BehindTheMedspeak: It is more important to know something is not right than exactly what is wrong

As so often happens, events in the operating room and the practice of anesthesia can be extrapolated to the world outside.

Last week I undertook a what appeared to be a routine anesthetic induction: fentanyl, midazolam, propofol, succinylcholine, oxygenation by mask, endotracheal intubation with my trusty Mac 3 blade and a 7.5 endotracheal tube.

When I did the laryngoscopy things looked funny, with what appeared to be the trachea and vocal cords off the right side instead of midline, but I rationalized the odd appearance as due to the patient's being old (late sixties) and natural human physiologic variation.

When I connected the tube to the breathing circuit and squeezed the bag there was "fog" in the tube (evidence of water vapor, produced in the lungs with each exhalation and evidence of correct tube placement: a tube in the esophagus doesn't show such condensation).

I watched the lady's chest and abdomen and there wasn't much chest movement — in fact, there wasn't any, and the stomach seemed to inflate with each breath I gave.

Well, I rationalized, sometimes that's the case even when the tube's in the right place.

The circulating nurse, sensing my doubt, said, "Oh, I can see the fog in the tube, it's fine," and went off to do what circulating nurses do.

I taped the tube in place, glancing over at the end-tidal CO2 trace for confirmation that the tube was in the trachea (no CO2 = esophageal intubation) — but there was no CO2 trace or numerical value.

Huh.

Must be, I rationalized, that the thing is still warming up (it was the first case of the day, and sometimes it takes the machine a couple minutes to start working).

Then I reached for my stethoscope to listen to breath sounds, but before I could put it against her chest the high-pressure alarm on the ventilator started beeping.

Okay, I thought, that's four things that aren't right — enough.

I pulled the endotracheal tube out and took another look: this time things looked like they were supposed to, big fat white vocal cords midline (top) — the way they should be.

I put the tube in and guess what?

The chest rose and fell the way it's supposed to, the CO2 trace appeared on the monitor and the ventilator showed 22 cm of inspiratory pressure, again, the way it should be.

Breath sounds were equal bilaterally, as well.

Oh, in case you were were wondering: the events described above — from my initial look inside the mouth until I replaced the tube — took place over a span of about 30 seconds.

But you can see how it can be that you can be fooled — or, rather, fool yourself — into thinking things that aren't quite right are still somehow okay.

It's nice to be the compulsive sort in my line of work.

By the way, I still haven't the foggiest (sorry about that) idea where the initial tube was — but then, that's the lesson, isn't it?