Cricothyrotomy

Although I was called doctor by my patients and the nurses, I was not licensed to practice medicine until I completed my first year of residency. I could only practice medicine in the hospital of my residency program. My Medical License came the first day of my second year of residency.

Hospitals in the small cities that surrounded Toledo were always in need of Emergency Physicians. These hospital Emergency Centers were managed by national for-profit corporations that did not have enough patients to support board certified Emergency Physicians. They relied on residents, and other specialists who were moonlighting.

Moonlighting was a common practice back then. Residents were tired of living a life of penury. I would sign up for about five shifts a month at various hospitals in addition to my work in the residency program. These were either 12 or 24-hour shifts. Slow hospitals would allow 24-hour shifts. When they were hard up, they would allow 48- and 72-hour shifts. The nurses loved to work with most of the residents.

I arrived at one of my moonlight shifts at 7 AM. The department was empty, so I told one of the nurses that I was going to the call room for a nap. About half an hour later, I was awakened by the phone. The nurse was frantic. She said EMS was bringing in a patient who had hanged himself.

The squad arrived with an unconscious middle-aged man who was having sonorous breathing. They had him in a cervical collar. He had red stripe across his upper neck from a rope. I was taught early in my training that resuscitation required attention to the ABCs, airway, breathing, circulation. The airway was not secured. Back then, the preferred method to intubate was nasotracheal intubation. This was the process of putting a tube through the nose, down the throat, through the larynx, and into the trachea. Once in the trachea, the balloon on the end was inflated and the patient would have his airway secured.

Nasotracheal intubation required finesse. The tube did not like to go where we wanted it to go. The natural path was to go down the esophagus. To avoid this, the tube had a wire to the end and a little loop. Pull on the loop and the end would curl up. The accepted method was to insert the tube through the nose to the correct spot in the back of the larynx and then pull the loop to get the end to curl toward the larynx. Physicians use fiberoptic scopes to do this currently. At that time, we would listen at the end of the tube to determine where the scope was.

I considered myself adept at nasotracheal intubation, but I was unsuccessful. I believe the injury caused by the rope was preventing the intubation. The airway needed secured and thus I had to perform a cricothyrotomy. A cricothyrotomy requires using a scalpel to make a hole in the cricothyroid membrane at the bottom of the larynx at the front of the neck and inserting the tube directly into the trachea. I had performed them on dogs in training, but never on a human.

 Did I forget to mention that one of the nurses proclaimed, “That is Doctor Taylor.” just before I started the procedure? I responded, “Who is Doctor Taylor?” She replied, “He is a local Family Practice doctor who works here.” Thankfully, the procedure went without a hitch and the airway was secured. This all occurred within the first five minutes of arrival. I ordered the needed x-rays and preliminary blood work.

Word got out quickly that Doctor Taylor had hanged himself and was in the Emergency Center. Within minutes, the resuscitation room was full of physicians. One was the hospital Anesthesiologist. They intubate patients in the Operating Rooms. The Chest x-ray showed that I had inserted the endotracheal tube too far into the trachea and it needed to be pulled back a little. The Anesthesiologist looked at me and said, “If I pull that out, can you put it back in?”  I guess he had never seen an acute cricothyrotomy.

Dr. Taylor was admitted to the Intensive Care Unit and made a complete recovery. He was subsequently transferred to a psychiatric hospital in Columbus that had a good reputation for treating impaired physicians. I lost track of him.

About a year later, Dr. Taylor called me and asked if he could buy me lunch. Over lunch, he explained that he did not remember that morning. He was being sued for malpractice and was severely depressed. His son delivered newspapers and when he arrived home from his morning route, he opened the closet door and found his father hanging.

Dr. Taylor returned to practicing Family Medicine.