My First Laryngospasm

Being a student is to be the embodiment of insecurity. Why have I chosen this career? I'm never going to remember any of this! What if I let someone get hurt? Who would trust me to look after them? Am I strong enough for this?

During my paediatric training I was faced head first with a make or break moment. A two year old. Same age, same hair, same eyes as my own two year old sibling. They had come in for a hernia repair, simple. Simple enough that they didn't need to be intubated (where a tube is placed in your trachea to help you breathe) they were done with an LMA instead (a tube that sits at the back of your mouth/throat). 

.
..
.

Now one of the most common anaesthetic emergencies in paediatrics is something called a laryngospasm. It sounds like a big word, but let me explain. You have probably experienced food 'going down the wrong way', yes? This is a protective reflex that we all have where our vocal cords will slam shut if something like food or liquids touch them. They slam shut to prevent anything from getting down into our lungs, which could cause infection or make us drown. Now for the average person, once our vocal cords have slammed shut, our brain moves on to the next step of the reflex which is to force us to cough and push whatever it is away from our vocal cords and out of our lungs. So we cough, we splutter, then slowly the feeling eases and we can carry on with our day. 

In anaesthetics, the drugs that are given can mess with the brains ability to carry out its usual reflexes. The brain is too sleepy, so it can start the reflex but not finish it or it doesn't carry out the reflex at all. 

Not doing reflexes isn't always a bad thing. This Mouse can reassure you that the team looking after you is fully equipped to take over and do the bits your body is too sleepy to do, until you wake back up again. But starting a reflex and being too sleepy to finish it - that's where things get tricky. 

If something tickles your vocal cords - some saliva, plegm, turning your head too suddenly, etc - your brain can start that protective reflex to keep stuff out of your lungs. So your vocal cords clamp shut. However, because you're too sleepy to cough, you get stuck where nothing can move in and out of your lungs. You can't get any oxygen in. 

It's this lack of oxygen that makes it an emergency. This is an laryngospasm. A spasm that occurs in your larynx where your vocal cords close and no air gets through. You start going hypoxic, turning blue and your body starts running out of oxygen. It can be quite terrifying to see and very dangerous for you.

The team looking after you when you're sleeping are well versed in how to fix this. It's as simple as three easy steps:

Step One: Airway Management.

If your vocal cords are /mostly/ closed, rather than all the way closed, then we can put a facemask on you and push air into your lungs under pressure until the vocal cords relax. 

We like to refer to this as 'Riding out the Spasm.'

Step Two: Deepen Your Anaesthesia.

If your vocal cords are completely closed, we need to give you medication. This is through your cannula. This medicine is the same stuff that puts you to sleep. The rationale is that if your brain gets more anaesthetic, it will make you relax and 'forget' you were having a laryngospasm in the first place.

I like to think of it like this: Our brains are super computers. Sometimes, computers freeze and the only way to fix it is to hold the power button and force it to turn off before restarting. People need a similar treatment sometimes, let's turn them off and then turn them on again!

Step Three: Force your Muscles to Relax.

Sometimes, our forced restart isn't enough. Our bodies are 'locked' or 'stuck' into a spasm. In this instance we need to take away the body's ability to contract its muscles. If you can't contract your muscles, then the vocal cords can't hold themselves closed.

We do this is through the use of a medication called a muscle relaxant. You may hear us say that this medicine 'paralyses' you for a little while. This isn't a really accurate term because it implies that you will be 'stuck' into whatever position your in, when it actually forces you to go really limp and relaxed. We can give this medicine through a cannula into your veins or we can inject it into the bottom of your tongue (a sublingual injection) and let it work that way. Once you've had this medication, you need us to take over your bodies needs (like breathing) until it wears off.


Wow, that was a long explanation.
Let's get back to the story, shall we?

.
..
.

What happened was simple. The child went off to sleep and was brought into theatre to be lifted onto the operating table. While we were lifting them and positioning them just right, a glob of saliva that had pooled along the edge of the LMA and slipped down, touching the sensitive tissue of the throat near the vocal cords.

That touch triggered a laryngospasm.

When you aren't getting enough oxygen, the body starts to change how it looks. People go very purple, then blue, and in very serious instances - grey. 

So here I stand. Second year student Mouse, watching as this child starts turning very purple. Their chest heaves as they try to cough, ineffectively. Monitor alarms are blaring, I know they are piercingly loud and yet, I feel like I can't hear them at all. All I hear is the internal screaming in my brain. I feel like I'm panicking. I can't think beyond the convinced, insistent thought that I am about to watch this child suffocate. 

They are blue now. 

Between one blink and the next, I am at the anaesthetists side shoving a vial of Propofol (the induction medication) and a syringe into their hands.

Now, let me be clear. The child is fine. 
They are safe. They are well.

They were put deeper to sleep to make the brain forget it was having a spasm, and their throat was suctioned out of all those gunky secretions. To the team, it wasn't fully an emergency - it was so well controlled. To me, it was the single scariest moment I had ever experienced. To me, this child was on the brink of demise and I kept getting stuck on the fact that they looked so similar to my sibling.

After any kind of emergency or tense situation, we have a debrief. A space to reflect on what happened and help people process the experience. In the debrief it was brought up that I was the first to respond to the patient's dropping oxygen. I was told I was calm, collected and efficient. It made me laugh. I felt like I was so woefully underprepared emotionally. I had panicked! My head was a screaming mess of sound and lack of conscious thought. My internal panic was balanced by an external calm and move to action. My training had kicked in and later when I was reflecting on that experience I realised that maybe I was safer in my practice than I thought. Perhaps I was creating a solid foundation for what would later become my practice.

.
..
.

Now, as a more seasoned Mouse, I work with students. I share what wisdom I can and encourage them to not make the same mistakes I do. I see them going through the same experiences that I did. I see them realise that they do know more than they think. They get to start to trust in their training.

It's a cycle of growth.

Because of that kiddo and the visceral, emotional response I had to that experience I have become a better practitioner. 

Thank you, young Zed for letting me be part of your care. 






Comments