Welcome Aboard “Emergency Airways”

This young guy had just been visiting the USA for the sheer fun of it, and had picked up a cold along the way. Travel exposes any of us to new viruses and we all succumb to them no matter how healthy we like to think we are. He shook off the cold, but it left his throat rather raw, and so an abscess formed in one of his tonsils or other pharyngeal lymph glands. The throat is the front door of the body, and is equipped with a lot of immune system tissues which act like bouncers to see off any incoming threats. Sometimes these worthy defenders become massively inflamed under fire and directly threaten the airway. I give you “the quinsy”:

tonsillitis

Nasty tonsillitis, impinging the airway.

On this occasion the abscess pointed both outwards and inwards. It bridged the outer airway and also the inner fascial planes of the neck, a place it had no business being in. With every cough and sneeze, pus was driven deep into the tissues of his neck and beyond.

Within a few hours the whole of his neck and central chest were suffused with very nasty bacteria producing gas which only insufflated his tissues more than his coughs and sneezes were already doing. This handsome young fellow began to resemble this personage:

jabba-the-hutt_b5a08a70

I was summoned in to the hospital by my colleague who was clearly out of her depth. I felt no more certain than her of solving the problem. The patient was rapidly choking to death. I asked the attending surgeon if he could perform an emergency tracheostomy under local anaesthesia, but he blanched at the suggestion as the front-of-neck anatomy was so distorted. This left only one option: an awake fibre-optic intubation; this was a procedure I had only read about but never performed.

An intubating bronchoscope was rapidly fetched from theatres and a narrow-bore endotracheal tube was slid over it. I inserted the ‘scope into the patient’s nostril injecting and spraying local anaesthetic all the way. The anatomy was all grossly distorted by the swelling. I found my way to his larynx and trachea by just following the bubbles of exhaled air. Once the tip of my endoscope was in the windpipe I ordered the general anaesthetic drugs be given, and I was then able to railroad the breathing tube over the ‘scope and secure his airway definitively.

At this point the crisis was over. We shipped the patient off to the care of ENT and chest surgeons who were at some distance from our simple district hospital. The patient did well and resumed his studies after a couple of weeks. This is a true story, and I earned a fair few grey hairs during the living out of it.

 

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Taking The Micks

Michael is an ancient name.

From the Hebrew name מִיכָאֵל (Mikha’el) meaning “who is like God?”. This is a rhetorical question, implying no person is like God. Michael is one of the seven archangels in Hebrew tradition and the only one identified as an archangel in the Bible.

It is a very popular name the world over, but for some reason it has become associated with Eire, to the extent that Micks are synonymous with Paddys in the slang universe.

There were two significant Micks in my professional life, and this article is my way of mentioning them in despatches, for they are both excellent geezers.

The first Mick was my senior registrar at the major city teaching hospital. He bore a remarkable physical resemblance to Rodney Trotter, though he was very far from gormless. In fact he was very laconic and acerbic.

One time, a pale-skinned, copper-haired lady junior doctor of lesser rank spat venom in his direction over some minor clinical misunderstanding. He silently repelled the attack, but after she had left, he, speaking to himself mainly, remarked that only a few centuries ago, a woman like that would have been burned at the stake. I liked his sense of humour.

I bumped into this Mick a good few years later. I was still a junior anaesthetist, but he had become a Consultant at a large district general hospital. In the meantime he had married and had several young children. He hadn’t yet managed to break into the plentiful private practice available in that locale, so was only scraping by on the standard NHS salary. His everyday commuting vehicle was a lowly “Montego”of venerable vintage, and his snottier, more superficial, elder colleagues nastily nicknamed him “Montego Mike”. I think that says more about them than about Mick.

************************************************

The second Mick was also my senior registrar at the same hospital, but he was a very different character. Possessed of a Blackpool accent and upbringing, he had a low tolerance for any southerner’s nonsense. I learned a tremendous amount at his kneeside. He had long curly hair, like some rock artiste, and was mega-computer-literate at a time before “Windows” had even been written. He was also wise beyond anyone I could compare him with.

pg-8-chris-addison-bbc

This looks a little like Mick 2 as I remember him.

At the satellite hospital in the suburbs was an ITU sister who was pulchritudinous enough to launch a thousand ships. Unfortunately, she also knew this. As a result, she felt and acted like someone possessed of infinite power over men, and often she succeeded.

Mick was uncompromised by her looks and charms, though not because he was gay or such-like. Mick was just too “eggs, chips and beans”, and happily married, to fall for it. Whenever he encountered her, all he could see was a spoilt princess requiring some needful upbraiding. This he delivered with his workaday northern patter. She melted before his mastery every time. It was like the taming of the shrew, perhaps.

This second Mick taught me a lot of wisdom, though he was/is a professed atheist. Whenever I see an image of the “Angel of the North”, I think of him.

Fly-Angel_crop

By David Wilson Clarke – Transferred from the English Wikipedia. Original file is/was here. (Original upload log available below.), CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=38249358

 

The Impossible Question

Although I was automagically enrolled into the college’s student union, I chose to remain a non-combatant. The lies and fisticuffs of politics were just not my thing. What amazed me then, and still does, was the political sophistication on view from many of my peers. They like me were barely out of nappies but yet were full of the buzz-words and right-on opinions and attitudes du jour. Clearly, my prior education had been deficient in preparing me for this strange new world.

The most precocious of students were those studying Politics, Philosophy, and Economics (PPE). This is unashamedly a course designed to nurture future shapers of society. Several of these classmates of mine are nowadays political leaders in real life.

Anyway, in my second year I attended a full meeting of the college’s undergraduates to witness the election of the new president of the student body. There were six or seven candidates. Each gave their brief spiel, and then the floor was opened for questions. Several nasally voiced attendees asked about the finer points of policy or made issue with the political process itself. It was all terribly tedious to me, but while necessity may be the mother of invention, restlessness is a strong contender for its father.

And so, on a whim, I flung my arm up in the air and waved it around like an epileptic dervish might. My attention-seeking behaviour worked and I was asked to pose my question to the assembled. The college fool and dunce spake forth:

“If each of the candidates was NOT standing for office, then which of the other candidates would they vote for?”

As the last of my verbalised syllables reverberated off into the present quiet, an awkward silence fell upon the assembly, and lasted for some thirty seconds. You could  even hear a pin drop upon the threadbare carpet of that junior common room just then. Eventually the first candidate admitted that they were unprepared for this question, before dwindling away in a burbling fashion. None of the others did any better.

Eventually the Chair of the meeting asked for any other questions. Dissatisfied with the outcome, I headed out for the college bar, its incumbents, and its pinball machine which all provided far more solaceful company.

lethal_weapon_playfield

I still think there has to be more to life than politics.

Mondegreens And Mumpsimi

A mondegreen is a misheard word, phrase, or song lyric that forever after is remembered and used as if it was the genuine article. This is an international and multicultural phenomenon with alternative synonyms for it including Hobson-Jobsons, soramimi, malapropisms and eggcorns.

Examples abound: “Old-timers disease”, “spectaclear”, “chimleys”, “immunogoblins”, “nucular”, etcetera.

A Mumpsimus has been defined as a “traditional custom obstinately adhered to however unreasonable it may be”, as well as “someone who obstinately clings to an error, bad habit or prejudice, even after the foible has been exposed and the person humiliated; also, any error, bad habit, or prejudice clung to in this fashion”.

I confess to being a bit of a mumpsimus myself. I thank my reverend mother for this gift. She was most definitely talented at liquidising ideas and words into some entirely new parrot-dimes.

One Sunday lunch, the whole family of eight of us was eating her wonderful roast lamb dinner and several glasses of wine had been sunk by all. At a pause in the banter, Mater asked if any of us had seen the new film starring Daniel Day-Lewis, about the severely disabled Irish author and artist Christy Brown, called:

“Mind My Foot”

We all of us scratched our heads mentally for a few moments before realising she had meant “My Left Foot”!

For ten minutes and more we all rolled around on the floor laughing at this mondegreen, though never at our mother. With such inspired but un-self-willed genius she had actually invented a better title for the movie and book. I still laugh to this day when I remember that meal.

Anyway, her gift passed onto me, and I commonly mishear and misunderstand a lot of what floods my ears ever since. For instance, this trashy pop-rock song was playing on the radio in 2003, while I was busy in theatre dealing with a leaking aortic aneurysm. Such a case is the most labour intensive of all for the anaesthetist: Blood loss is galore, haemodynamic instability is epic, and mortality is pacing up and down impatiently outside the door like an expectant father. I was squeezing bags of blood into this patient faster than I could complete the paperwork while I formulated my explanation for the coroner….

Then this rocky little ditty came over the airwaves:

Honestly, I thought the lyrics were “I believe in a thing called BLOOD”!

Benylin And Lemonade

cocktail

Some drugs leave you unshaken yet stirred.

Benylin, in two of its current formulations is an over-the-counter cough syrup containing the active drug dextromethorphan. I think it is a pink viscous syrup, flavoured with cherry-I have never taken it myself.

It is supposed to quell an overactive cough reflex by action upon the cough centre in the medulla oblongata in the brainstem, though some trials show it is no better than a placebo. Here’s the Wikipedia article about it.

Now I would be a strange kind of anaesthetist if I had any problem at all with drugs being used to relieve unpleasant symptoms and conditions. If I did, I would be arguing myself out of my job. Heck, I even approve of recreational drug use where it is legal, socially acceptable, and non-injurious to the good of the imbibers and those around them. Thus social drinking and moderate use of tobacco are fine by me, and I must confess to having both those minor vices, neither of which make me suffer personally, though my wallet is always starving.

I have no desire to truck with drink-driving, overdosers, or alcohol fuelled violence. Believe me, many healthcare professionals and I have lost an awesome amount of sleep trying to patch up patients who have fallen foul of that unholy trinity.

Anyway, dextromethorphan when taken at 3-5 times the normal dose can produce dissociation, euphoria, mania, hallucinations and even temporary psychotic states. It should thus be no surprise to the reader to discover that dextromethorphan is a common drug of abuse. It is particularly popular with “snowflake” abusers who want no hassle with the Fuzz, such as teenagers. It is just so readily available at any pharmacy, look you.

By all means, if a respiratory infection is preventing you from sleeping or otherwise functioning, by nasty symptoms like a dry cough, then freely medicate yourself while sticking to the proper dose. Cease use when you are better. Don’t become a “Benylinite”.

When I am feeling lousy with the dreaded lurgi, I dose myself up with a swig (20 mls) of “Night Nurse” which contains paracetamol, the dirty old antihistamine promethazine, and, errrh, a small dose of dextromethorphan, though not so much as you would notice.

“Night Nurse” looks and tastes like a cheap knock-off of crème de menthe. The product name is a piece of marketing and advertising genius:

Ash Wedneday 2018

Philippines Ash Wednesday

As a Catholic, I try my best to live my life according to Catholic teachings. One of these is to devoutly observe the Grace-filling penitential season of Lent, which this year commenced on 14th February, Ash Wednesday.

Following a night-shift and after a pretty dissolute Shrove Tuesday, which also included a rake of delicious pancakes with various toppings, I awoke the next morning like a teetotaller knowing that this was as good as it ever was going to get for the next forty days and nights. I had to fast and abstain for the next 24 hours at the very least. Fasting means getting by on one and a half meals per day, and abstaining means no meat. I had two huge mugs of sugarless tea to wash down my diabetes tablets. Fortunately I had a day off from work, so I did not have to worry about mental fitness to practise. The weather was cold and wet so I stayed indoors. My wife was at work at her school. I gave my son a lift to college. He is currently suffering from an ingrown toenail on his spastic foot, and I felt he deserved some help from my otherwise unemployed capacity that day. I returned home and did some housework. By now it was only 10am and I had six hours home alone before I had any company again…. (Our household has no pets).

The purpose of ascetic practises in the spiritual life is to prove to oneself that God will never let us be led away from Him, though our Faith will become seriously tempted in the process.

In this proper, Lenten, spirit and season, fasting and abstinence are simple ways for us to give our spiritual enemies, our weaknesses and our temptors, a beckoning finger or two. And thus we start to beat their dirty kung-fu with our more honest and humane, Divinely-gifted martial art: self-sacrifice.

This video provides a loose simile. Watch the neophyte in white being shown how to fight for his life by his master, playing his devil’s advocate, in black:

What that clip portrays to me is what Lent is all about: The more you think Salvation is all about your own efforts, the further it recedes from you. Salvation like all the best things in life is a free gift, from A Better Other.

Ash Wednesday’s summit for me was having the Christian symbol anointed with palm ash on my forehead by the priests fingers.

Who knows except God if I will ever receive the Holy ashes on my living forehead again, with these words being spoken over them.

Remember man that thou art dust, and unto dust thou shalt return

The Eskimo Joke

I have worked with a lot of eye surgeons over the years, and they are splendid chaps who do an awesome lot of good. The eye is the window of the soul, it is said, and these fellows are surely the window-cleaners, as it were. [OK, let’s get the silly video out of the way then-Ed:]

For the anaesthetist, eye surgery can be a bit of a bore. All the surgeon wants is a patient who isn’t running around the theatre during the minimally stressful procedure, and providing just that is child’s play, to be honest. Also, operative blood loss is less than I suffer when shaving my own chin of a morning.

To add insult to injury, they often require the theatre lights turned off so that they can better see what they’re working on under the operating microscope. If I get bored in a darkened room, I quickly start snoring. I’m a bit of a narcoleptic like that. Fortunately, my snores are so loud that I immediately wake myself up in a panic. I am sure I am very amusing to observe when I do this, like a dog is when awoken by its own farts.

Anyway, one afternoon during an eye surgery list, I decided to lighten the tedium by telling a silly little joke I had recently read or heard somewhere:

Q. Did you hear about the Eskimo who took his girlfriend to bed one night?

A. When they woke up, she was six months pregnant!

Now I know that this joke will never win the Nobel Prize for humour, but the surgeon and his assistant that afternoon were both so amused by it that they couldn’t continue to operate on the patient’s eye because they were convulsing with laughter. Their laughter infected everybody else in the room in a feedback kind of way (except the patient of course). It took a full ten minutes before order was painfully restored by the forced stifling of mirth. Ophthalmologists require the tremor-less dexterity of a master watchmaker to earn their crust, you see. I can’t explain why they found it so funny. Perhaps they didn’t get out much.

That operating list overran by ten minutes, but we never recorded exactly why. The incident, thankfully, became submerged in the sands of time. Nowadays, the overrun would be picked up by surveillance software and a bean counter might authorise an investigation perhaps, with formal interviews under caution…..

I exaggerate perhaps, but one thing is certain: NHS workplace morale is at an all time low right now because we the workers are more tasked with measuring mere process than in improving outcomes. The eventual collapse of the NHS will be perfectly recorded upon all available auditing media. Meanwhile the sick will just have to wait, or die.

Now Don’t You Laugh!

hand-with-iv

Only witch-doctors, quacks, and GPs can do without intravenous access

It was panic stations. The screaming mother in labour was wheeled rapidly into theatre and transferred tout suite onto the operating table. There was no time for the parenting friendly awake spinal anaesthetic. Only a rapid-sequence-induction general anaesthetic would save the life of her baby and herself.

I had all the necessary drugs drawn up already. The obstetricians scrubbed up at speed and approached the supine near-naked woman in their gowns, gloves, hats and masks. They waited on my say-so, for the lady was still conscious, and conscious most likely of her possibly impending doom.

My assistant was holding the oxygen mask to the lady’s face and also gently feeling for the cricoid cartilage on the front of her neck. Pressure applied there would prevent highly acidic gastric juices from flowing up into her throat and down into her lungs, which would kill her.

That poor woman was scared almost to death. Her adrenal glands were pumping adrenaline into her bloodstream in huge amounts. Her pulse rate and blood pressure were massively elevated, she was panicking and thrashing about, and her skin was deathly pale and clammy. There was not one second to to be lost.

I pushed the syringe of thiopentone into the cannula on the back of her hand and delivered the standard 375mg (15 ml). As I tried with one hand to disengage the syringe from its push-fit, the cannula itself came out from the patient’s vein. The adhesive dressing which had been holding it fast had failed because of her intensely sweaty skin.

At this moment, I had a severely compromised patient whom I had just rendered even more compromised by my injection of pentothal, and I now lacked a route via which to deliver any further life-saving drugs. The most important thing to achieve in the next few seconds was to deliver a muscle relaxant (suxamethonium) which would allow me to intubate her windpipe. I had never ever faced this scenario before. In the few moments I took to realise my near check-mate, the Angel of Despair gave me a knowing wink and a wicked chortle.

Brigid the obstetrician, a delightful Fraulein in other circumstances, chose this moment to giggle nervously at my clear and present discomfiture. I shouted

“Don’t you effing laugh!!!”

in my confusion and worry. This only made Brigid giggle all the more. The patient was beginning to turn blue, and it started to look like it would be “Game Over” very soon.

Then it was that the miracle occurred. I suddenly remembered accompanying a Consultant anaesthetist for an operating list over ten years before at some major teaching hospital. His surname was Harris, and thus he was awarded the nickname of “Bomber” by we unruly juniors. He was a solitary and eccentric young bean whom nobody ever really got to know.

He had asked me: ” How do you deliver suxamethonium (the fast-acting muscle relaxant) if you don’t have an intravenous cannula?”

After a pause I shook my head to clearly signal my witless ignorance of the answer.

“You inject the suxamethonium into the tongue!”

This made perfect sense to me. In mammals the tongue has a huge blood supply. Any overheated panting Alsatian will demonstrate this to you: They hang out their tongues to cool themselves off as they pant their breath over and around it.

Furnished with this recollection, I injected the 100mg of suxamethonium into the patient’s tongue and within a few seconds, her muscles began to twitch and relax. I successfully intubated her trachea and the caesarean section commenced and proceeded swimmingly.

In the time window provided, I inserted a new intravenous cannula, and all the other drugs were delivered via this route.

Mother and child did well, all thanks to good old “Bomber”. I discussed this scenario with all my colleagues, and none of them had heard of the intralingual injection technique before.