Intubation

[Gail in Ca]

I posted after my sternal wire removal 3 months ago, that my tongue was traumatized, and it took many weeks for it to be back to normal. I did hear from the doc who was in charge and found that a resident had tried to place the breathing tube, was unsuccessful, and so the supervisor anethesiologist took over. I have found out since from talking to a nurse, that the tool that is used to hold back the tongue can cause trauma.
(I actually saw one on 'House', it looks like it would cause trouble)! Anyway, I mentioned my tongue trauma to my PCP, and she said it happens, and I was lucky I didn't loose a tooth!!! Apparently, when being intubated, some people get a tooth knocked out. I never had heard of this, so I thought I would bring it up, as something to consider when choosing more surgeries with a tissue valve.
I asked her what I should do if I ever need to be intubated again and she suggested I ask for the most qualified anethesiologist present to do the intubation, one that has done the most with greatest success, and to mention that I had a problem twice in the past. (I remembered my tongue was sliced and a piece came off about 1" square, while recovering from my 3rd surgery, same supervisory anethesiologist).
Anyway, FYI.
Happy New Year!

 

[ramjet]

I posted after my sternal wire removal 3 months ago, that my tongue was traumatized, and it took many weeks for it to be back to normal. I did hear from the doc who was in charge and found that a resident had tried to place the breathing tube, was unsuccessful, and so the supervisor anethesiologist took over. I have found out since from talking to a nurse, that the tool that is used to hold back the tongue can cause trauma.
(I actually saw one on 'House', it looks like it would cause trouble)! Anyway, I mentioned my tongue trauma to my PCP, and she said it happens, and I was lucky I didn't loose a tooth!!! Apparently, when being intubated, some people get a tooth knocked out. I never had heard of this, so I thought I would bring it up, as something to consider when choosing more surgeries with a tissue valve.
I asked her what I should do if I ever need to be intubated again and she suggested I ask for the most qualified anethesiologist present to do the intubation, one that has done the most with greatest success, and to mention that I had a problem twice in the past. (I remembered my tongue was sliced and a piece came off about 1" square, while recovering from my 3rd surgery, same supervisory anethesiologist).
Anyway, FYI.
Happy New Year!

Dear Gail in Ca.

During an operation that requires a general anaesthesia (ie the patient is totally apleep), an endotrachael tube (abbreviated to "ETT") is often placed into the mouth and between the patient's vocal cords, and it is through this tube that a gasesous mixture is blown into the lungs via an anaesthetic machine (A ventilator) and then exhaled air is removed via this tube also. It is essential to keep you alive during the operation, and also to allow your lungs to be deflated if necessaary. ie it is often called a breathing tube and your life depends on it being placed correctly, quickly and then kept inn the right place throughout the operation.

Many operations now employ the use of a laryngeal mask airaway (otherwise known as an LMA), which is a less complicated breating tube that fills the back of the oral cavity and a patient is ventilated via this device. It doesn't usually need the tongue to be manipulated out of the way etc, unfortunatey during complicated surgies, prolonged surgeries or procedures where lungs need to be deflated, an LMA is simply not suitable. Hence an anaesthetist is required to use an ETT, and in order to insert an ETT (breathing tube) the anaesthetist needs to get a good view of the vocal cords, and this is done by inserting a long curved metal blade with a little light on it ...its called a laryngoscope. This device is usually quite simple, (althoughthere are some complex emergency variations depending on the circumstance) but it requires an experiencd and skilled operator who has had lots of experience to use it properly.

Everyone has slightly different anaotomy, mouth different sizes, tongues are different, and neck different, etc etc, and somtimes its use is very very simple and easy to place an ETT, and other times it can be quite tricky, and in some very few instances the laryngoscope simply can't provide an adequate view and alternate methods to place an ETT or another device need to be used. I was trained in the use of the laryngoscope by training initially in anotomy, then theory of use, then lots of simulation practice on plastic dummies, then supervised very very closely by an axperienced anaesthetist in an operating theatre for a long time. In rare instances a tooth can be damaged however the anaesthetist is always very very careful to avoid this, but sometimes if it gets tricky it can be a choice between damaging a tooth or having the patient almost suffocate because they can't breathe. Rest assured that any training or experienced anaesetist is always very careful to avoid damaging teeth and tongues and other structures etc, but unfortunately this can happen in rare instances, but it is not done deliberately, and the fact that you are still alive and not brain damaged means that they got the procedure correct, its just that unfortunately they have damaged your tongue in the process. The anaestetist would be very upset to know about this, very very distressed and belive me would have tried everything to avoid this. Please try not to be too dissapointed or angry about what happened, because it is an incredibly complex process to insert a breathing tube in some patients and ensure that you stay well oxygenated and alive during surgery.

We all focus on the heart surgeon, he is a key person to the procedure, but equally as important in the whole process is the cardiac anaesthetist, (and the rest of the cardiac team) who is often one of the real heros behind the scenes. He/she also give you special drugs and medications, some of which have the side effect to make you forget your interations/discussions with the anaesthetist, so you just don't remember how kind and gentle and friendly they were to you just before you went to sleep on the operating table. Soooo.... thats a long way of explaining that really, honestly, I just know and I am sure everyone will be very very upset that your tongue was damaged in the process of placing a life giving breathing tube, and everyone would have tried their best to ensure that this would not happen, but it did happen, and perhaps even the very experienced anaestetist took over the process to ensure that you didn't turn blue (ie become hypoxic) and die while they were trying to get the breathing tube in place.

During the "preoperation" discussions I had with my anaestetist I was careful to explain to my anaestetist that I didn't mind if he accidently damaged my teeth, or tongue, but I explained I just wanted him to please do your best to make sure I don't become hypoxic (turn blue) and have brain damage. He would have my life in his hands ( as does the surgeon). I said that if for some reason he couldn't place the breathing tube quickly he has my permission to cut a small hole in my neck (ie perform a surgical airway) in order to keep me alive. Your tongue was unfortunately damaged, hopefully it recovers fully, but you are alive and your brain is still working so please believe me that they have actually done a good job otherwise.

I can give you some examples if you like, of cases where in experienced anaesthetists have caused the patient to die (or become brain damaged which is worse) by doing the wrong thing with the ETT or the breathing machine...in fact cardiac anaesthetists are a very skilled sub speciality of medicos, and it is an extraordinarily complex profession, and many surgeons will "hand pick" the anaestetist they work with during cardiac surgery. If for some reason your tongue does not fully recover, then you may have access to an insurance claim. Anaestetists are required to have insurance to cover unforseen and unfortunate occurances that may occur, but to some extent, you may actually end up sueing the very person whose skill kept you alive, and unfortunately your tongue was damaged despite their best attempts, whereas a less experienced anaesthestists who may have been more careful with yoru tongue may have let you die inadvertantly whilst delaying the process......

I hope that puts you at ease somewhat. I would be careful to explain to your anaesthetist in the future that your tongue was damaged during your previous opertaion, and any future procedures may be varied to ensure that this hopefully does not happen to you again. Take care and remember, they did in fact keep you alive and kicking!

 

[VegasBAV]

Wow. Scary stuff. I'm kind of glad I didn't read this before my surgery.

 

[Jkm7]

I would love to read that post as it looks very interesting but I cannot.
I wish there was a way to put paragraphs. Tired eyes have a hard time with such a large block of script.

 

[tom in MO]

I have a similar problem, but with my throat. It's hard to find your way through mine to insert the tube. My first operation, 18 years ago for a colon trouble, they had to call in a throat specialist to insert the tube. My throat was quite sore afterwards and they told me why. I was also told that now since I know I am "different" to warn the anesthesiologist next time. It's not a common occurance. Gail, you and I our the "outliers." For my next two operations, I have warned them in advance. The anesthesiologist have all been quite thankful to be warned in advance and I've had no noticable trauma since the first operation.

 

[ramjet]

Sorry JKM7, once I get going I just type in the hope that it makes sense. If you abbreviate too much it can cause even more confusion, and I am sure many people will know bits about what was written, but some people just aren't aware of what actually takes place during surgery. I've edited my post a little bit and hopefully some paragraphs help make it a bit easier to read.

There are literally thousands upon thousands of operations performed around the world each day, and in every instance the patient's life is not just in the hands of the surgeon, but everyone in the medical and nursing team. One of the most neglected and unknown heros is the anaesthetist. He keeps you alive, he manages your airway and breathing with devices without which you will die in minutes, he manages your blood pressure, he magages your muscle tone, in many instances he will completely and thoroughly paralyse you with special medications that are hand picked for your particular case and medical history in dosages that are very closely monitored, he manages your pain and anxiety with other specialist medications, he will resuscitate you should yo suffer a cardiac arrest, he will adminsiter fluids and blood products (packed red blood cells, plasma, whole blood etc) in order to keep your brain and organs alive and well perfused, he will deflate one or both of your lungs during surgery, he will awake you in a particualr way so you don't die during teh process, and need I go on....honestly, the anaestehtist is an amazing person in this process.

No I am not an anaesthetist, but I personally know many of them and have worked closely with a few very senior specialists during their daily work, and my life, and that of my wife and my young daughter have had their lives (their airways, their blood pressure, their pain, their brain etc) very much in their hands during surgical procesures that were quite minor in surgical terms, but the anaesthesist went about his job in the background and the good anaesthetists make the procss look easy and they often get taken for granted, if it goes wrong, then someone dies.

Over a century ago all they used was ether to put people partially to sleep, today, the anaesthetists have a trolley that resembles a specialst pharmacy (Drug Store), literally....they have hundreds of specialist and dangerous drugs, each medication has a range of indications, contraindications, doseages, routes of administration, different metabolism pathways, and sometimes the drugs are chosen on experience, others have particular individual roles, let alone a range of technical devices, breathing machines, airway tubes of a range of sizes and lenghts, and special medical gasses and oxygen mixtures etc, etc. and they are expected to know the detail of each and every medicication and dose and antidote (if available) and reversal agents etc.

Let me see, from memory I can name just a few of the drugs they use each day during their working life, and many will have been used on us before, suring and after our operations in a variety of speical combinatios particular to our procedure, our state of health and our size, age and weight etc, there a few fixed recipies of medications that suit all of us. ....Suxemethonium, vecuronium, rocuronium, fentanyl, midazolam, morphone, cocaine, diamorphine, aramine, propofol (implicted in the death of Michael Jackson), entenox, isofloruane, desflourane, remifentanyl, atricurium, neostigmine, suggamadex...then there are a range of betablockers, parasympathetic blockers, sympathomimetics, antiemetics (ondansetron, maxolon etc), and the list simply goes on and on and on....seriously, the anaesthetist know about each of these drugs and what they do to your body and how they allow the surgeon to does the work and how it keeps you alive, asleep, appropriately paralysed, appropriately oxygentated and appropriately perfused with blood and an adequate blood pressure. The surgeons don't know and don't need to know anything much at all about thezse drugs, they simply ask the anaesthetist "put them off now", giveme more muscle relaxation now", I'm finished youy can start to wake them up", and the anaesthesist goes about his business with a flurry of syringes, medication vials, infusions, injections, ventilaor settings, tweeking, adjusting, injecting, infusing ....just doing their complex and delicate job and all the while making it seem easy and routine, when in fact a lesser trained and experienced person would kill us in a heart beat with just one mistake.

Just have a look at the medical case of Elaine Bromely, which details a very tragic event that involved some very senior anaesthetists during a relatively minor procedure (not a complex cardiac procedure) that unfortunately went very very wrong. It is the case of Elaine Bromely "Just a Routine Operation" Here is the web link to a You Tube video

http://www.youtube.com/watch?v=JzlvgtPIof4

I post this video not to frighten or scare, just to help put the injured tongue and sore throat side effects and issues into perspective a little bit. I would hate to have an injured tongue or a sore throat post surgery due to the breathing tube, but thankfully we are alive and well no small thanks to a very skilled anaesthetist. When things go wrong sometimes decisions have to made to keep us alive, and that might result in a sore throat or an injured tongue of a broken tooth, but hopefully we stay alive.

 

[Jkm7]

Ramjet,
Thank you for two amazing posts and for the paragraphing.

Your posts are so informative and certainly gave a perspective on the importance of having the best possible anesthesiologist/anaesthetist taking care of us.

I've had two OHS and two abdominal surgeries and am grateful for what must have been excellent care as I survived them all intact and well.

Thank you for sharing this valuable information with us.

 

[ElectLive]

Ramjet,
Thank you for two amazing posts and for the paragraphing.

I couldn't agree more, on both counts, so thanks to you both. :thumbup: My own lazy eyes gave up prior to the reformatting, and sure am glad I returned, those two posts are a must read in my opinion.

You know, I've joked once or twice here how my first medical intervention pre-surgery was a horribly botched line for the anesthesia team that was tried and failed at multiple locations. It finally resolved itself only after about half an hour of trial and error (needle sticks, bruises, etc) in basically the last available location, leaving me with a potentially very unnerving pre-surgery moment. Fortunately, things like that don't bother me, though, in fact I was actually laughing at them. But, much to my regret at the time, given my sense of humor, I resisted the temptation to say: "Does this mean we're going to just have to use a local?" :eek2: :biggrin2:

Well, the bookend to that moment was my first memory waking up, not at all a fan of the tube in my mouth, desperately trying to sign to someone that I was choking horribly. Fortunately, the memory lasted only 30 seconds or so, and next thing I know (hour or so later) I'm awake, breathing on my own, and felt like a million bucks quite honestly, given the circumstances. So anyway, I laughed at one moment and was briefly more than a little perturbed at the other. I tell you what, though, one thing I never did was really think about everything that happened in between. Thanks to these great posts, I have the perspective to do that now, so thanks for that Ramjet.

It is kind of interesting but predictable I guess how surgeons get all the glory, so many appearing in "signatures" on this site. Don't think I've ever seen a specific member of the anesthesia team ever mentioned or honored in remotely the same way. I sure know who I'll be thankful for next time around, though...

 

[Mom2izzy]

Intubation

There is one time I bet the anesthesiologists get the recognition they deserve. When they appear to give women in labor their epidurals.

I can tell you that I almost named my child after the anesthesiologist who was there during my labor (which ended up as a C-section)! If I had had a boy he may have been called Schrock. It didn't really work for a girl...ha ha.

 

[OldManEmu]

Ramjet
I know what you are on about, I only met the head anaesthetist who is also the profusionist for my redo and was very relaxed after my discussion with him pre surgery. His two assistants are just the extra hands on the day. I am a bit of a control freak and like to be fully informed and document the risks and the rolls and responsibilities before anything takes place.

 

[ramjet]

I couldn't agree more, on both counts, so thanks to you both. :thumbup: My own lazy eyes gave up prior to the reformatting, and sure am glad I returned, those two posts are a must read in my opinion.

You know, I've joked once or twice here how my first medical intervention pre-surgery was a horribly botched line for the anesthesia team that was tried and failed at multiple locations. It finally resolved itself only after about half an hour of trial and error (needle sticks, bruises, etc) in basically the last available location, leaving me with a potentially very unnerving pre-surgery moment. Fortunately, things like that don't bother me, though, in fact I was actually laughing at them. But, much to my regret at the time, given my sense of humor, I resisted the temptation to say: "Does this mean we're going to just have to use a local?" :eek2: :biggrin2:

Well, the bookend to that moment was my first memory waking up, not at all a fan of the tube in my mouth, desperately trying to sign to someone that I was choking horribly. Fortunately, the memory lasted only 30 seconds or so, and next thing I know (hour or so later) I'm awake, breathing on my own, and felt like a million bucks quite honestly, given the circumstances. So anyway, I laughed at one moment and was briefly more than a little perturbed at the other. I tell you what, though, one thing I never did was really think about everything that happened in between. Thanks to these great posts, I have the perspective to do that now, so thanks for that Ramjet.

It is kind of interesting but predictable I guess how surgeons get all the glory, so many appearing in "signatures" on this site. Don't think I've ever seen a specific member of the anesthesia team ever mentioned or honored in remotely the same way. I sure know who I'll be thankful for next time around, though...

Thanks for the reply "EL", and if the anaesthetist "pranged" ("missed") getting your IV there is usually a few reasons ....you may have unfortunately poor vein presentation, or you were actually quite anxious (naturally... like we all are at this time) and your peripheral veins had "shut down" somewhat, or you were somewhaty dehydrated ( as we are due to having fasted prior to the operation) and your veins had collapsed a bit...I'm sorry it was messey getting your IV, but at least you could laugh at the situation...these folk usually get IVs so quickly and so effectively.... they make the rest of the medical profession look like amateurs (or just maybe they were letting the junior person have a crack at your veins, and instead of asking for help the junior person persisted and persisted having a go....the most experienced sometimes miss an IV, and they have no hesitation in asking someone else to have a go rather than persist making a mess of your arm etc)...sometimes just another set of eyes and another technique can make all the difference when getting a tricky IV. Once again, I would not hesitate to let the medical staff know next time you have an IV that you can be notoriously difficult to cannulate and hopefully they will get the IV first time.

I also "awoke" with the ETT tube in my mouth, but I couldn't open my eyes or move for a while, I could hear people talking. I can remember thinking to myself I will lie still for a bit, then when they aren't expecting it I will sit up and deflate the ETT cuff (by busting off the small pilot baloon) and remove the breathing tube. Later that night, when fully awake, my wife told me that I had kept everyone amused as I had sat bolt upright a few times (after open heart surgery mind you) and disconnected myself from the breathing ventilator machine, which in turn activated a range of alarms (low pressure alarm, hypoxia alarm, tachycardia alarm, hypocarbia alarm)...they held me down and reconnected me while they gave me a conconction of their wonderful drugs to settle me and sedate me until my body was fully ready to remove the ETT tube.

The process of removing the ETT can be quite a tricky time, and they have to get the timing just right. If they remove the ETT too soon your airway can occlude and you can choke and die, and if they leave it in too long you awaken and try and yank it out yourself, which can do a lot of damage as there is a small baloon near the end of the ETT which sits beyond your vocal cords and in your trachea, and if you yank the ETT incorrectly you can damage your vocal cords. They call this phase the "emergence" phase...where you are "emerging" from your general anaesthesia, and we all emerge differently and at different times. I once emerged (or awoke from anaesthesia) giggling uncontrolably and convinced they had done a caesarian section on me...fancy that, and I'm a male!!! I giggled until my mouth ached, and it went on for about two hours and everyone else was laughing with me as I must have looked funny, especially when I kept asking for my baby, and giggling all the time. I just could not stop.

Clearly I was having a pleasent "side effect" from one of the many medications they had given me. I had never had anything more than occasional headache tablets before, so I guess it was no surprise that I had a funny reaction.

Anyway, I totally agree; the anaesthetist is indeed the forgotten and neglected specialist...I gave mine a special box of chocolates and arranged to give him a special thankyou to him.. I wish I could have given more as it just didn't seem enough.

 

[ElectLive]

There is one time I bet the anesthesiologists get the recognition they deserve. When they appear to give women in labor their epidurals.

Very good point. Thinking about this even further now, if my wife had been with me (she was with our 2 1/2 year old) during my little pre-surgery adventure, she might have joked that since she gave birth to our daughter sans epidural then I should just "man up" and do the same... :rolleyes2:

 

[ElectLive]

ramjet - Thanks for even more great info. I was certainly not overtly anxious but hard not to be on the inside obviously, particularly with a 2 1/2 year old and pregnant wife waiting for my safe return. Dehydration certainly could have been a possibility too. I'm a child onset diabetic so have had many opportunities for iv's in my life, and hundreds of venous blood draws, all generally without problem, so it was a little surprising. In fact, I had what I called the perfect "target" in my right arm for blood draws that basically got "destroyed" while all that was going on, so my A1C punctures are not quite as easy now as they used to be.

It was a "junior" member of the team at first, and he quickly brought in the "senior" member for assistance. They were both incredibly professional, far more apologetic than they really needed to be, and I never really doubted anything they were doing...just one of those things that can happen.

Your story about "emergence" is very interesting. It seems like we have had hundreds of different stories of that phase here, it's just different for everybody. I literally couldn't have asked for a better "awakening". I was crystal clear, not the slightest ill effect. If it hadn't of been for that brief 30 second window of time with the tube, I would of thought I'd just taken a nap, and never imagined my surgery was actually complete.

 

[enkaynj]

I didn't realize you could have the sternal wires removed. Mine are still in and we are BFF.
Any idea why they would remove the wires ? Doesn't that need more surgery ?

 

[Gail in Ca]

Certainly, I'm glad to be alive with no brain damage! However, I do like to be informed before a procedure, and the fact that a resident was going to place the tube was not brought up when I spoke to the doc. However, I know he must be my surgeon's choice for long, complicated surgeries, and I have had no problems awakening after OHS or this latest procedure. I guess I just felt that more care should've been given me, as I've been through 3 OHS, subarachnoid hemorrage, endocarditis, and just thought the chosen one would place the tube, not the resident. After having endocarditis that led to my 3rd AVR, I am more cautious about possible infection, and the major bruising, laceration and numbness of my tongue gave me a bit of the worries on the endocarditis front. I do know that we tend to minimize the importance of the anethesiologist, just take it for granted that this will not be the problem area when having OHS or any other general anethesia procedure. Well, I've been through 5 general anethesia procedures in my lifetime, and have had my tongue injured twice, now. When I wanted my wires removed this time, I didn't know until talking to the anethesiologist the night before, that it would be general anethesia. I have to say I was bothered by that, but I was already admitted, and so went ahead. My daughter said later that she had a bad feeling about my decision to have the procedure, so maybe I had a dicey time on the table, but luckily didn't know it. Also, I would've been happier if the doctor or nurse in post op would've told me my tongue had been traumatized.
No one said a word to me about it and I had to bring it up to the nurse as she wheeled me to the elevator to go home! I was awake enough at that point to feel it.
Anyway, I'm here, and hope to never have another surgery that has anything to do with anethesia or my sternum!!

 

[Jkm7]

Gail,
I am so sorry to hear of the trauma you suffered but just want to point out whenever we go to a teaching hospital, there is every reason to think interns and residents will be involved in our care.

I certainly do understand all the points you make and would not like it anymore than you do. A teaching hospital will have their interns and residents do the 'hard' cases along with the routine as that is how they learn. We all hope they don't learn the 'hard' way on us.

I definitely think a doctor or at least a nurse should have spoken with you about the injury to your tongue.
Hope it heals well and the worst of it is behind you.

 

[Gail in Ca]

Thought I would add a final bit on this issue. I went to my dentist last week for regular cleaning, check-up and mentioned what had happened to my tongue. He said he often has seen chipped teeth from this procedure, so there you go! It does seem to happen more frequently than I ever thought it would. He said one of his patients had both front teeth badly chipped! Yikes! So, I guess this is something that's good to know ahead of time, as a risk of any general surgical procedure.

 

[aviator67]

Wow. Scary stuff. I'm kind of glad I didn't read this before my surgery.

Oops, I just read it and I go in next Monday! I believe I meet with my anesthetist on Friday morning.

 

[Debbrn]

Not only do the anesthesiologist take care of your breathing, they also put in the different lines for complex surgeries. The morning of my surgery I asked the anesthesiologist what kind of lines he was going to put in me. When he told me the answer i laughed. I explained that only one nurse in that institution had been able to even put in a medium size IV, that the last time they tried to put in a central line it took several tries, and then he realized he could not put the art line in the usual place. His response was "so this is how I am going to start my day". The surgery I was going to be having was my 4th OHS. He was able to get 4 large IVs. Three out of four went bad in the first 48 hours. It took him several tries to get the central line in. He also ended up putting my arterial line in my ulnar artery which most anesthesiologist will not do because of the risk. The ulnar artery is the one on the pinky side of your wrist.

One of the reasons that I traveled for my OHS was because I knew I needed an anesthesiologist that was experienced with someone with poor IV access.

Debbie