It was 2021 and I will never forget when I was a Locum Tenens provider in Maine… A small baby had been admitted to us for a viral pneumonia and within the hour required an intubation (required a breathing tube for increased work of breathing, or cessation thereof, in this particular instance) for secretions… It was my 1st intubation as a Pediatric Attending, and it made my heart soar to be successful (I had called the anesthesiologist to be backup because i was so nervous)… But then, 30 minutes later I got one of the worst phone calls of my life when the transport team taking him to the referral hospital called… They had made a u-turn back into our ER concerned that the tube had come out… I ran down to the trauma bay, they removed his tube, he had already received analgesic medications for the transport and was paralyzed, and his body was grey… His heart rate dropped, his oxygen dropped, we started chest compressions…….

Three years later.

After my 70th call shift as a Neonatology Fellow (yes, i kept track), I remember calling my mom to tell her about an experience that had happened overnight: one of my scariest and most validating moments of fellowship… I will never forget the night I got the non-urgent phone call from nurse practitioner across the street at our delivery hospital connected to our higher level NICU that one of the babies at the other side needed to be intubated. An extremely premature baby, as was not uncommon, had began to lose what we often refer to as pulmonary/lung reserve and the immaturity of his respiratory system was not sustained by non-invasive ventilation (anything sufficing by oxygen support not entering past the nostrils/mouth openings past the throat). My attending looked at me, a relatively newly minted 2nd year fellow (of 3 years) and asked if felt comfortable going across the street to assist for this ~900 gram (~2lb) intubation. I beamed at the idea of having my first shot of freedom, back in academia. After spending my time as a Locum Tenens doctor and facing the brunt of autonomy and also responsibility, and now transitioning to the role of a Fellow where others were in charge and I was no longer the final say, it was an odd feeling to be faced with this task again… But I boldy said yes, was so thankful he pushed me back into that role, swallowed my fear, and stepped across that literal and figurative bridge without him to help.

It is common for us to give medications prior to inserting breathing tubes to assist with pain and sedation for this procedure, so I was accustomed to, and ready, for our routine administration of fentanyl. I was ready, watchful, and at ease as the medication was given and the nurse practitioner prepared to take the first attempt at the intubation as I stepped back as my supervisory role as a second year fellow and in my 4th year of being a doctor after residency. But, all things have side effects and as she looked to intubate, I will never forget watching what happened next…

Fentanyl has been known since 1953 to have a side effect of something called “Wooden Chest Syndrome” during which the chest wall becomes rigid and ventilation by any mechanism becomes very difficult. Reversal of the medication with an opposing agent, paralysis to counteract the rigidity (which sounds counter-intuitive i know) or immediate introduction of an invasive airway are necessary to continue ventilation, but sometimes easier said than done, and for us, we didn’t really have the reversal agents at hand.

I will never forget as she went to intubate, stopped to withdraw the blade to refocus, and I watched as our heart rate and oxygen saturations started to drop… Lower and lower… The body of this small human began to stiffen, he began to turn grey. The room turned cold, the nurse all ran in, there were 6, no 10? of us in the room… My heart raced and I realized very quickly, if something didn’t happen soon, if we didn’t secure an airway, he would Die.

As calmly and sternly as I could, I called out to one nurse to call for the pharmacy for the paralytic medication to reverse our “rigid chest,” to another I called them to urgently call my attending to sprint from across the bridge for backup, to the rest I prepared them for chest compressions, for CPR, for a full blown CODE BLUE.

His heart rate had dropped from 160 to 60 (normal >100 for babies this size), his oxygen had dropped from 100% to 20% (normal >90%), his skin was grey, he was lifeless… My heart sank… I paused and turned to the nurse practitioner and will never forget, “Ok, I’m going to intubate now.” I didn’t have much more time to think, i grasped his small skull the size of my palm in my hand, with the other stuck a laryngoscope blade in the mouth, desperately looked for his vocal cords and slid a breathing tube into a target less than 0.3 cm in size as smooth as cutting butter with a hot knife. I turned to the nurse helping to bag-mask ventilate him and will never forget as I focused talking ever so slowly, “[M], You’re doing great. Focus, go slowly, he’s doing fine.” Meanwhile, my heart sank. The baby recovered, his heart rate went up, and everything was fine.

Damn. If my current self could go back in time, the things I would share with my former self… If my former self could come forward, the things I would admire about my present self. I am endlessly humbled by every experience and am cautious which each day of learning. I am stronger, smarter and wilder than ever, and it is always an adventure.

Image Credit: Photo by Laurenz Blickwedel on Unsplash