Room 6418

I approached the closed door of room 6418, the only bed occupied by someone under the age of forty on this ward. Floor six, ward four is a high dependency respiratory and airway care ward, typically reserved for those entering the hospital with exacerbations of chronic lung disease, such as emphysema, but it also functions as a step down ward for certain people leaving the intensive care unit. In the case of room 6418, this ward was chosen as the temporary home for a young man leaving the intensive care unit with a tracheostomy tube in place.

Staff here often help the families of those leaving the hospital with a permanent surgical airway learn about airway management so they can return to their home and re-establish some sense of normality following hospital admission. Unfortunately, this young man was deemed too high maintenance for his aging parents and thus his stay in the ward was extended until a position in a specialist residential care facility became available.

Four months ago the twenty one year old entered the hospital via ambulance following a failed attempt at suicide by hanging. At the time of his attempt he was found hanging by his neck by one of his parents, likely just moments after knocking the chair from beneath himself. Being six foot three and ninety kilograms, his body weight and the short drop was enough to tension the rope and cause significant damage to both his anterior and posterior neck. Had the rope remained in place for mere seconds longer than it did, the tension would have also occluded his carotid arteries, preventing the flow of blood to his brain. However, quick action by the parent led to him being conscious for the initial portion of the rescue effort. The young man fell the short distance from his suspended position and crumpled on the carpeted floor, completely aware but unable to move.

Paramedics arrived at the scene shortly afterward finding him catastrophically hypoxic (low oxygen) without any respiratory drive. By nothing short of a miracle the young man’s healthy heart continued to pump, despite the lack of oxygen being drawn into his lungs. The problem here was found to be one not with his lungs, nor an availability of oxygenated air, but both with a traumatic occlusion of his upper airway and high spinal cord injury from the initial tensioning of the rope. The paramedic attending to his airway at the time noted ligature markings over his larynx extending circumferentially around his neck to his cervical spine, which was described as significantly bruised and deformed. The rhythmicity of breathing is mediated by the Brainstem, more specifically, a region called the Pons. Whilst there was likely no damage to this region of the brain sustained during the short fall and tensioning of the rope, nor the diaphragm below the lungs that controls the movement of the rib cage in inspiration, the pathway between them was no longer functional. An x-ray and ct scan shortly after arriving in the hospital would show fractures to his second through fourth cervical spinal bones as well as a corresponding spinal cord injury. On the front of his neck the scans showed a fractured hyoid bone and profuse swelling to and around his airway.

The young man was unconscious at this point, but not before suffering through the agony of suffocation whilst the ambulance was on the way. The prompt action by the paramedics thereafter undoubtably saved his life. An initial intubation attempt via direct laryngoscopy (passing a breathing tube through the vocal cords to a point just above the branching of the two lungs) was unsuccessful as the young man’s airway was already so swollen that the cords were impossible to view. Foreseeing this problem, the paramedic had already prepared for an emergency cricothyrotomy and moved to locating the appropriate landmarks. The site was disinfected with a povidone iodine wipe and the scalpel inserted, opening a hole in his neck by which a smaller tube was subsequently passed through. The rhythmicity of breathing normally provided by the pons was now replaced by the paramedic’s rhythmic squeezing of a self inflating bag attached to oxygen. The initial oxygen saturations of 68% slowly lifted until they maxed out at 100%.

The other paramedic had inserted a cannula into each of his antecubital fossa veins on either arm and was now preparing for sedation. In his suffocated state the young man’s brain starved, craving oxygen and resulting in damage that would only be apparent much later in his hospital stay. At the current time though, the return of breathing and some oxygen was enough to reboot a portion of his brain and elicit a fractional combative response evidenced by twitching in his face and his jaw tightening up. Tragically, his arms and legs remained motionless. The paramedics prepared and attached an infusion of both fentanyl and midazolam, sending the patient into a deep sedated state with which he would return only from weeks later. Transporting the young man to hospital, his neck was kept motionless, lest any further movement exacerbate the injuries. The young man’s stay in the emergency department was brief and he was promptly moved to the intensive care unit where intensivists, surgeons, respiratory therapists and nurses would repair him to the point with which I would meet him today. Four months confined to a bed had rendered him but a shell of the man he once was. He now weighed seventy kilograms, his athletic frame atrophied into skin and bone. What was once a dominant footballer at the beginning of his best years of life was now a man destined to spend the rest of his life in a care facility attached to a respirator. I knocked, then opened the door of room 6418. The young man’s family were seated around him in the room. Words can’t really describe how difficult an experience this must have been for them. My appearance represented the finale of their four months of daily visits to the hospital. For them it was four months of desperation, praying for return in normal brain function. Four months of frustration, dealing with the bureaucracy of the healthcare system and establishing the young man’s new life when the day finally came to leave hospital. Four months of guilt, contemplating why they didn’t pick up on the signs earlier that he was struggling with his mental health. As I entered the room, their conversation stopped and all eyes were on me. I introduced myself to each person in the room shaking hands and attempting to remember names, then finally to the young man who lay in a motionless, mostly unresponsive state. After briefly confirming a few details I began the process of moving the man to our stretcher. It would be a delicate process as the bones in his neck were still healing and he was attached to the respirator. I stood at his head and looked down at the site of the tracheostomy. Visible just above it was the scar from where the paramedic had inserted the scalpel and breathing tube that saved his life. Just further above that was another scar which was likely from the operation to repair his hyoid bone. A halo brace still remained around his head keeping his neck motionless. With a gentle roll and a coordinated push/pull, he was moved from the hospital bed onto our stretcher. Four motionless months in hospital may have wasted away his bones, but his height was unaffected, leaving his size thirteen feet dangling off the end of the stretcher. I returned the slide boards used in the transfer most of the way under the stretcher and placed a towel on top, leaving a platform for his heels to rest upon, a gesture that was appreciated by the family. I smiled briefly to myself as the paramedics that brought him into this hospital on an identical stretcher would have noticed the same thing likely engineering the same solution. As we exited the ward the family followed. No more words were exchanged between them, only tears as we pushed the young man into the ambulance and off on the way to his new normal.