The five-pound ex-23 week preemie infant on my operating table has already lead a challenging life in his mere 128 days on this planet. A portion of his gut has died and been resected due to a condition called necrotizing enterocolitis. His friable blood vessels have already bled into the ventricles of his brain on more than one occasion. His severely underdeveloped lungs cannot not oxygenate his body without high-pressured mechanical ventilator support.
Now he is here with me in OR 1 being prepared for a surgery which would enable him to breathe through a small plastic tube emanating directly from his neck. It is an operation I have done hundreds of times on all ages of patients ranging from neonatal to geriatric in my more than decade career as an ENT surgeon. I may have even done a thousand by now if you also count the seven years of training during residency and fellowship.
There is a tension in the air that I don’t remember feeling before early-March of this year.
The difference with this case is that it is being performed in the unprecedented Covid-era. The preparation for an airway procedure with the pandemic raging is elaborate. It involves complex plastic draping over a structure of metal rods, proper filtration of air and specialized masks under standard surgical masks, then covered by shields. This system is all target to contain the aerosolized particles in a narrow field, thus limiting exposure to the anesthesiologists, surgeons, and operating room staff as much as possible. We are finally ready to transport the baby from his self-contained isolet onto our operating table.
The performance of a surgical tracheostomy on a neonate is a relatively straightforward procedure, from an anatomical perspective. First, we position the baby. The neck is extended on a roll made of a single baby blanket and the head is secured in a rubberized “doughnut.” The level of the cricoid cartilage is marked in blue as is the future incision site, two finger breaths above the sternal notch, marked with a blue “V.”
The baby’s skin is prepped with betadine by my nurse, Fran, while I step out to scrub my hands and arms with my resident and medical student at the nearby sink. We drape the patient in sterile white towels and a light blue disposable split sheet with sticky ends. Then it is time to begin. We incise the crape-like skin with a sharp 15 blade, cutting through the dermis down to the subcutaneous fat. We then core out a yellow piece of fat down to the fascia, the connective tissue which forms a sheet over the underlying strap muscles. This is a safety measure, to enable rapid replacement of the newly placed tracheostomy tube in the event of an accidental displacement, which we hope never occurs.
Then the dissection begins. “Stay exact midline,” I remind my surgical assistant as we divide the multi-layer muscles of the anterior neck along the pristine avascular plane known as “the midline raphe.” We are approaching the level of our intended depth using the electrocautery instrument known as the “bovie” to elevate all the remaining attachments off the cartilages of the airway. I want perfect visibility of the tiny c-shaped rings of the trachea at this point. This neonatal airway is only 3 mm in diameter, roughly the size of this tiny baby’s tiny pinkie. I glance at the mayo stand to confirm that we are totally prepared. The 3.0 tracheostomy tube is accessible, lubed and the attached balloon is tested. The 5.0 suction is ready to slurp up any blood squirting from cut edges. The fiberoptic scope is attached to the light source. There is a brief window where this routine surgery can get dicey and it is fast approaching.
During the exchange from the intubation tube from above to the tracheostomy tube below, the baby’s underdeveloped lungs are tested. First, the high oxygen levels provided by the anesthesiologist are dropped below thirty percent to reduce the risk of the most dreaded complication, an airway fire. Finally, the airway is entered. A sharp blade is used to make a perfectly straight vertical incision through the second through forth tracheal rings. The newly created hole is then dilated with a mosquito clamp and thick secretions and blood are suctioned from within the hole. The PEEP (positive-end exploratory pressure) which is used to maintain the patency of the fragile gas-exchanging alveoli is temporarily suspended. It’s the stress point of the surgery and we must all move swiftly to secure the new airway and reconnect ventilation. The oxygen levels start dropping as expected. I can hear the cadence of the beeping, signifying the oxygen saturation is below ninety, then below eighty, seventy, sixty. I inadvertently hold my breath. The seasoned anesthesiologist works swiftly to re-inflate the lungs, squeezing the green bag rhythmically. The pitch of the beeping escalates, signifying its climb back to one-hundred percent.
I exhale. The baby is stable. Confirmation of proper tracheostomy tube placement is achieved by direct visualization with the scope. The image on the screen displays a short distance from the tip of the tube to the branch point between two black holes, the right and left mainstem bronchi. The tension in my neck and upper back relaxes and suddenly realize I am hungry and thirsty.
“When did I last get to pee?”
“Did my babysitter make dinner for the kids?”
“I hope Juliette did her math homework.”
My mom, non-surgical checklist begins to scroll through my mind while my residents secure the new airway around the baby’s neck with a soft Velcro tie.
The neonatal ICU staff is notified that we are done. The respiratory therapist is dispatched back to help transport the baby back upstairs to his room. While the monitors and IV lines are being organized for the one-flight elevator ride, I leave to find the anxiously waiting parents.
“Everything went smoothly. The trach tube is in place.”
“Thank you. Thank you so much doctor.”
The mom begins to cry awkwardly. Usually, this emotion escalates to a sobbing hug but this is no longer socially acceptable, due to Covid-19…
Back in the locker room, I toss my specialized magnifying loupes into my locker and change out of my scrubs. I dial the hospital dictation number and my mouth moves on autopilot as I detail the steps of the operation into my iPhone.
Patient was prepped and draped in the usual sterile fashion…
A 15 blade was used to create a horizontal incision in the crease of the neck…
It’s time to go home. The contrasting blast of hot air startles me as the doors of the pediatric hospital slide open and I exit the over-air-conditioned interior of the hospital. I jump into my car heading south.
During the drive, I replay the events of the day.
Tonsillectomy, tonsillectomy, ear tubes, ear tubes, excision of midline neck mass, infant tracheostomy ….
My consciousness lurches back to the baby’s mother. I was once a NICU-baby mother. Luckily for me, my Milla’s lungs was able to oxygenate her tiny body after only one day of external support. She spent the two-month of her ICU stay mostly as what they called “a feeder-grower.” But the fear, the helplessness, that emotion I remember acutely even though she is now seven.
Today, the procedure went relatively smoothly, and their baby now has an alternate airway. But, the parents’ road to a healthy child is still long and hard. His immature lungs will be dependent on machines for many more months, at minimum. Then, the damage to the delicate tissue of the lung from extended mechanical ventilation will result in a condition known as bronchopulmonary dysplasia or BPD. This will last for years. Beyond this, there are a myriad of other developmental and neurological hurtles ahead as well.
The sky is dark as I pull into my driveway, even though it’s still during the long lazy days of summer. I notice that my husband has left the garden hose draped across the driveway right as the front wheels of my SUV drive over it, crushing the green plastic. At the threshold of the garage door, I trip over a pair of size 4 sneakers. I spot hazelnut Nutella smeared across the metal door handle. In the kitchen, Milla and Scarlett are arguing heatedly about whose iPad charger is plugged into the island.
“I hate you. You are THE WORSE sister.” I hear just before opening the mudroom door.
MOMMY!!!!!!
Three energetic girls come bounding to the door to give me a hug…. And then the complaining starts.
“Scarlett stole my pen.”
“I forgot my tennis racket at camp.”
“I’m starving and I ate nothing all day because lunch and dinner were gross.”
Milla leans over and pushes Scarlett off the chair.
At least one of them begins crying, I can’t tell which.
I realize I never got around to peeing since leaving the house at six-thirty am.
My mental mantra begins to play.
Keep perspective, keep perspective. They are healthy. You are so lucky. Remember the baby. Deep breaths…
It’s tough, though. Life is personal. As much as my brain tells me not to be annoyed or snap at Alex when I notice the dirty dishes pilling up in the sink, I just can’t seem to stop myself. There are toys, pieces of toilet paper (WTF?) and unlidded markers that I just purchased on Amazon littering the stairs and the hallway.
Remember, it could be worse, so much worse.
These are trivial things. You have a loving family. You have a fulfilling job. You are respected. You can provide for your family. Six-years out from Stage 3 breast cancer, and you are still NED (no-evidence of disease).
You are alive. You are watching your daughters grow up, something you never dared to dream as you stared at that awful mammogram image with the high-density, three-centimeter white tumor.
I sneak upstairs into the solace of my bedroom and stand alone for a blissful two minutes.
“Mommy, Mommy, Mommy. I NEED YOU!”
My phone starts buzzing in my pocket. I am on-call at the medical center and we are covering facial trauma this week. The story of my day is not completely over.
But for now, in this moment, life is good. It’s all good.