Securing the Airway Is Important (3)

I sat on my officetel sofa, repeatedly tearing and stitching the neck of thin air dozens of times.

This lecture was starting to get interesting.

ㅇㅇ(211.36): All right! Keep your head in the game! Next question!

A new anatomical image was uploaded.

The epiglottis. The little flap that opens and closes the airway.

The epiglottis, which should normally be thin and pink, was swollen up a deep, angry red.

The swollen epiglottis looked ready to burst at any moment, almost completely blocking the already narrow airway.

ㅇㅇ(211.36): Now then! Acute epiglottitis

(*acute epiglottitis)

This is a patient whose throat has swollen shut because of it! He's barely hanging on, and it wouldn't be strange if his airway completely closed at any moment. He needs intubation immediately. What size tube do you use in a case like this, and how should you manage it!

Screw it.

This is a trap.

If I shoved the laryngoscope in carelessly, I could irritate that hyperswollen epiglottis and trigger a complete airway obstruction.

I broke out in a cold sweat and desperately wrote out the answer in my head.

HellJoseonSlave1: You'd use a smaller tube than usual. About one or two sizes down.

Why?

Because the airway would be swollen all over. The size you normally use probably won't go in.

ㅇㅇ(211.36): Correct. Then what else should you be careful about? What should you prepare, and what should you watch out for? Explain in detail.

I wracked my brain. First, I had to minimize stimulation.

Don't carelessly press down on the tongue or stimulate it with the laryngoscope. Keep the patient as calm as possible. In pediatric patients especially, the top priority is to keep them calm so they don't cry or thrash around.

Right then, the pediatrics ghost made a ghostly entrance.

PediatricsGhost77: Hey! Now you're finally sounding a bit like a doctor! Never shove a tongue depressor or anything like that at kids! The moment they get startled and start crying, their airway can block and they'll turn blue right away! Let them stay in their mom's arms, keep them as comfortable as possible, and gently give them oxygen!

Anesthesia/Pain Medicine: And this isn't a procedure to do in a corner treatment room in the ER. As a rule, the most experienced doctor performs it with an ENT doctor and an anesthesiologist standing by. If intubation fails, then ENT

(*ENT, ear, nose, and throat)

has to cut the neck and perform a tracheostomy.

ScalpelGod: If you touch that with your filthy hands, it's a 100% airway obstruction. You should just stand to the side and watch, and if it really comes to it, cut the neck like I told you.

I etched what they taught me into my head.

And no sooner had that lecture ended than the next image was uploaded.

ㅇㅇ(211.36): Now, next is a patient bleeding like crazy from the throat!

In front of my eyes appeared the throat of a patient who had undergone tonsil surgery.

As if a blood vessel at the surgical site had burst, bright red blood was gushing out from deep in the throat.

ㅇㅇ(211.36): The reason is probably something like secondary bleeding after the tonsil removal! What would you do in this case? The blood is one step away from blocking the airway. What should be prioritized right now? The patient can't breathe, and the oxygen saturation keeps dropping.

Ah, wait, what was it again?

Shouldn't I suction out the blood first?

Suction?

Suction is a given, you brat!

Suction is a given. After that comes securing the airway. Use the largest laryngoscope blade to sweep away the tongue and blood clot in one go, then shove the tube in as fast as possible to secure the airway and the cuff

(*cuff, an expandable part attached to the end of the endotracheal tube that applies pressure)

needs to be inflated so the blood doesn't flow into the lungs!

Securing the airway, and protecting the airway.

I see.

Note that down, note that down.

And so I sat on my officetel sofa, repeatedly killing and reviving imaginary patients dozens of times.

***

The alarm rang.

Same time, same sound.

The signal that it was time to return to hell.

Dragging my body, torn to shreds by the study session, I mechanically got ready for work.

What could I do?

The ER morning passed by faster than I expected.

There wasn't all that much work, and since most of the patients were minor cases, it wasn't too much of a burden.

The ER afternoon was a marketplace, just like always.

I was holed up in a corner of the station writing up the chart for a simple laceration patient who had just come in. A middle-aged man who'd stumbled around drunk and slammed his head into the asphalt.

“Geez, sir. You really should drink in moderation.”

I muttered to myself and kept charting.

The boring, draining daily routine of an ordinary ER.

After seeing about ten patients like this in a day, my soul felt as ragged as gauze soaked in disinfectant.

That's when it happened.

“Dr. Han!”

The voice of the senior nurse at the triage desk rang out.

“Could you come over here for a moment? A patient just came in, and I think you should take a look right away.”

Those words from a veteran nurse always sent a chill down my spine.

Tremble, tremble.

I saved the chart I was working on and stood up.

When I went to the triage desk, a young man who looked to be in his early twenties was sitting in a chair with a thoroughly frightened expression.

I walked up to the patient and pulled a chair over to sit down.

“Yes, sir. What brings you in?”

At my question, the man looked at me with anxious eyes and answered.

“Well... I had a tonsillectomy last week. It smells kind of bloody, and it feels like there's something there...”

Ah, hold on, tonsil surgery?

A bloody smell?

“You had tonsil surgery a week ago. You said there's a bloody smell coming from your throat and that you feel a foreign-body sensation, correct? Could you tell me more about it?”

“It doesn't exactly hurt or anything... but it keeps smelling bloody in my throat... and every time I swallow, it feels like something sort of lurches and goes down. It's just so unsettling...”

I first reassured the patient and picked up a penlight.

“Yes, could you open your mouth wide for me? I'd like to take a look inside your throat.”

The man opened his mouth.

I shone the penlight deep into his throat and examined the area where the tonsils had been removed.

At first, nothing seemed out of the ordinary.

But the moment I lightly pressed down his tongue with a tongue depressor to get a better view—

I saw it.

Bright red beads of blood seeping out from a tiny gap between the scabs at the surgical site.

It was slow, but it was definitely active bleeding.

My mind went blank.

Right now it was only leaking little by little, but it was a time bomb—at any moment, blood pressure could rise or one bad cough could make the vessel burst completely.

'I'm screwed.'

I hid my expression as much as I could, trying to seem calm, and asked the patient.

I prayed desperately that my voice wouldn't shake.

“By any chance, did you have the surgery at our hospital?”

“Yes. A week ago, with Professor Kim Jaeyoung in ENT...”

The instant I heard the patient's answer, the ghosts' hellish training flashed through my mind.

'Now! A patient bleeding like crazy from the throat!'

'This is airway management. Securing the airway is the top priority, you idiot!'

'Use the largest laryngoscope blade to clear the tongue and blood clot in one shot, then shove the tube in as fast as possible to secure the airway and inflate the cuff so blood doesn't go into the lungs!'

...Crazy. So this is why the ghosts made me practice airway management? Are these bastards shamans or what?

Ah, right, they're ghosts. Is it some kind of ghostly intuition?

“Sir, please listen carefully from here on. There is some bleeding at the surgical site. It doesn't necessarily mean it's going to become a major problem, but just in case—just in the off chance something unexpected happens—we'll start a few measures.”

I turned away from the patient and started shouting to the nurse standing behind me.

“Please get us a bed in Area A right away! We'll start monitoring immediately!”

(*post-op bleeding, postoperative bleeding)

This is post-op bleeding!”

At my urgent shout, the peaceful air in the ER froze over in an instant.

“And please get two IV lines in right away! Send out a CBC and coagulation studies STAT, and prepare a crossmatch for 4 units of PRBCs immediately!”

My mouth didn't have a chance to rest.

“Please call the ENT on duty right now!”

(*active bleeding, active bleeding)

We're seeing active bleeding after tonsillectomy! They need to come down right away!”

I took a breath and gave my final order.

“And... please prepare the largest laryngoscope blade, a 7.5 tube, and a suction machine, and bring them to the bedside. Right now.”

The nurses began moving in perfect coordination.

One held the IV line, while another attached the patient's label to the blood sample tubes.

For now, I was relieved the bleeding wasn't that heavy.

For now.

But bleeding like this could turn explosive at any moment.

For the time being, until ENT and anesthesia arrived, there was only one thing I had to do.

Keep the situation as stable as possible.

“Nurse, the Bosmin

(*a drug that constricts blood vessels to achieve hemostasis)

ampoule and a long Kelly

(*a long-ended clamp)

and some packing gauze, please.”

I requested the supplies I needed from the nurse.

A moment later, the items arrived on a stainless steel tray.

I carefully soaked the gauze with Bosmin solution. Then I clamped the gauze firmly onto the end of the long forceps.

“Sir, I'm going to press on the bleeding spot for a moment to stop the bleeding. It may be a little uncomfortable. Please open your mouth wide.”

Explaining it to the patient, I carefully pushed the forceps deep into his throat.

Found it.

I found the tonsillectomy site.

I began pressing firmly on the bleeding site with the long forceps.

The patient grimaced. I soothed him while maintaining steady pressure with the hand holding the forceps.

Just then, an indifferent voice came from behind me.

“What is it?”

I didn't even need to turn my head to know who it was. Han Jaeeon, third-year emergency medicine resident.

Before I knew it, Han Jaeeon had come up beside me and was looking down at the scene with her hands in her pockets.

Keeping hold of the forceps, I only turned my head slightly and began briefing her.

“A 22-year-old male who had a tonsillectomy at our hospital's ENT department a week ago. He shows signs of post-op bleeding, so I'm packing it with Bosmin gauze for now.”

(*oozing, bleeding that seeps)

The active bleeding isn't severe; it's mostly oozing. His vitals are still stable, and I've already notified ENT and anesthesia.”

As she listened to my briefing, Han Jaeeon lowered her head and glanced quickly at the patient's throat.

“Hmm. Oozing, huh. It's not arterial. Keep pressing like that until ENT gets here.”

With that, she headed back to the station again.

What, you're not helping me?

The moment I thought that, Han Jaeeon grabbed something and started coming back this way.

Ah, so she hadn't ditched me after all.

I focused on the patient again.

I could feel the pulse transmitted through the forceps.

Fortunately, I no longer felt any blood seeping from the compression site.

It looked like the pressure hemostasis was working.

Phew, still, I'm glad the bleeding isn't severe.

At this rate, we'll probably just cauterize the wound and be done with it.

A sigh of relief escaped me on its own.

Fortunately, I wouldn't need to use that hellish airway-management technique the ghosts taught me today.

After all, reality isn't that dramatic.

Because not every patient spirals into the worst-case scenario.

I stared at the patient's stable vital signs on the monitor, waiting for this boring period of compression to end quickly.