machine. I asked my resident if I could "tube her" - put the breathing tube in her trachea. He had already prepped me: Stand behind the head, insert the laryngoscope into her throat, just anterior to her epiglottis, then pull up and the epiglottis opens, showing the vocal cords, then slide the tube through the cords and into the trachea.

Eyes wide, he said, "Just don't tube the goose!" Or rather, don't mistakenly put the tube into the esophagus - the "goose." To ensure this, you have to "make sure you see the cords. Don't do anything until you see the cords," he said. I had never ever seen the vocal cords on a living person. Secretly, I doubted I ever really would.

We bag-breathed her to increase her oxygen saturation to 98 percent. My resident sedated then paralyzed her with drugs. Her muscles went flaccid; there was no way could she breathe on her own and I knew that as soon as I said the word to stop bagging and let me intubate, her oxygen saturation would begin to fall.

"OK, stop bagging," I said; my own pulse quickened. I put the blade above the epiglottis and pulled up.

My resident asked, "You see the cords?"

I squinted and moved and squinted. "No," I said.

He said, "Reposition. You're fine," but more doubt crept in. I glanced at the saturations which were now 94 percent. I repositioned, and the epiglottis flopped down, then I lifted it up again. I still couldn't see the cords when I heard someone shout "90 percent." Bed alarms started screaming.

"You see 'em?" he whispered.

"Eighty-seven percent," someone shouted.

My resident put his hand on my back. "Talk to me," he said.

I knew where the cords were, but the epiglottis blocked my view. I imagined her brain cells dying - "84 percent." I felt cold sweat on my spine - "80 percent." I pushed the tube in, blindly.

The respiratory therapist smiled when he put the CO2 meter onto the end of the tube, its yellow color indicating a successful intubation. The oxygen saturation came up quickly to 90 percent then 96 percent.

My resident high-fived me and said, "You see how important it is to see the cords?"

My fellow intern high-fived me. My attending said "excellent work." I never ever told anyone until now that I never really saw the cords. I just got lucky.

A few days later, I asked an anesthesiologist to teach me how to intubate. As he bagged the paralyzed patient, he said, "You will have all the time you need to see the cords. If you don't see 'em, no worries; we bag and give you another chance. Everything is under your control. Nothing needs to be rushed. Get into the zone and believe it's gonna happen."

He was a cool guy, calm. I believed him. I got into the zone. And when he stopped bagging, he looked at me and said, "Oxygen saturations are 100 percent. You have all the time in the world and you are in control. Do you believe you will see the cords?"

I nodded, then inserted the laryngoscopy blade, lifted up, and there I saw them, those beautiful silvery white parallel vocal cords.


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