Monday, July 4, 2011

The bougie.

What is a bougie? Well, I don't actually know how to describe it, but it's the most insignificant-looking thing ever. It looks useless, but catching it in action reveals its true value. Like most important things in life, it is firm, and slightly pliable. A long tool, of differing widths, made out of some sort of plastic I think. Some are hollow inside (those are the coolest cause you can actually ventilate through them!) and others are not. On the whole, absolutely nothing to write home about at first glance ... but let me tell you, once you experience a bougie, there's absolutely no turning back.

A bougie is a life-saver. It saves yours figuratively, and that of the patient literally. I can personally vouch for that. It can reach those places that few other tools can. I have my own bougie (a top of the range hollow one), in a funky blue colour. I just wish I knew where it was. It was always in my bag, but somewhere between my multiple moves, it got misplaced. Misplaced ... and forgotten ....

So a bougie is used for difficult intubations. The idea is to get it into the trachea, then railroad the endotracheal tube over it. Thus securing a difficult airway. The one thing that consoles me is that everyone has an epiglottis, and everyone's epiglottis lies over their vocal cords. So even if you can't see them - they're there. And somehow, the bougie almost always finds that spot.

The patient had a BMI of 47,9, plus co-morbidities. The procedure was a shoulder replacement. The position was "the beach chair". Intubation was inevitable. I could almost feel the problems around me. On the table I tried to position the patient as best I could. Position is extremely important for a satisfactory intubation especially in huge people. Anyway the painful shoulder kept getting in the way of the perfect position. So we were basically screwed before we even started. The IV was nothing but a stroke of luck. The arterial line proved much more of a challenge, but the cherry on the cake was the intubation. It will most certainly stay with me.

On induction, I could ventilate, but had to use both hands to hold the mask. Not exactly fun, but anyway. I decided to check the airway before relaxing the patient. The mouth opening was really small, with a 2cm overbite, (not good), but I could see the vocal cords. So far so good. Previous neck surgery made me a little wary of fiddling with the neck too much, but hey I could ventilate which (at the expense of my arms) was a huge bonus.
Muscles were relaxed with esmeron, and as I injected it, I wished that I'd had the sense to bring some Bridion ( suggamadex) back with me. Bridion reverses esmeron almost instantly. It's really quite awesome.

So we relaxed and ventilated. First attempt at intubation confirmed all my lingering doubts. I could see the cords but the mouth opening was so small and the ET tube just wouldn't go where I wanted it to. The introducer was too pliable and just kept bending the wrong way. The teeth were in my way and the neck was stiff. What joy... In between, I spent long agonizing moments ventilating. I cursed the patient for being so fat. I cursed the surgeon even more for operating without putting the patient on a diet first. And I cursed my short arms and small hands. After two more tries I asked for the difficult airway trolley and was considering a fast-track LMA, when I spied a bougie!!! Yay a bougie !!!!

Well, what could've been quite a disaster, became a very smooth and sophisticated procedure. The bougie - just pliable enough to bend into the shape I wanted, and firm enough to hold the shape - found its mark with the first try. The tube slid elegantly over it ... and we were in business! I said a mental prayer of thanks for the genius that invented the bougie. Would most willingly have kissed his feet at that moment.

My arms shook for about half an hour after all that, and ached for about three days. There was a damn good reason why I used to carry my own bougie around. How could I have forgotten?

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