The Time I Hesitated

One night when I was the night trauma chief, I hear overhead: “Code blue, medical ICU. Code blue.” Code blue means that a patient has gone into cardiopulmonary arrest (or is dangerously close). Fortunately, surgeons are not part of the response team, so I only respond when it’s one of our patients. Since we didn’t have any general surgery patients in the medical ICU, I breathed a quick sigh of relief and kept on going.

A few minutes later, my pager goes off. It reads: “Need a surgical airway ASAP, MICU.” Definitely among the top sphincter-tightening pages you can get as a surgery resident. It means the code blue team cannot move air into the patient, probably have tried and failed to place a breathing tube through the mouth, and need to resort to cutting a hole in the neck. Each additional second is another second her organs (including her brain) are deprived of oxygen. I call my attending while running towards the ICU, who tells me he will be right there.

A frantic crowd awaited me in the ICU. “Are you surgery??” I nod yes, and people part ways as I’m ushered into the room. Aside from the nurse giving chest compressions, I feel all eyes are on me. The patient’s face was bloated, expressionless, and pale. Her oxygen saturation was in the 70s. The anesthesiologists at the head of the patient spoke up: “We haven’t been able to intubate. She has a large neck tumor. We paged the head and neck resident, who isn’t here yet. It’s up to you, we can try to intubate once more or you can make the cut.”

In that pivotal moment, the next few seconds felt like minutes.

My mind floods with too many thoughts. I’ve never made a surgical airway before… but I’ve done it once on a cadaver. Her oxygen saturation has bottomed out, brain damage is setting in… Just do it, the risk is justified. Fear stays my hand. What if I cause bleeding that obscures the field? What if I end up compromising our best shot at an airway? Maybe I should have anesthesia try one more time?

Instead of making a decision, it’s made for me. My attending comes racing in, less than a minute after I arrived. He hears the same story from anesthesia, pauses a moment, then agrees that we should make the cut. I ask for a scalpel, cursing myself for not carrying one in my pocket at all times. A nurse dashes out the room to the supply closet.

Along with the nurse, the head and neck resident who was paged earlier comes running in. I recognize the trepidation in his face, I probably had the same expression moments ago. Since it’s a head and neck patient, my attending guides him through the procedure as I do my best to assist. We are able to secure the airway quickly and safely.

Walking away, I couldn’t shake my feelings of frustration. My attending did exactly what I had envisioned. I could have done it, echoes through my mind. I tell myself that I should be satisfied that the procedure went well.  Months later, I’m still not sure what the right answer was — did I do the right thing, making sure someone with experience was available? Or should I have had the confidence and will to carry out what clearly needed to be done?

The only thing I can say for sure right now is that you should always carry a scalpel in your pocket at night.



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