Securing the Airway is Crucial, Part 4: A Tedious Battle of Pressure
A tedious battle of pressure. I stared blankly at the clock hanging on the station wall. Time crawled by at an agonizingly slow pace. The vital signs on the monitor remained peaceful, and though the patient frowned in discomfort, he had stopped spitting up blood.
See? It's nothing major. I let out a silent sigh of relief. The crazy ghosts who had put me through hellish training on my day off must have just been trying to scare me. Reality isn't actually that dramatic. Blood spraying like a fountain, patients turning blue from suffocation—that kind of stuff only happens in dramas...
Right at that moment, the patient suddenly gasped and flinched. An ominous sensation surged up from the depths of his throat. A suppressed cough broke through reflexively.
"Cough! Hack, hack!"
And then—splaaash!
I felt the long Kelly forceps in my hand get violently pushed back as a fountain of crimson blood erupted from the patient's mouth. The blood vessel, which had barely been held in check by the pressure, had completely ruptured, unable to withstand the force of the cough.
"Argh!"
Red blood splattered everywhere—across the patient's chest, over my white coat, and onto the floor. The patient vomited up pools of blood. At the same time, the monitor began to scream frantically. Beep-beep-beep-beep! The oxygen saturation level plummeted from 98% to 90%, then straight down to 85%. A massive blood clot had blocked his airway.
"W-what?!"
My brain froze. Where had the peace from just moments ago gone? A literal hellscape had unfolded before my eyes. It wasn't just blood flowing back up from the patient's throat anymore; it was thick, gelatinous clots. A sickening, gurgling sound echoed terribly. The patient's face turned blue in an instant.
"Doctor! The patient's stats are dropping! It's in the 70s!"
"Suction! Get the suction machine, quickly!"
It was pure chaos. My hands trembled violently. The ENT department hadn't arrived yet. Han Jae-eon, the third-year resident, had gone to see another patient. Think. Think. Think, Hyeon-jae.
Airway, airway! The comments of the ghosts rang in my head like tinnitus.
"The anesthesiologist isn't here yet, right? They're still far away?"
"Yes! No contact from them yet!"
Let's do this. The decision took less than a second. I rushed to the head of the patient's bed and shouted.
"The things we prepared earlier! Give me the intubation set right now! The blade and the 7.5 tube! Along with the suction tip!"
At my desperate cry, the nurse hurriedly handed over the tray. I grabbed the laryngoscope with trembling hands. Left hand. The laryngoscope always goes in the left hand. I adjusted my grip on the laryngoscope with my left hand and pried the patient's jaw open. Then, I gasped at the sight before me. It was a literal hell.
The patient's mouth was already a sea of crimson. Gurgling blood and thick clots were so thoroughly mixed together that it was impossible to distinguish the tongue from the throat.
I grabbed the thick suction tip with my right hand and shoved it deep into the patient's mouth. Gurgle-gurgle-gurgle! The suction machine shrieked as it pulled in the blood clots. But it was useless. The speed of the blood welling up from the depths of the throat was far faster than the speed of the suction. My field of vision remained completely red. I couldn't see a single thing. The oxygen saturation monitor had now begun its countdown toward cardiac arrest. Damn it. I can't see. I can't see anything. I can't insert it like this.
I abandoned all reason. I shoved the laryngoscope blade in my left hand deep into the patient's mouth. Then, I swept the tongue and the backflowing blood clots entirely to the left.
"Gasp!"
For a split second, the blood receded, opening up a tiny window of space. However, because the mucous membranes were swollen and bloated from the blood, I couldn't tell where the epiglottis ended and the vocal cords began. I was completely lost. Where is it?! Where do I insert it?! The number on the monitor now read 55%.
I grabbed the hand of the nurse standing anxiously beside me. "Nurse! Here! The patient's neck! This protruding bone right here, press down on it with all your strength! Downward, and then toward me!"
The nurse pressed down hard on the patient's neck. It was at that exact moment that my field of vision shifted slightly. Amidst the bloodbath, the faint outline of the epiglottis appeared, and beyond it, I caught a glimpse of a V-shaped white structure. The vocal cords! Found you, you bastard!
Filled with a surge of triumph, I pushed the tube in my right hand toward that white gap. This was it. Once it was in...
Ting.
The tip of the tube hit something and stopped. It wouldn't go in.
"Why won't it go in?!"
The worst-case scenario. Laryngospasm. Oxygen saturation was at 50%. It was over.
...Right. This was my last hope. Without pushing the tube any further or pulling it back, I held it perfectly still against the entrance of the vocal cords. One second, two seconds, three seconds... The heart rate on the monitor began to slow down. Please. Please open up. Please.
And then—slide.
The resistance I felt at the tip of the tube vanished like a lie. I didn't miss that split-second window and pushed the tube all the way in. It was done. It was in.
"Whew..."
Just as I let out a sigh of relief and wiped the sweat from my forehead, a voice cut through.
"Hey! What do you think you're—!"
Han Jae-eon, the third-year resident, ripped open the curtain and rushed in, only to freeze dead in her tracks at the sight before her. A patient covered in blood, and a first-year resident calmly auscultating with a tube shoved down the patient's throat. Han Jae-eon's eyes shook violently.
Han Jae-eon's gaze darted back and forth between the laryngoscope in my hand, the tube lodged in the patient's mouth, and my blood-soaked white coat.
"The vessel ruptured when he suddenly coughed," I said, my voice remarkably steady. "The massive bleeding blocked his airway, and his oxygen saturation dropped to the 70s. Based on my clinical judgment, I performed an immediate endotracheal intubation. A size 7.5 tube was inserted, and cuff ballooning is complete. I just checked bilateral breath sounds while bagging with the Ambu bag, and the tube placement is correct."
Han Jae-eon's expression shifted as she listened to my report. She snatched the stethoscope from my hand and pressed it directly against the patient's chest. Verification—that was the senior's role.
"Breath sounds on both sides... the tube is definitely in," she muttered softly before immediately switching into commander mode.
"Stay glued to the patient's side and hold the tube so it doesn't slip out. I'll set up the ventilator." Han Jae-eon then began barking orders at the nurses. "Pour in one liter of normal saline through the current line immediately. We need to restore volume first."
"Yes, Doctor!"
"And check with the blood bank to see if the PRBC we sent for cross-matching earlier can be brought down right away."
"I'll check and let you know immediately!"
"Just in case, mix a norepinephrine ampoule and have a line ready on the infusion pump. If the blood pressure drops below 80, prepare to start it immediately."
"Understood!"
"And prepare an A-line kit. If his blood pressure keeps fluctuating, we'll need to insert an arterial line right away."
Han Jae-eon headed toward the station without looking back. I nodded, using a piece of gauze to wipe away the blood splattered near my mouth. I actually did it. I shoved a tube down the throat of a patient who was actively gushing blood. It felt completely surreal.
Moments later, Han Jae-eon returned, wheeling the heavy ventilator. The screen lit up with a mechanical hum. Her fingers flew across the touchscreen. With a soft whoosh, the machine began forcing oxygen into the patient's lungs. The patient's chest rose and fell rhythmically. The oxygen saturation level climbed steadily—80%, 85%, 90%... and finally, struggled its way up to 95%. The immediate crisis was averted.
Without turning to look at me, Han Jae-eon shouted to the nurse, "Nurse Nayeon! Call anesthesiology and ENT again right now. Tell them the patient ruptured and intubation is complete! Tell them to get down here as fast as possible!"
"Yes, Doctor!"
Then, she finally turned back to me. What is it?
"Han Hyeon-jae."
"Yes, senior."
"Go to the medicine room and grab two ampoules of midazolam and one ampoule of rocuronium. The patient is starting to wake up, so we need to sedate him immediately."
Only then did my senses fully return. I dashed to the emergency medicine room. The sedative midazolam, and the muscle relaxant rocuronium—medications that would put the patient into a deep sleep and paralyze his muscles, allowing him to adapt perfectly to the ventilator. As I gathered the drugs, the scene from moments ago replayed in my mind in slow motion. ...I really pulled this off. A hollow chuckle escaped my lips. My hands were still trembling slightly.
When I returned to the patient, Han Jae-eon gestured toward the syringes in my hand. "Got them? Administer them directly through the IV line."
I connected the syringe to the three-way stopcock of the fluid line attached to the patient's arm. First, the midazolam. The clear liquid pushed into the vein. Next, the rocuronium.
"Okay. Let's secure the tube now." Han Jae-eon brought over a long strip of medical tape. We wrapped the tape firmly around the patient's mouth to ensure the tube wouldn't slip out.
"Now, call for a portable X-ray to check the tube depth." Han Jae-eon's instructions came without a moment's pause. I picked up the intercom and contacted radiology. A short while later, a technician arrived wheeling the portable X-ray machine. The scan was finished in no time. Less than a minute later, the newly taken X-ray image popped up on the station monitor.
"Let's see..." Han Jae-eon and I stood side by side in front of the monitor, looking for the tip of the tube. It was positioned perfectly. "The depth is spot on," Han Jae-eon murmured quietly. I swallowed hard instead of replying.
Then, Han Jae-eon took over the next step herself. She felt for the pulse at the patient's radial artery on his wrist, then plunged a syringe in without hesitation. Bright red arterial blood surged into the syringe. "Send this to the lab immediately!" The syringe filled with blood was handed to a nurse, who dashed off toward the lab. Now, all that was left was to wait for the results. As if the entire chaotic storm had been a lie, tranquility returned to the emergency room. Only the rhythmic hum of the ventilator echoed. All initial measures were complete. The patient was temporarily stabilized.
My hands shook, and my heart pounded. Did I... did I actually do that? Am I crazy? Truly. What was this feeling? This inexplicable, racing sensation in my chest.
Only then did Han Jae-eon shove her hands into her pockets, leaning against the wall as she stared at me. Her expression was unreadable.
"Hey."
"...Yes, senior."
"What you just did." Han Jae-eon paused, choosing her words. "You did a fucking amazing job."
"...Pardon?"
"How did you do it? Blood was gushing like that, yet you didn't even tremble as you put it in? And you did it all by yourself?"
I couldn't exactly tell her, 'The ghosts forced me to preview this a few days ago.' Instead, the most textbook response slipped out of my mouth.
"I just did what I was taught."
Han Jae-eon let out a dry chuckle at my answer.
"Bullshit." She smirked. "If doing things 'by the book' was all it took, why would we ever lose a patient?"