“I threw some drapes over her body leaving the neck exposed. It looked as thick as a tree, I felt for the bony prominence of the thyroid cartilage. But I couldn’t feel anything through the rolls of fat. I was beset by uncertainty…where should I cut? Should I make a horizontal or vertical incision? …and I hated myself for it. Surgeons never dithered and I was dithering.”
The above is an extract from an article, “When Doctors Make Mistakes” published in 1999 in The New Yorker by Atul Gawande. Back then he was only a young surgical resident when confronted with a case in which a life and death situation had to be made. It was this case only that he referred to in his article; a 200-pound female car crash victim was presented into the ER, found unresponsive to pain with her pulse being at a100 and BP 100/60. On examination it was determined that she was not oxygenating well so attempts were made to intubate her. They failed. An emergency tracheostomy (inserting a breathing tube into her trachea or windpipe) had to be performed with time being a ferocious enemy. The woman had only 4 minutes. For her brain to be deprived of Oxygen longer than that, she would have suffered permanent brain damage. In the extract above Gawande describes how her thick neck initially hindered his attempts to cut through her neck and insert the tube. Amazingly however, the patient managed to survive and made a full recovery as later, another an anesthesiologist managed to slip a pediatric sized endotracheal tube through the vocal cords.
Tracheostomy is a very common procedure performed mostly on patients who are unable to breathe on their own after a trauma. According to The Mayo Clinic website, “A tracheostomy provides an air passage to help you breathe when the usual route for breathing is somehow obstructed or impaired”. A tracheostomy is often needed when health problems require long-term use of ventilator to help you breathe. In rare cases, an emergency tracheotomy is performed when your airway is suddenly blocked, such as after a traumatic injury to your face or neck. Though it is a relatively simple procedure there are risks associated with tracheostomies. However serious infections are rare.
The patient in Gawande’s case had one trachesostomy-associated risk factor: she was an alcohol abuser (later it was found that her blood alcohol level was 3 times the legal limit). More importantly, her increased body mass also added to the risk. According to the John Hopkins website, “Other risk factors may occur in children, espescially infants and newborns, smokers, diabetics, immuno compromised patients, patients taking cortison or steroids and patients with chronic diseases or respiratory infections”.
According to Dr Razia Hussain, head of Department Of Anesthesiology at Hamdard University, most common complications of tracheostomies include:
- Profuse bleeding due to vessel rupture while performing it
- Airway obstruction (if tracheostomy tube gets blocked by mucus/pus/custration inside tube)
- Tracheomalacia (necrosis of cartilage due to keeping it for a long time)
- Accidental removal of tube due to coughing
- Local edema: local inflammation
In a study conducted by Mayo Hospital, Lahore to evaluate indications, complications and outcome of patients requiring tracheostomy. 250 patients were given this surgery as a life saving procedure. It was found that the overall complication rate was 25%. There were 15 cases (6%) of primary hemorrhage and 6 cases (2.4%) of secondary hemorrhage. There were another 10 cases (4%) with surgical emphysema involving the neck and upper trunk but they were managed conservatively. There was 1 case (0.4%) of tracheo-esophageal fistula, 10 cases (4%) of postoperative dysphagia and 11 cases (4.4%) of stomal stenosis. Peristomal granulation accounted for 11 situations (4.4%). Some patients had more than one complications. There were a total of 2 deaths (0.8%). All the deaths were directly related to the patients’ primary conditions and not resulting from the tracheostomy operations per se.
There may be later complications of tracheostomies ie when the person is stable and is expected to make a recovery. While these are rare a surgeon needs to be on the lookout for them. One such complication is Tracheo-Innominate Artery fistula (TIF). A fistula is an abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs. The website of The International Anesthesia Research Society states, “ One of the proposed mechanisms of fistula formation is mucosal necrosis due to pressure caused by the elbow, tip, or cuff of the tracheostomy tube. TIF is a life-threatening complication of tracheostomy that usually presents with acute and massive tracheal bleeding. Without prompt surgical intervention, the outcome of this complication is grave.”
Complications from tracheostomies may be rare but they can be sudden and a capable surgeon has to be vary enough to identify the exact cause on time. As one of the most common life saving procedures, a lot of time and care needs to be devoted by surgeons to make sure every tiny detail is immaculate, that follow-ups are done without anything going amiss.