Sunday, September 19, 2010

Double lumen delight.

The correct placement of a double lumen tube brings a level of elation that's difficult to explain. It's not that it's so hard to place, it's just that you have to get it exactly right, or there is no point.

A double lumen tube is basically two endotracheal tubes rolled into one. It is used to ventilate either the left or right lung in isolation, or both lungs independantly of each other.
What could be cooler than that?? I'm sure some would say, small things amuse small minds, but there you have it ... a double lumen tube really excites me!! The down-side is that more often than not, they are accompanied by sick patients, sick lungs and major surgery ... but for now we'll stick to the bright side.

I was fortunate enough to have a very patient and down-to-earth teacher, so where double lumen tubes sometimes strike fear in the strongest hearts, for me they are an absolute thrill. An integral part of placing the thing, is the use of a fibre-optic bronchoscope to confirm correct placement. Luckily, or unluckily, for me, training in deep dark Africa, a back-up plan is always far more important than the gold-standard which is usually not available due to lack of funds, lack of function, or lack of fingers with integrity. So I was taught another, extremely simple, yet well-documented, and basically fool-proof method of confirming tube placement and functionality.

Can't say I was surprised when I learnt that double lumens were not a big part of island- style living, but I was disappointed. Just another skill that would get lost at the expense of greener pastures.

Imagine my surprise when the bane of my existence ( a fellow anaesthetist), called, booking me for a right-sided pneumonectomy ( removal of right lung). I had introduced myself to him about ten months ago. He'd declined to shake my hand, and has never spoken to me.

After the call, I sat back and reflected ... This was good ... and ... this was bad.

Good was the fact that the chance to prove myself had finally come. A successful pneumonectomy, with a thoracic epidural, and lung isolation spoke volumes.
Good was the fact that I'd get to play the double lumen game again.

Bad was the fact that I hadn't done a lung in about three years, and very bad was the fact that I'd be working with an unkown surgeon, without any back-up. Oh, my colleague offered his support and services during his phone call, and I just thought to myself, WTF!!!!!

I sprang into action!! Arranged to meet the surgeon a few days before the case. We had a lovely discussion, familiarised ourselves a bit, and were in full agreement on how to handle the case. Then we spent a significant amount of time examining the patient together, and answering all his questions. I felt confident that things would be ok, and that the surgeon was decent. It does make a difference you know.

The case was booked for 9 am. At 8 am I put up all the IV lines, the arterial line and the thoracic epidural. A 8:50 the patient was induced and I picked up the pre-prepared 39F left-sided double lumen tube. My moment had come!!!!!!

I gently inserted the laryngoscope and started inserting the tube. There is a very specific way of doing this and I was concentrating. Next thing I knew, huge hands were roughly grabbing my tube and twisting it in such a way that my entire placement technique was totally screwed up!! The surgeon had shoved in the tube!!!!! And I didn't know what the position was!! I quickly checked, and of course it was down the right lung instead of the left lung.

I felt personally violated.

Always poised and professional, ( that's my policy) I politely told him to remove himself from the intubation process. He tried to argue. We agreed for me to have a go, and for him to do the cross-check with the option to place it himself if he was in any way dissatisfied.

With an audience made up of my esteemed colleague, the surgeon, the assistant, the referring GP, the scrub sister, all the junior nurses and runners in the complex as well as a fantastic anaesthetic nurse, who was being wasted as a runner, I proceeded to place my tube.
I made a huge show of checking the position and function, all the while praying that everything was as I expected it to be. I showed off my good - old confirmation technique to the full (thank you Sandy!!). Only once I was totally satisfied, did I beckon to the surgeon to perform his check.

Exactly two minutes later I got a wink and a hug. And exactly two days later I was given the option to dope for him on a regular basis.

Seems actions speak louder than words.