Backup plans

A patient was brought back to the OR for an emergency exploratory laparotomy one night while I was on call. I didn't scrub in on the case but instead hung out at the head of the bed with the anesthesiologist. Soon after he intbuated this patient, it became apparent that everything was not going according to plan. Oxygen saturation was dropping to the mid-80's indicating that the patient was not being ventilated properly.

The anesthesiologist quickly confirmed correct placement of the endotracheal tube then determined that the problem was with the ventilation machine itself. There was a leak. "Let's bag him," the anesthesiologist called out (referring to bag-valve mask ventilation). Ordinarily, the Ambu bag is kept in the back of the mechanical ventilator cart, but no Ambu bag could be found.


In this moment, I saw an "oh sh*t" look of panic in the anesthesiologist's eyes. Pointing to a nurse: "Go get me an Ambu bag from another room." Meanwhile, he started troubleshooting the leak in the ventilator machine. He found the faulty valve and fixed it in about 30 second to a minute, before the nurse came back with the Ambu bag, and stabilized the patient who by that time had oxygen saturation in the high 60's.

The surgeon quietly watched this all unfold, letting the anesthesiologist do his job without interfering. "I thought I was going to have to do mouth-to-tube ventilation," the surgeon joked after the patient was stabilized. I chuckled. After the excitement passed, though, I realized that the surgeon had probably actually considered the possibility of ventilating his patient by breathing into the endotracheal tube.

This gave me a lot to think about.

Narrowly, this experience has taught me that I should always have an Ambu bag at my fingertips before intubating a patient. More broadly, every anesthesiologist who I worked with has emphasized the necessity of having backup plans. Know what you're going to do to stabilize a patient if something goes wrong. Have a backup-backup plan if your first backup plan fails. It's one thing to hear it, but that lesson takes on a much greater significance seeing it unfold before my eyes.