Battle of the COVID-19 Tracheotomy

I was sitting with my favorite Chief in the not-so-nice resident room just shooting the breeze when the consult call came in. Patient who had been intubated and on the vent for 4 weeks, COVID+.

As the Rhinology fellow, I hadn’t had to deal with this situation yet. However, I knew our Chairman was on call for the week, and I was always looking to impress him by going above and beyond with faculty duties – especially when the residents were staffing things with him. I made sure the Chief kept mentioning my name as I accepted the surgical consult on his behalf.

The next afternoon, I took this relatively young man – admitted for an ICD-10 code previously unfamiliar to me, J80.29 “confirmed acute respiratory distress syndrome (ARDS) due to COVID-19” – down to the OR after my regularly-scheduled programming. At first, I told My favorite PGY-2, who was on the consult service, to leave the room for his own safety. He stays. Together we wait and wait for the patient to roll in.

Three CRNA’s come in with a cumbersome critical care bed and our patient in it, wearing ‘secret’ N-95’s under plain surgical masks, full faceshields, and gowns. They would not give me, my residents, or our scrub tech any of those things. We beseeched the Charge Nurse. The patient, however, was unstable, and he could not tolerate being away from the unit for too long. Thus, we proceeded in our regular garbs. And we certainly proceeded in typical fashion.

With my PGY-5 at the head of the bed, I took the PGY-2 through his first full trach. We marked out the laryngeal landmarks, made a small incision with a 15-blade in a skin crease, dissected down with hemostats and the Bovie, then took Kittner’s to expose the tracheal cartilaginous rings. Like A-B-C 1-2-3.

Since he had gotten that far with only one wild bleeder, I had my junior make the incision into the airway, and I used a curved Mayo myself to open a large window into the endotracheal lumen. The tube came out and our 6.0 cuffed Shiley slid right in. End-tidal return followed. We sewed it all in and rolled the patient back to the ICU. I called his wife, who thanked Jesus and then thanked me. I told her that surgery went smoothly and that I would tore off my scrubs and showered, aggressively cleansing my anterior neck, forehead, and hands. The patient’s postoperative course was unremarkable and without complication. I do not think his recuperation was meaningful, as his chest imaging was daunting throughout.

Though I feel disheartened looking at the long-term picture, I was proud to command a team who was refused proper PPE, march my friend through a quick tracheostomy creation, and to keep everyone as safe as possible while accomplishing our operative goals. Doing a coronavirus trach on an infected patient was adrenaline squared. But we stayed focused and mere minutes later established a reliable surgical airway without exposing our OR to too many errant respiratory particles.

We did what we were asked to do and what we were trained to do. And we executed it with planning, forethought, steadfast communication, and by turning our fear and worry into action and accomplishment.

Jordan Teitelbaum, DO AOCOO-HNS Otolaryngologist/ENT