Chapter 3: New Year’s Eve Intubation

I remember the first time I felt like a doctor. It was January 1st, 2018 at 0630, halfway through my intern year.

I was an intern on 24 hour trauma surgery call for New Years Eve 2017. The hospital was pandemonium. My pager went off so often I couldn’t delete the pages fast enough. I went to more than 20 traumas over 24 hours. On average we admitted 1 patient every hour to an ICU bed. In the emergency room young patients, mostly intoxicated, overflowed into the hallway. The hospital ward beds were at capacity. I sat down 3 times over 24 hours. Finally at 5:30AM the following day I signed out my fellow intern and turned off my pager. All I had to do was round on my 12 colorectal patients, write notes, and go home. After reviewing the morning labs and vitals for my colorectal patients I received a call from the general surgery chief resident. He requested my assistance in the trauma bay. 4 critically ill patients involved in a horrific car accident would arrive in the emergency department within minutes. I dropped my list of colorectal patients and ran to the ED.

The 4 patients required every available physician and nurse. My senior resident managed the first two traumas himself, intubated both, and managed their triage- one to the operating room and one to the CT scanner. The junior surgical resident managed the third trauma, intubated him, and took him to the second available CT scanner. I was alone to manage the 4th trauma- luckily Dr. Amar Shah, an excellent emergency medicine physician, was available to support me. After a several minutes both of us noticed our patient’s decline in mental status- in a trauma patient this is concerning because it might mean they will not be able to breath on their own or become unable to “protect their airway”, meaning oral secretions can travel into his lungs causing aspiration pneumonia. We both agreed the patient should have a breathing tube inserted to prevent both complications.

Suddenly a nurse appeared with two drugs, etomidate and rocuronium, and a respiratory tech appeared with an intubation tray. Before I realized what was happening, we performed a time out to confirm the correct procedure and both drugs were injected. The respiratory tech handed me the laryngoscope.

There are two kinds of laryngoscopy (looking at the vocal cords): direct and indirect. In direct laryngoscopy the physician must tactfully move all anatomic structures out of the way in order to obtain a “direct view” of the vocal cords. In indirect (aka video laryngoscopy) a lens is placed at the end of the laryngoscope blade, giving the operator a much clearer view of the vocal cords. Video laryngoscopy is easier to learn especially for non-anesthesiologists.  

Unfortunately for me both of the video laryngoscopes were used by the surgical residents. As I felt the patient’s jaw relax and his breathing stop I slid the direct laryngoscope past the right side of the tongue into the vallecula, the space immediately behind the epiglottis. Just as I achieved a Grade I view of the vocal cords someone I heard a loud sound- for a split second I looked to see what it was. I looked back at the patient- now I had a grade 4 view.

Successful direct laryngoscope relies on millimeter-precision movements of the elbow and shoulder. Useless. At that moment the patient’s oxygens saturation started to drop- first to 95, then to 94. I knew I had to get this tube in before his oxygen saturation dropped to zero. My heart rate skyrocketed.

I was physically and mentally exhausted. I hadn’t slept in over 24 hours. I had no cortisol left in my body. Then something happened. I slid the MAC4 past the tongue and into the vallecula, achieved a grade I view, then smoothly passed the endotracheal tube past the vocal cords. As I ventilated my patient with a purple ambu-bag his saturation continued to drop. Then it bottomed out at 68%.

As I ventilated him his oxygen saturation returned to 100%. It felt like the slowest intubation of my life- but it must have occurred in less than 15 seconds per the patient’s starting and ending oxygen saturation. I felt like my sympathetic nervous system and fight-or-flight response were turned off. I checked my heart rate: it was exactly 60. One beat per second.

After that moment everything seemed the same but somehow completely different. I was still tired, hungry, and had to work long hours for minimal pay; but I wasn’t the same person anymore. My perception was fundamentally different.

Published by Nabil

Nabil Othman, MD is an anesthesiology resident physician at Cedars Sinai Medical Center in Los Angeles, CA. As a Michigan native he advocates calling carbonated, sugary beverages "pop". When he is not an indentured servant in the hospital he enjoys CrossFit, telling everyone he meets about CrossFit, and attempting dangerous hikes in Hawaii with his college roommates.

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