This blog post is a companion piece to our core content piece on tracheostomy emergencies published earlier this week.
Like many horror stories this one began on one of my first shifts as a newly minted community doc. It was 11:00 pm and the only services in house at this hour are Emergency Medicine and Internal Medicine. I received a call from the charge nurse saying “There is a women here with a tube in her neck and she is not breathing very well”. I quickly explained to my patient with chief complaint of ear wax that I would have to come back.
I ran to the critical care room and what I saw in front of me was a morbidly obese female with a tracheostomy in place, hyperventilating and mouthing “I cant breathe”.
As I soiled myself a few thoughts raced into my head “Where is ENT? Where is anesthesia?” and then slowly came to the realization that no one was in house right now bedsides an internal medicine doctor and ME.
Two respiratory therapists who clearly knew the patient well from prior visits were at the bedside and offered up that the patient “is here all the time because she doesn’t use her misting at home and doesn’t take care of her trach.”
I put the patient on the monitor. She was saturating 98% but was tachypneic to 35 and becoming more agitated. I took a look through a fiberoptic scope and could see that a circumferential build up of mucous had partially obstructed the tube. We tried misting and wet suctioning the tracheostomy without success. Seeing as ENT was not coming to the rescue and that the tracheostomy was old with an established tract, I decided to swap it out.
We suctioned her neck, deflated the cuff and removed the old trach which was covered in mucous . I lubed up the new trach and attempted to push it in. What I did not anticipate was that the patient would not stay still- she started moving her arms and legs thrashing and grabbing at her throat- dislodging the partially placed trach and in the process causing mechanical damage to her neck- she started bleeding and the stoma appeared to swell. In that moment I had a vision of all my mentors looking at me, shaking their heads and saying where is your bougie? What is your backup plan?
In her thrashing she had disconnected herself from the monitor, so I had no idea what her saturation, HR or BP were. Also I realized in that moment that her IV was no longer patent. All of this while her stoma was getting smaller and smaller and the respiratory therapist screaming “She’s bleeding! She’s bleeding! She wont be able to breathe!”
I took a deep breath, made a conscious decision to avoid the panic building in my gut and asked for a bougie and a 5-0 tube. Throughout my training, whether in a township near Capetown, an urban city in Kerala or during residency at Bellevue I knew that if you have a scalpel, a bougie and an ET tube you’ll be fine. My colleague preloaded the bougie and I railroaded it into the stoma. I inflated the balloon, suctioned the area and exhaled.
I told her we had an airway which helped calm her anxiety and breathing, placed a new IV line and hooked her back onto the monitor. Though she was essentially breathing through the equivalent of a straw in her neck, it was a temporary solution.
Many hours later ENT came in from home, we discussed the case and decided to pretreat with some valium as she was very anxious. ENT was able to change over the tracheostomy with mild difficulty and she was admitted overnight for monitoring.
- Always have a backup
- Suction is your friend
- The bougie is your friend
- A little bit of benzo can go a long way
- Always bring a fresh pair of underwear
1. Grant C, Dempsey G, et. al. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. British Journal of Anaesthesia 96 (1): 127–31 (2006).
2. Seung WB, Lee HY, Park YS. Successful Treatment of Tracheoinnominate Artery Fistula Following Tracheostomy in a Patient with Cerebrovascular Disease. J Korean Neurosurg Soc. 2012 Dec; 52(6): 547–550.