[[1000 Cope Like a Cardiac Surgeon]] # A Commando Story Despite the removal of most of its contents, the fat man’s neck remained very fat. Most of the people I have seen with head and neck cancers have been slim, whittled down by the interference of the malignancy with their digestion, consumed by the extra metabolism of their uninvited guest, or brought low by the alcohol and tobacco and the life that is associated with their excess. This man was portly, and I remember him as being in his fifties, as I picture his salt and pepper hair. He had undergone what was known as a Commando procedure. Some large portion of his tongue, the floor of his mouth, and the accompanying lower jaw had been removed as one continuous lump of tissue to eradicate his cancer. To make sure no fugitive cancer cells were left, making a break for the open range of the rest of his body, the lymph node networks of his neck and several of the adjacent muscles were removed. There had been some reconstruction of the hole that was left- definitely a muscle and skin flap, and I could be wrong, but I think there was also a bone graft to try to repair his jaw, because I remember that his jaw had been wired shut to act as a splint. Whether it was wired or not, his throat had become an impassable no man’s land of inflammation and reconstruction, so the breathing tube going into his windpipe from his nose used during the surgery to ventilate him was exchanged, as usual, with a tracheostomy tube. This shorter, wider diameter tube is less resistant to the passage of air, and goes straight into the windpipe from the skin at the base of the neck. A word about the name “Commando Procedure.” If you look it up, you will find at least two surgical procedures that bear that name. The first, by legitimacy and seniority, is the head-and-neck procedure I have described. It gets it’s name honestly, as an acronym of COMbined MAndibulectomy and Neck Dissection Operation. But people have short memories for the etymology of surgery, even when the name is that of the inventor. All people remember is the name, and the fact that it is a long, hard, dramatic action. Every branch of surgery has one, the Whipple, the Thoraco-abdominal aneurysmectomy, a procedure that takes skill, stamina for the patient as well as surgeon, and takes all day. By their very nature, they are risky. In cardiac surgery, the procedure where infected artificial valves in the mitral and aortic positions are removed along with chunks of the fibrous skeleton of the heart, and then two new valves are implanted after reconstructing the framework with animal tissue has also taken the name Commando procedure. Here, the name comes only from the intensity and risk of the process, and the sympathy and identification that most surgeons feel with the military in general, and special forces operators in particular. The analogy would be that such life-saving coups-de-main can only be accomplished by those who have volunteered to acquire such skill and daring through special selection and wash-outs, and long, hierarchical training. The analogy, to which I am admittedly attracted, is, however, too flattering to the surgeon. No matter how bloody it gets in there, the surgeon has a pretty good chance of making it out alive. I had been drawn to surgery, and so welcomed the militaristic training hierarchy that I enlisted before I needed to. I had already matched in the program that was to be my home for nine years earlier that year, and if I had been like many of my classmates, I would have been taking easy electives -“vacation rotations” before starting the rigors of internship. I lived in fear of showing up for residency and not knowing what to do in the middle of the night. The way I looked at it, I was paying ungodly amounts of tuition to be taught medicine, and I aimed to get the most out of my employees. Since I had fallen in love with surgery, my otherwise loveless and fairly lonely life had made it easy for me to come in and volunteer on surgery services and intensive care units during holidays, so I knew the ICU well where the Commando patient had been admitted after surgery. But I am not the hero of this story. There is no hero in this story. The patient did well after the marathon surgery. Blood loss wasn’t too bad. He woke up quickly after the prolonged anesthetic and was unplugged from the breathing machine to breathe on his own power with an oxygen mask over the opening of the tracheostomy tube. There was only one problem. The tracheostomy tube was a little too short for the obesity of his neck. Occasionally he would move around and the tip of it popped out of the hole in the windpipe. He would have a moment of difficulty breathing, would signal his nurse over, and she would push it back in. The second time it happened, they called the Chief Resident of the Head and Neck surgery service, who had assisted in the case, to let him know. He explained that they had looked around the OR for a tube with greater length, but hadn’t been able to find one, and they had finished rather late at night so there hadn’t been anyone to assist their search. He had considered using one of the longer tubes, endotracheal tubes, that are used to get into the windpipe for anesthesia through the nose or mouth, but they are not designed for the purpose, and would have been harder to breathe through and would have a tendency to go too far in. He said he would look around for a longer tracheostomy tube first thing in the morning. Somewhere around one in the morning, the tracheostomy tube popped out, and the nurse couldn’t pop it back in. She called for help, and the physicians and other nurses in the ICU flocked to her side. The most senior amongst them tried, but could not insert it. The patient, anxious at first, became increasingly agitated and became part of the problem. The ICU surgery resident tried to insert the tube, first blindly, by feel, and then with a special viewing scope, but the first few attempts resulted in false passages of the tube, where it entered the neck, but not the windpipe, sliding along it. When they would hook it up to a ventilation bag and puff on it, it was clear that it was not in correct position. Each puff made the task harder as it insufflated air into the neck that could not escape, puffing it into greater thickness like a bullfrog’s, increasing the distance between the neck and the hole in the windpipe. From an olympian vantage point, removed in time and emotion, suggestions bubble up that at the moment were surely considered and deemed to be unlikely to succeed. Get a wire cutter , clip open the jaws and put the tube down that way, or down the nose with the special viewing scope. Perhaps to find a throat closed off with inflammation, and where are your wire cutters right now? Get a knife! Cut the skin hole as wide as a church door if you need to, but find that windpipe hole! From my own vantage point, behind the first and second rows of responders, I could see glimpses of the patient’s face getting progressively redder, then bluer as his struggle continued. I saw his EKG signal speed up at first, then slower and slower until, his struggles settled now to only occasional agonal inhalations, and the heart stopped beating in fibrillation. From my vantage, I was perfectly positioned to see the face of the Chief Resident of Head and Neck Surgery, framed in the doorway, as he stopped momentarily to take in the awful sight as CPR was initiated. I have been known to miss emotional cues throughout my life, but even at that age, I was as sensitive to the negative emotions as a submarine sonar, and what I saw in his face resonated within my own heart, and it was powerful self-loathing. This emotion I knew well, vide supra loveless and lonely. I could see the guilt, regret, sadness as in a flash he considered every chance he’d had that day to avoid this outcome. The first thought I had was that I never wanted to feel the way that man felt at that moment at any point in my future. Easily said, and many obvious lessons to be learned. So obvious that you think you’ve learned them when you really haven’t, and there is no checklist net with holes that aren’t wide enough to let through the fatal human error. The alternate futures branch out from the different decision points, like shadow-walking in Zelazny’s Nine Princes in Amber. Endotracheal tube instead of a tracheostomy tube through the neck hole at the end of the surgery, responding after the first call, the knife, the wire cutter. Walk down any one of these paths, the result might be the same, and down many the portly man is alive. Suffering from a wound complication or other such, but alive. But we only get to walk down one. Pick your lesson to learn. One thing I learned from the conversations that ensued the rest of the early morning. Whether it was applicable to the situation, or would have changed the outcome, I don’t know, but it made sense to me at the time. The big lessons need to be constantly learned as a tide of ignorance washes away the observances and the defenses that are constructed to prevent the dangers. The little lessons at least have a good chance of sticking. A junior resident shook his head later when we talked about what happened. “He should have left trach sutures behind,” he said with mild disapproval. He explained that many surgeons put in a couple of long sutures that have passed into the windpipe on either side of the hole and are brought out through the skin hole. Until the inside and outside hole have healed into one around the tracheostomy tube, if the tube is accidentally dislodged, you can pull up on them to bring the hole in the windpipe up to the hole in the skin of the neck. They can be tedious to put in. Nowadays quite a few tracheostomies are done with percutaneous kits where you never have an opportunity to put them in. For 28 years, though, I have never failed to put them into any tracheostomy I’ve done open. Overlink