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Tue Dec 2 16:05:40 GMT 2008

NYTimes

A Scare Forever Etched
By LARRY ZAROFF, M.D

This happened in the 1960s, when I was a young doctor, a fellow in thoracic
surgery at a Boston hospital. My patient was 2 years old, a beautiful boy, a
Van Gogh sunflower, yellow hair, blue eyes, alert and tranquil despite the
near-fatal accident that had put him in the hospital.

His father, a physician, had given him an aspirin. The pill, perhaps too
large for his age, had lodged in his windpipe. The doctor, not a surgeon,
performed an emergency tracheotomy with a kitchen knife - made a hole in the
neck into the breathing tube. He saved his son's life.

At our hospital an expert plastic surgeon revised the makeshift tracheotomy,
inserting a silver tube for an airway. Except for the period in the
operating room, the father never left his son's side.

The boy recovered remarkably well, breathing through the metal airway
without difficulty.

Several weeks after the operation, the silver tube was corked. Again the
child did well, able to breathe without difficulty around the tube. After
several more weeks at full activity, he was readmitted to the hospital for
removal of the tube.

I was the resident on call. And I was well prepared for any eventuality. Or
so I thought.

The corked metal tube slid out easily. I placed a small dressing over what
was now a hole the size of a dime in the center of his throat. I made
rounds, dictated discharge summaries and descriptions of that day's
operations. Every hour I checked on the child.

Around 11 that night - a time of silence and emptiness and loneliness in a
hospital - I noticed he was breathing faster. Within minutes his color
turned dusky, then blue. His airway was blocked. He could not breathe.

It was a crisis, like no other I had faced. From the emergency materials in
his room, I took a pediatric bronchoscope, a thin tube with a light at the
end, to visualize the airway, and tried to pass it through his mouth into
the windpipe.

The bulb blew out. (No fiber optics back then.) I quickly inserted another
bulb, which promptly blew. I had no idea how much time had passed. But I
knew that in minutes the child would be dead, or at least brain dead.

I had a tracheotomy kit, with surgical instruments to incise the neck and
insert a new tube. But I had no assistant.

At that moment, an experienced resident happened by, making late rounds. I
grabbed the knife and slashed - no other word works - through the dime-size
hole in the boy's neck.

I found the windpipe completely divided. The previous metal tube had been
acting only as a stent, supporting the separated parts of the trachea. When
the tube was removed, the distal end of the windpipe, its lower half, had
collapsed and retracted. That critical part, connected to the lungs, was now
under the breastbone, blocked and useless as a conduit for air.

Using a long clamp, I was able to pull the distal end into the wound and
hold it open to the air. The child breathed. I did the same.

I then inserted another tracheotomy tube into the lower, divided end. By now
the boy was pink and alert. I sutured the new tube in place and then,
finished, I felt finished.

I sat for a moment, terrified at what might have been: the death of a child
under my care. His father, a physician, just outside.

I recovered enough to talk to the father. His son, I explained, had had an
emergency operation to save his life. I called the plastic surgeon, who for
the second time revised the tracheotomy in the operating room.

I knew the child would eventually require a definitive repair. But for now
he was stable, and so was I.

Such experiences etch the lives of young surgeons. In the following decades
of surgical experience, I have never felt as distressed as I did that
evening.

In perspective, the event was a great teacher. But one such lesson is enough
for a lifetime.

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