Ghost rider

To all diabetics and borderline candidates out there..
Please ensure good sugar control , healthy lifestyle eih..
You don't want to end up having your foot being debrided like the pics i took during my on call last night !!!

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"MAfeitz... please don't proceed with your case as we have a mediastinal mass case for intubation coming in... "

Alamak.. I was about to begin the first of my 6 diabetic food debridement , and it was 5 pm. I've promised the Orthopods man to start early !! However , you don't want to piss off your lecturer cum specialist on call by doing what you want. How bad can it be ?

There he was , 19 year old boy who has been unwell for the past one month came in today witha history of severe shortness of breath for the past 3 days. It was getting worse during work in McDonalds and was brought in by his friends to the Emergency department.

You could see him puffing away , with all his accessory respiratory muscles used up excessively. He was on high flow oxygen but his saturation only touched 88 - 90%. He was bending himself so much , looking for the best position to breath. His cough was very wet and not able to speak a single word without being very breathless.



Obviously , being presented to medical carers for the first time , there was no exact plan for him by anybody. He was referred to us for intubation ; airway protection by the primary team ; a typical referral to anaesthetist when one does not know what else to do. When we ask what will be the plan.. everybody just shrugged their heads.




A quick look... followed by a long sigh of the chest xray took our breaths away.We looked at each other , even Prof who was involved in the discussion was a bit puzzled wondering what to do now. Even the consultant Cardiothoracic surgeon was not able to offer anything . It is up to us now the anaesthetist to save the day.
"Mak ai... bloody big mass !! "

Thats one hell of a mass compressing the lungs and airways. You wonder how long has it been there as it is definitely not a 3 day story. He has enlarged lymph nodes all over his body ; making the provisional diagnosis of lymphoma being the most likely reason.

We prepared everything - all possible ways to intubate.The plan was to gas him down and have a look but he desaturated so fast as we begin to "sevo" him down. With this condition , fibre optic intubation was impossible because sedation causes him to not use his accessory muscles hence the direct obstruction to his airway.The trick is to maintain his airway while he is spontaneously breathing . Muscle relaxants are a no - no here ! We had to restrain him hard as he was struggling so much - being so exasperated for breath. At this stage he was very restless - being in a very severe hypoxic state. ABG showed PaO2 45 mmHg PCO2 122 mmHg ( normal 35 - 45 mmHg) .

"Lets just intubate him awake... " said Prof.
Wah.. tak pernah buat ni.. shoving in the tube with the patient awake ??

We sprayed some local anaesthetics into his mouth and gave him 100% Oxygen. His saturation maintained the same though. 20mg of propofol was pushed in to settle him down and the rush began . He was in a 45o position and that makes it difficult to laryngoscope .. not an optimum position.

Mak... tolong.. mak... toloonng.... he cried so hard. He was not ready to die.. not in this way.
His saturation just went crashing .. 70%... 50%....

" I can;t see the cords... He is fighting me.. " said my specialist. Damn..It must be so traumatic and uncomfortable for that boy having a laryngoscope shoved in . He was coughing and struggling violently.

40%.... 38%... 34%...

OK... got it !!

Prof ... I cannot bag him.!! Its too tight.. .
I can't hear any air entry here !
His lips are blue !!

Put him on lateral position.. now !!! I can sense that panic is taking over !

On my count... One.. two... turn.
ETT suction please... get the secretions out ..he is so chesty !!

OK better... better....

I swear to you , everybody was looking so anxiously at the monitor , watching his SPO2 and ECG , praying very hard that we will not lose him to hypoxia...

38%... 50%.... 65%..... 80 %.... 92%...
YESS !!!! There was an air of relief in OT 16 at that moment. Wow.. adrenaline was certainly pumped up really hard amongst us then...

After stabilization , we pushed him to the Cardiac ICU ; and there he was - so fragile and gullible. I really dont know what will happen to him.