Intubation

Endotracheal intubation. Image: emra.org

I wrote this a while ago when I briefly decided I would become a sort of ‘war correspondent’ of covid-19. That obviously didn’t happen (like most of my shiny-magpie ideas) but I think some might find it interesting. If nothing else, it’s a time capsule for me of a pretty unique moment in my medical career.

***

I’m standing at the head of the bed. Mr. G*, the patient, is looking up at me, eyes wide. The muscles in his neck are standing out like cords as he fights for breath. His oxygen levels are dangerously low and he needs to be put on a ventilator. I’ve just passed on a message from his son, who wanted me to tell Mr. G that he loves him. His son can’t be here – there are no visitors allowed on the covid wards.

I’m holding an oxygen mask tight to Mr. G’s face. I smile down at him and say, ‘nearly ready, okay? Just keep taking deep breaths.’

My voice is calm.

There are four of us in the room: Mr. G, me, Salma* (another anaesthetist), and Elena* (an anaesthetic nurse). Apart from Mr. G, we are all in full PPE: hat, visors, respirator masks, gowns, and three sets of gloves. I’m already sweating.

We run through our roles. I’m ‘airway’ – responsible for passing the breathing tube into Mr. G’s windpipe so we can connect him to a ventilator. Salma will give the anaesthetic drugs to put him to sleep and monitor Mr. G’s vitals. Elena will pass me the equipment I need. There’s another nurse standing outside the room ready to fetch help or more equipment.

I run through our plan and backup plans – Plan A, Plan B, Plan C, and Plan D. I don’t elaborate on ‘Plan D’, which involves cutting into Mr. G’s windpipe with a scalpel. Thankfully, that’s almost never necessary.

‘Happy?’ I ask the others. Strange word in this context, but it’s what we say. The others nod.

I can feel the blood pounding in my temples. I take a deep breath and blink the sweat from my eyes.

‘Okay,’ I say to Mr. G, ‘we’re giving you the anaesthetic now, keep your eyes open for as long as you can. We’ll look after you, and we’ll see you when you wake up.’

If you wake up, is the unspoken coda.

Salma gives the drugs. Within seconds, Mr. G’s eyes close and he stops breathing. From now on, it’s up to us. The only sounds are the soft clicks of the valves in my respirator and the pip-pip-pip of the monitor measuring Mr. G’s blood oxygen.

You don’t think of the patient as a person, in this moment. You can’t. You don’t think of yourself either. There is only your hand, the laryngoscope, the tube. A mouth, a throat, a larynx. A task.

‘One minute,’ says Salma, watching the clock. The paralysing agent will be working now: Mr. G is ready to be intubated.

I slide the blade of the laryngoscope into Mr. G’s mouth, pulling upward to move his tongue out of the way. My hands feel clumsy in three sets of gloves. I’m looking for the glottis, the entrance to Mr. G’s windpipe.

‘It’s not a good view,’ I say.

I can hear the pip-pip-pip of the monitor falling in pitch. Mr. G’s oxygen levels are plummeting.

‘He’s desaturating,’ says Salma.

‘Pressure,’ I say to Elena, who presses Mr. G’s throat. I put my hand over hers and move it right slightly. The glottis drops into view, a black hole framed by the off-white vocal cords.

‘Okay, tube,’ I say.

I push the tube into Mr. G’s throat and Elena inflates the cuff on the end to create an airtight seal. We ventilate. I can see Mr. G’s chest rising and falling.

‘Chest rise,’ I say.

‘CO2,’ says Salma – the monitor has detected carbon dioxide in the exhaled gas: the tube is in the right place.

The pip-pip-pip of Mr. G’s oxygen level begins to climb.

I’d been holding my breath – I let it out. Elena and I secure the tube in place and I straighten up. My body aches – I’ve been holding every muscle tense. My scrubs are stuck to the inside of my gown, my palms are slick in my gloves. I wish I’d panic-bought some isotonic drinks.

‘First one of the night down,’ I think.

But how many more to go?

*all names have been changed.