Difficult Airways and the Military

by Paul

After our wonderful dinner at the Runnels last night, I was invited to go with Sean to the Military Hospital today to see a few of their difficult airway cases.  They have a very accomplished maxillofacial surgeon who works with a lot of patients with very advanced facial and oral tumors.  From previous global health work, Sean has some very extensive experience with difficult airways and knows how to deal with cases like this.  Therefore he has been working closely with Christian, one of the Rwanda anesthesiologists, in developing a good difficult airway algorithm and approach that will fit the system here well.

So my day started off heading to the hospital, CHUK, to meet up with Sean for 7am morning report.  They, as usual, discussed an interesting and difficult case from the night before.  Sean then discussed an interesting initiative that they are starting to improve interdisciplinary communication for the general surgery patients.  This will in fact be similar to a project that was started with the OB/GYN patients and has seemed to have improved the communication around those patients.  It was interesting to watch how he stressed the goals and the objectives and pointed out specific items that were left out in order to try and keep this initiative as focused as possible.  It was a good lesson is clear communication and since this project is all about communication it seems prudent to start it off that way.

So after that, we took a drive out to the military hospital. This was particularly enjoyable for me, since we were in Sean’s late 80s Toyota LandCruiser that has a 4 cylinder diesel engine, that generates all of about 85-90 horsepower but has absolute ton of torque (comparatively).  It is a thoroughly enjoyable car and would be fun to go romping through a Rwandan game park or mountain trail with.  He has had his fair share of issues with it, including the power steering failing recently, which in retrospect he is happy about because the car has just that much more horsepower now.

We made it to the Military Hospital without incident and got ready to start the day.  Due to availability of people, we ended up having quite a bit of time to ourselves until everyone was ready to go.  This worked out incredibly well for me because we got to discuss difficult airways and how best to approach them depending on the tools you have available. Sean showed me a rather extensive file of cases that he was accumulated over the years of different difficult airways that comprised tons of very advanced pathology that we never see in the US.  He also gave me his difficult airway lecture and we even had time to go over some of the tools that he has with him.

By and large what seems to work well for him is a combination of a videolaryngoscope (for visualization of the glottis) and a fiberoptic scope (to be used as an introducer of sorts).  This is a great technique, one that I have used with and is championed by our very own Dr. Randy Blank, home at UVA. The 22 y/o male that we were going to take care of today had what turned out to be some sort of fibro-chrondro-calcified tumor that was where his left maxillary bone (check bone) should have been.  It was large enough to distort his face pretty significantly and it was pushing up in to his left orbit (eye-socket).  Thankfully it was still a fair distance away from his brain and it was not invading or significantly distorting his palate or his pharynx.  There was the possibility that we could have secured his airway by simply taking a direct look like we do for any standard case.  But given the possibility that the tumor could still have gotten in the way and that we were worried about being able to effectively mask ventilate him, we decided to use the technique that I described above.  In addition to that, because of the potential for the difficult mask ventilation, we decided to slowly titrate in some propofol and halothane to get the patient off to sleep but keep him breathing on his own.  That way if we were not able to effectively mask the patient, we could have woken him up and found another way to secure his airway.  The most important thing about this is that this whole plan was discussed ahead of time, everyone in the room knew the plan before we started, and everyone had tasks to perform – this is all things that Sean has been trying to hammer home over the last several months to improve communication and prevent hesitation and poor outcomes when these situations get hard/scary.

Thankfully, we did not have a lot of trouble getting the patient off to sleep.  He was difficult to mask ventilate, which was first attempted by one of the anesthesia technicians.  She was fairly petite however and was having trouble making an adequate seal.  After a little while, I was given the opportunity to try and with my significantly larger hands I was able to make an adequate seal at which point we paralyzed the patient and then intubated him using the videolaryngoscope /fiberoptic scope technique.  It was an interesting case to watch and had lots of good teaching points which led to many good discussions.  It took quite a while to complete which meant the palate tumor case that was to follow needed to be rescheduled for another day.  Oh well, that would have been very interesting to see as well.

After work, Sean needed to make a pit stop at one of the cellphone places to get his wife’s internet modem reloaded with the monthly internet access plan and he decided to pick one up for himself as well.  This led to a very interesting discussion about how travelers or ex-pats often try and find the way to get the fastest internet possible here.  There is the misconception at first that it is likely or even possible to get internet access speeds that approach those that we have in the US.  It can apparently become an utterly all-consuming mission for a few hapless souls, which almost universally leads to complete disappointment.  There are all sorts of rumors about finding exactly the right person to talk to, who knows how to get hold of a device that allows you to connect multiple USB modems together thus quadrupling the speed, etc.  Needless to say this does not exist and short of buying/installing a satellite dish (which I don’t even know if it is truly an option), you will not have similar speeds to those that we see at home.  However, how much does this really limit you…overall not that much.  Streaming video is difficult, netflix or similar services is all but impossible…youtube works sometimes and somewhat slowly, but on a good day is pretty reasonable.  The question is, do you really need this?  For a short-term trip like the one we are on, absolutely not.  But for those people who are here for 6 months or a year, I can see wanting that connection to home for at least some of the time.  I am glad for now that my first experience here is short term like this so that I can avoid this issue, because I could totally see falling into this trap and wasting an inordinate amount of time trying to eke out every last MB/s that I could from whatever connection capabilities that I had.

by Marcel

(and me ? I spent most of the day waiting for arrangements to be complete for a meeting with the Human Resources for Health management at the Ministry of Health. Unfortunately, the Honorable Minister of Health had called an urgent meeting for the HRH group, so my planned 9:30 meeting eventually became 4pm. It gave me plenty of time to get some reviews written and deal with other accumulated stuff in my Inbox. But it all worked out in the end. The ministry sent a car and driver to pick me up at the hospital, we had a thorough meeting of the minds with senior HRH management, and afterwards they even dropped me off at the Nyamirambo apartment.)

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