Friday, May 24, 2013

Laryngectomy




Some people think having a tracheostomy is the worst thing that can happen. This is ironic; most times a trach is placed to 'preserve the vocal cords' from damage from contact with the breathing tube for intubations that are expected to last over three weeks.

the little circle on the right is where I put the breathing tube


Anesthesia for a patient with an indwelling trach ('in-situ') are easy. You just hook up your circuit to the special connector that is shared like an accordion, connect to the trach, dial up the gas and give i.v. paralytic. The Respiratory Therapist will have told you the vent settings already. You just dial them in to the anesthesia machine. Typically these patients come down from ICU and have a lot of monitoring lines. So most of the case I untangle the lines and make sure they are not missing any doses of medicine that are due by checking the chart. That is, if blood pressure is stable. If it isn't , I work, and I work hard.

the anesthesia breathing circuit connect to the blue plastic

Putting in a trach if someone is intubated is sort of the same thing. But once the surgeon gets close, he or she asks me to deflate the balloon cuff, and pull back about four centimeters. Then he pops the new trach in. I hand the circuit over the drapes, and we make sure the new trach passes air properly. This is demonstrated by the presence of end-tidal carbon dioxide on the monitor. When we see the waveform, I pull out the tube and throw it away. If it doesn't , I advance my old tube, reinflate the cuff, and let the surgeon try again to fix it.

Sometimes for complex head and neck cancer, the ENT will put a trach in first. They use a long armored tube that is flexible, and they sew it to the chest so it won't come out. I have to watch closely to my monitors for signs of that happening too throughout the rest of the case.

Dr. Passey invented a device that is called the Passey-Muir valve. With it, a trach patient can talk!
They sound just like themselves. I always encourage the family to ask for it later when the patient is better.

And many times, after the trach is not needed, they keep putting smaller and smaller ETT unttil it can close completely. There is also a device called a 'button' that is a little plastic plug that can hold the trach hole open in case it is needed later, but the patient can breathe on their own in the meantime.

This is a 'button'. A Passey-Muir valve looks similar.


The scary ones are the Laryngectomy patients, some people get cancer there, and it has to come out. For that procedure, the surgeon makes a hole very low in the neck, inserts an armored tube, and does the procedure. But if the patient already had that and is coming to the OR for something else, like a knee? I use a special Laryngectomy tube that is short and bent funny. Once the patient is asleep I stick it in the hole, connect to the circuit, and tape like mad. It always wants to fall out. The anesthesia gas also leaks out around it, and I get creative trying to make sure only the patient goes to sleep, and not myself by breathing that stuff! I use wet gauze or Vaseline gauze for an air tight seal. At the end of the case I take everything out.


This is a laryngectomy tube for anesthesia 

The people with a Laryngectomy talk.



I am serious. They use this device, the Electro Larynx. This short video shows the old style and the new one together. The only one I have ever heard before was the monotone one:





I am surprised at what angry people the patients tend to be. (This Tony guy is very nice by comparison!) Most of the ones I have seen always want to give you a 'piece of their mind!'

 But as they hold the device to their neck and rant away, something is 'lost in the translation'. That device is a monotone. The whole picture of patient holding thing to neck and cursing but sounding like Donald Duck gone techno just cracks me up. So I smile, take a deep breath, and do what is reasonable to soothe the patient to help them calm down.

Why am I writing about this?

Because I have a passion to share that which I know. A lot of medicine is very 'exclusive'. It takes a while to learn it, but I look at the vocal cords daily and I think it is really cool. I hope you do too.

Birds do not have a larynx. They have something similar but it is called a syrinx. The very best ones at mimicry are the African Greys. I want one.


These amazing creatures display empathy, according to their owners. They will also call over the dog to the cage, stick their tail out, and say 'Poop!'. They will mimic the microwave, the telephone, the door bell, and even the voice of your spouse just to play tricks with you. My personality is more of a cockatoo one, however. These shy and reserved African Greys do not warm up to me. I am happy enough with my pet Goffin's, Harry Bird.

Birds with voices, anesthesiologists, humans with fake voices, and everything in between. All of it is Reiki for your brain cells. Now you have something to discuss at your Memorial Day events, perhaps?

Take care, and have a wonderful holiday weekend. I will not be writing for I have a conference to attend with Cobra. It begins tonight. I have waited for months for it to arrive! I feel like this!


I can't wait to go and be Galactic for a few days with other Like-Minded People. There is a big portal we are working together to open tonight; it is the very last one to open to usher in the New Golden Age. <3


Namaste, and Blessings from my heart to you,

Reiki Doc

P.S. Can anyone figure out why this song popped into my head this morning right before I woke up? It has symbolism, but I can't understand it.

Aloha and Mahalos





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