Tuesday, November 19, 2019

Transorbital Intubation - An Artful Airway

Just when I thought the days of art in medicine were extinct,  the above image made it's appearance in my email courtesy of a long time reader. This  patient had extensive facial surgery for an invasive tumor and her maxilla and eye were sacrificed in the process. In a subsequent procedure, the creative anesthetist used this artsy approach in securing her airway. Instead of passing the endotracheal tube pharynx-larynx-trachea, the path was eye socket - pharynx, (or what's left of it) - trachea. Very clever, but how in blue blazes can the pilot balloon be visualized when it's deep inside the patient's face. Art in surgery always has a down side

Whippersnapperns live in a data driven, evidence based world of healthcare, but I know of  a different world where art played a dominant role  like the transorbital airway gambit shown above. Medical arts buildings dotted the landscape and old school surgeons pulled the art card to explain complications or pathology beyond their understanding. I do think the "medical arts" terminology when applied to physician offices  was so much less pretentious than the "institute" label trending today.

Unlike the group practices of today, most vintage surgeons were solo practitioners operating with minimal oversight. These surgeons of bygone years shared something in common with Picasso and Monet, they worked alone and relied on their ingenuity as much as scientific principle. "Based on empirical reasoning, I'm going to take out this lymph node over here and maybe the one over there too," was a typical intraoperative response.

Artful surgery could carry a heavy price for the patient. Someone cobbled together a procedure to "cure" Parkinson's Disease that involved harvesting cells from the difficult to access adrenal glands and injecting  them intracranially in hopes they would generate some much needed dopamine. The aggressive surgery resulted in lots of complications with poor long term results. Artful, but dangerous and usually ineffective.

A more benign example of surgical artistry involved the use of surgical instruments. Orthopedic surgeons found a novel use for Satinsky vascular clamps in that they were perfect for nabbing errant bone chips. I've written about the creative use for grooved directors in a previous post. They make great tongue depressors, templates for duct filets, guiding suture, and as mini retractors. Artistry in surgery always has an unsavory component and burying the sharp prongs of a towel clip in an unsuspecting abdomen to test the level of spinal anesthesia always shivered my timbers.

Unfortunately, patient's bodies make for a poor canvas and scalpel wielding surgical artists often come up with an unintended surprise on their hands. I wonder how that patient above felt about breathing through her eye socket. Breathing is a whole lot different than seeing.


  1. Good to have you back OFRN! You describe the surgeons you worked with beautifully! I feel sorry for that patient...

    I was watching a documentary recently about an elite maxillo-facial surgical unit in Adelaide here in Australia. The surgery they performed was amazing. I was watching thinking what a terrific time to be a theatre nurse when we are capable of doing such life-changing surgery for these poor people. I was positively envious of the young whippersnappers today! Sue

  2. That is...something.

    I love pictures and stories like this, but man just looking at that image makes me shiver a bit. Incidentally, I think I love the ER for the reasons you've described - there's enough data and reasoning and "institute" to satisfy my love of facts, yet plenty of room for the artistic side of medicine. We are, after all, the second best at MacGyvering - only after you OR folks, that is!

    1. We had such a dearth of facts to deal with back in the "good old days" and way too many procedures were done on an "empirical basis."

      The MacGyver moments were few and far between for me, but I did enjoy cutting fancy geometric designs across the top of my sharps bag with my trusty straight Mayos.

      ER nursing in Chicago terrified me. You never knew what the police were bringing in next (there was no EMS.) Things are worse today and I deeply admire your courage and commitment to such challenging work.

  3. Young nurses do indeed have the wonderful opportunity to really cure some of the patients that all we really had to offer were comfort measures. The less invasive laproscopic procedures are so far ahead of the surgeries I was involved with.

    The only downside is the derailment of contemporary healthcare by dollar signs.

  4. The Top Nurse Blog 2019 award on your site looks impressive OFRN - congratulations from Sue!

    1. Thanks so much. I received a Fitous blogging award and another one quite some time ago, but did not want to toot my own horn. I guess my fragile ego needed a boost or my humility is waning so I plastered that latest award front and center

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