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Memorable Moments

be sent to pick us up. I asked that a transport respiratory therapist be sent down, too.

I also recommended that the child be intubated at the sending hospital before we left. This was accomplished in an OR by an anesthesiologist on their staff.

On the flight back, the crew included the pilot, the respiratory therapist, the nurse, and myself. We made room for the boy's mother as well. I remember it was a challenge, and we had to rearrange the equipment to fit everyone in.

Sadly, the boy died 13 hours after he arrived at DHMC. It turned out that he had a massive tumor in his left chest that no one knew about until it was too late.

Recently, I was representing DHART at a New Hampshire Fisher Cats baseball game in Manchester. The boy's family happened to be there. His father came up to thank me for all that we had done for his son. He said that if I hadn't interceded that day, it would have taken longer to get his son to DHMC. He and his family were grateful for all that we had done, even though his son died.

Drew Remignanti, M.D., M.P.H.
Remignanti, a 1975 graduate of Dartmouth College (and a member of Dartmouth Medicine's Editorial Board), earned his M.D. at Rutgers and completed his emergency medicine residency in Jacksonville, Fla. He currently practices at North Shore Medical Center in Massachusetts.

Just as I headed into the ED on-call room, to get a little sleep, I heard the emergency services radio begin to squawk. I tried to convince myself that it was either random interference or a routine radio check from a neighboring town. But instead of getting comfortable in the on-call bed, I wandered back out to the ED to listen in.

Sure enough, it was a real trauma case. Generally EMTs are pretty solid and reliable, but this one sounded a little rattled. She reported that she was at the scene of a single-car motor vehicle accident (MVA) with a young male who had a neck laceration from ear to ear that—get this—was "possibly self-inflicted." This made no sense. First, how could you draw a knife across the entire width of your own neck? Second, why at an MVA and why just "possibly"? Why not ask the guy how it happened? Anyway, the EMT described the patient as stable but breathing through his neck and reported that their ETA was eight minutes.

As we warmed him up, all the severed blood vessels that had been clotted off began to bleed again.

The nurses and I moved into the resuscitation room to prepare for whatever. I was sorting various-sized tracheostomy tubes with my back to the door when I heard them coming in. I turned and saw this guy on his back on a gurney with his head thrown back. His neck lay open like the Grand Canyon. It was truly sliced from ear to ear. His lower neck had sagged down toward his chest so the wound was open in all directions. The EMTs were holding a non-rebreather oxygen mask loosely over the opening as the patient breathed on his own.

I had never seen anything like it before. Everyone turned to me for professional words of guidance. "Holy s—!" was all I could manage. Then I said it again for good measure.

The tracheostomy tubes were obviously useless, so I tossed them aside and

grabbed a laryngoscope and an endotracheal (ET) tube. The worst thing was that this guy was fully alert; his eyes were bugged out and darting rapidly around the room. The neck wound had obviously bled extensively, but by then had all but completely clotted up, thank God. As I examined the wound to determine the status of his airway, the guy was swallowing reflexively. With each swallow, his lower neck took on a life of its own—heaving chinward in a vain effort to meet its mate. The epiglottis, the guardian of the entry to the trachea, was visible as his neck muscles relaxed and the gap again fell open.

I considered passing the ET tube through the wound into his airway but discarded this idea when I realized the tube would get in the way of repairing the wound. Intubation via the usual oral route seemed preferable, so I selected a laryngoscope and was about to insert it into the patient's mouth. But his eyes bore through me as he gritted his teeth tightly. He was beyond reasoning with, and in fact he tried to get off the table. It was frightening to see a man in his condition needing to be restrained by four people, each holding a limb.

"Valium, five milligrams, IV," I ordered. After a repeat dose, he was much calmer. I then opted for a nasal approach. Under ideal circumstances an endotracheal tube passed through the nose will follow the natural curve of the throat and, with a minimal amount of head positioning, will find its way smoothly past the epiglottis and into the trachea where it belongs. In this case, however, the tube began by following its expected course but then rose like a cobra through the patient's neck. I grabbed the tube with forceps and redirected it past the epiglottis into its proper position. Once the integrity of the patient's airway was ensured, I could finally take a few deep breaths of my own.

In the meantime, the nurses had been following standard procedures without direction from me. In fact, the only thing I had managed to say until ordering the Valium was "Call in the general surgeon and the ENT surgeon." By then the patient had two IVs in place, was on oxygen and a cardiac monitor, and was having his vital signs monitored. I noticed that he was both hypotensive, the blood pressure gauge showing an abnormally low reading of less than 90, and hypothermic, with a body temperature of only 86 degrees. We were resuscitating him with warmed intravenous saline solution and heated oxygen mist via the ET tube. His heart was racing, not

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