Earlier this year, I treated a critically ill patient in the emergency room. He was essentially unconscious. He needed intensive care, which we initiated. He needed a breathing tube – meaning I was going to have to temporarily paralyze him, open his mouth and place a plastic tube into his windpipe, which we would then connect to a ventilation machine to breathe in his place.

My initial assessment was that intubating him would be routine. There is no such thing as an “easy airway,” but there were no red flags that it would be unusually difficult.

And yet…

Prepare for the worst

Whenever I intubate a patient, I always assume the situation will be chaotic. That way, if it doesn’t, everything goes smoothly, and if it does, I’m ready.

Emergency medicine training prepares doctors like me to identify delicate airways before beginning the intubation procedure. There are mnemonics that remind us of things to watch out for, both in terms of anatomy And physiology.

If anything from these checklists stands out, I will let my colleagues know so that everyone knows to adjust accordingly. For example, if I know the patient has suffered head and neck trauma, I might anticipate a hematoma (a trapped collection of blood) in the airway, which could block our tube, or worse, become a land mine and explode in our face. An airway full of blood is pretty much the worst case scenario during this procedure.

Bring your “A-Game” to every case

Even though I think the matter seems common, I still prepare myself for challenges. This means several things:

Use video. In the past, we would intubate using non-fiber optic video equipment. In fact, I trained both ways (with and without) and for a long time preferred intubation without video, because I preferred to “own the airway.” When everyone can see what’s happening on a video screen, a lot of unsolicited advice begins to circulate. I don’t like it. But medical literature says it’s best to use video first. So I changed my practice. I’m not above data. There are still times when video vision of the airway is actually worse than that seen with the naked eye, but I start these days with improved video equipment.

Suppose I will need the elastic candle. What is a spring candle (pronounced BOO-zhee)? It’s a long, thin piece of plastic with a curved tip. It is much thinner than the hollow breathing tube and easier to handle. Basically we put the candle where the breathing tube will go. Once it is in place, we place the breathing tube on top of it. Imagine that the breathing tube looks like a large, fragile straw. The candle is like a wand. Once the wand is in place, you can slide the straw over it. Once in place, you remove the wand. It’s like a guide wire.

Now, I don’t use the candle automatically even though it probably increases overall success rates. For what? Because it adds steps, which add time. But I always have it next to me, ready to use. This way, I benefit from it without delay.

Set up. I almost always intubate with the patient’s bed at about a 30° angle, not flat. This helps in several ways that I won’t go into, but it takes time to set up. Sometimes I feel like my teammates are getting impatient, but it’s worth it. It’s actually one of the main “hacks” that turns seemingly difficult airways into easier ones.

You know how you play tennis, chess or whatever, you do better when your opponent is good? I feel the same way about the airways. I’m at my best when things are at their worst. So the cognitive trick is to try to get as good at routine cases – bringing my A-game to each airway.

When things are bad

In this case, I had organized everything as if it were a difficult airway, even though nothing seemed unusual.

Just before we started, the nurse tested the IV line, as always. It “rinsed” well. She then administered sedative and paralytic drugs. I waited for the paralytic to take effect. You can tell when the paralytic is working because the patient stops breathing. This moment is always a little exhilarating (it’s “departure time”) and terrifying; the second we remove the oxygen mask so I can access the airway, time is running out as the patient is no longer receiving oxygen.

The paralytic may take 15 to 30 seconds (or more) to work. Those are long seconds, I tell you. In this case, something was wrong. He continued to breathe. The paralytic was not working. This is, I must mention, physically impossible. Once the paralyzing drug is in your bloodstream, it only takes a short time for the skeletal muscle in your diaphragm to be completely prevented from contracting.

“Why the hell is he still breathing?” I thought. I asked the respiratory therapist to put the oxygen mask back on the patient, saving time while we went through a checklist.

• Had the nurse given the correct medications? Yes.
• Did the nurse flush the tubing after administering the paralytic (to ensure the medication is in the body and not the tubing)? Yes.
• Did we give the right dose? Yes.

I had no answer to our riddle. “Okay, we can intubate without a paralytic. So maybe we should just move on,” I said. After all, this was an otherwise common airway. I have intubated several times without a paralytic, but usually during CPR. I was about to continue when I thought about it. Maybe the paralytic was in the body, but not in the right place. Maybe the IV wasn’t actually in a vein, even if the nurse felt that way. This can occur when a patient has an unusual amount of soft tissue. The fluid appears to flow freely through a vein, when in reality it just diffuses easily into the soft tissues of the arm (usually we feel a lot of resistance on the syringe when this happens, but not always).

“Actually, let’s take a break.” I said. “Put in a new IV and let’s start again.”

I ordered an ultrasound machine which I used to examine the area under the original infusion. I put 10 cc of saline into this IV and looked at the vein. It didn’t light up like it would if the IV was in the vein. Instead, the saline solution could be seen spreading into the soft tissue around that vein. Indeed, the paralytic was in the patient’s body, but not in the vein. It sat there among the ligaments and muscles and fat.

This meant that the paralytic Ultimately act once absorbed into microscopic blood vessels, but not for several minutes. I asked the pharmacist if a full second dose would be harmful, because 20 minutes later the patient would have actually received a double dose in this case. It felt good to do it, she said.

The nurse started a second infusion. We confirmed it was in vein. She gave another dose of paralytic. The patient immediately stopped breathing. I have made progress in the procedure.

What I discovered when I reached the epiglottis – the border where the respiratory tract and gastrointestinal tract divide into two – was completely unexpected. This patient’s airway anatomy was going to be extremely difficult to navigate. The hardest I’ve seen in years. Getting the breathing tube through the vocal cords was going to be like threading a needle – with arms outstretched, at a funky angle, with the pressure of time and an audience.

I grabbed the candle and managed to guide it right between the vocal cords and into the windpipe – even that wasn’t easy, but I managed it. After that, I slipped the breathing tube onto the bougie and connected the patient to the breathing machine.

Mission accomplished. The respiratory technician gave me a very nice compliment. I don’t remember exactly what was said, but it was a great feeling. These people know crazy airlines.

Fast is slow and slow is fast

One of my mentors, Scott Weingart, MD, always says “fast is slow and slow is fast.” What he means is that if you try to rush something, you’ll end up making a mistake that will cost you more time than you saved. And taking the time to save and start again may seem extremely slow, but it actually saves time.

I think if I had continued the intubation without stopping the procedure for the nurse to place a new IV, the patient’s breathing (and any other movement – he was not entirely unconscious) would have forced the breathing tube to be inserted in this trachea almost impossible. This would have increased his time without oxygen, which has obvious consequences.

What initially seemed like a routine procedure became almost impossible. Fortunately, we handled the situation well. The difference was not a technical feat, but rather a cognitive process. I think this is common, not only in medicine, but in many difficult situations, in almost any demanding field.

Have you thought about getting out of sticky situations in your work? Share your best moments in the comments below!

This post was originally published in Inside Medicine.