This was probably more exciting in my 20s lol. I'm a firm believer in rule 1.

Update on my portly patient after no doubt one of the most unusual thread derails I have seen:

He is still unable to breathe without staying on at least 20 mg of Prednisone and Budesonide inhalers. He feels that his symptoms have actually worsened since I last saw him and since he had his flexible bronchoscopy. He has gained back most of the weight that he had lost since he contracted COVID-19, but he is using his CPAP machine at his wife's urging/nagging.

Today we went to the O.R. for a laryngoscopy and biopsy. He was a somewhat difficult intubation for anaesthesia (roughly 5'6" and 240#), and very difficult for me to safely get a laryngoscope into position without damaging his lips, teeth, etc. He had to be intubated three times, because he could not keep his sats up with the smaller laser tube I had wanted to use. The larger laser safety tubes are made of metal, and they constantly "flip" around the laryngoscope when you are trying to work posteriorly. And he was NOT a candidate for jet ventilation, obviously. I am not sure if his constant desatting was due to his tracheomalacia or maybe some residual scarring in his lungs from his COVID or just his overall poor medical health (obesity, hypertension, diabetes, hypercholesterolemia). Tidal volumes were also very low with the smaller tubes. Constant battle between me and anaesthesia trying to find a "happy medium". By the time I was able to get down to his cords and subglottis, there was already swelling and bleeding. We like to keep the FiO2 no higher than 35% for laser cases, and he was having significant desaturations during the entire case. Ugh.

Now for the findings:

The granuloma on his left vocal cord had completely disappeared. As he was not having hoarseness, my suspicion is that the granuloma which was apparent on the flexible bronch was not actually an intubation granuloma but a pedunculated portion of granulation tissue (there was PLENTY of that) which had "flipped" to the left. Alternatively, Baby Jesus loves him and cured his granuloma or it just went away on its own. Who knows.

The entire posterior tracheal wall was covered with very friable granulation tissue, consistent with his worsening symptoms. Everything I did to it made it bleed. I will try to attach some photos, but their quality is not the best in each case. At the end, I was able to get a pretty good airway open by using the laryngeal skimmer and the light pipe with CO2 laser and upbiting cup forceps. I had to constantly put straight adrenaline on pledgets to control bleeding, and I left them in place and tied the strings to the laser tube so they wouldn't get lost upon extubation (a little trick I learned in 'Nam (Parkland Hospital)). I did inject the bed with triamcinolone. I will try to attach a couple of photos later on and see how they come out. They were taken by a nurse from my cellphone, and there is glare of the room lights, but you can get the gist from some of them. Not a fun day.

View of the friable tissue




Upbiting cup forceps and a heave ho



Laryngeal skimmer turned upside-down


CO2 laser with light pipe



And after all that I realize I really never got a good "finished product" picture. I was overly focused on dealing with bleeding, avoiding a laser airway fire, and not sending him home in a pine box.
Probably the cleanest "late" picture I got, with annoying blood hiding full view:

Dude. So much over my head but you're awesome.

Be honest. Did you blame anesthesia after you busted up his lips?

aggiemike02 said:

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Dude. So much over my head but you're awesome.

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In keeping with Page Juan and in order to make suitable for general viewing audiences, we take up where the story left off:

Really Fat Dude isn't getting better.
Really Fat Dude admits that he has rediscovered biscuits with gravy.
Balding Surgeon resorts to the first maxim he learned in surgical training, "When in doubt, cut it out".
Balding Surgeon speaks with Really Fat Dude and Anaesthesiologist in a Hazmat Suit this morning, Really Fat Dude signs a consent.
Balding Surgeon tells Anaesthesiologist in a Hazmat Suit he is going to use a laser to control bleeding, asks for the smallest laser intubation tube available.
While Balding Surgeon is dressing into scrubs, Anaesthesiologist in a Hazmat Suit pulls out a tube that is NOT the smallest available, thinking that Balding Surgeon will not notice.
Balding Surgeon tries to get a look into Really Fat Dude's airway once he is asleep, "Time Out" has been performed, etc.
Balding Surgeon cries a lot, because the tube keeps slipping in the way of his line of sight, so much that Anaesthesiologist in a Hazmat Suit acquiesces and agrees to put in the REAL smallest laser tube available.
Anaesthesiologist in a Hazmat Suit changes to the smallest tube, looks at her fancy monitors, pushes on some kind of green balloon-looking bag, and says something to Balding Surgeon.
Balding Surgeon cannot hear Anaesthesiologist in a Hazmat Suit because he is old and she is in a Hazmat Suit, but Anaesthesiologist in a Hazmat Suit flails arms and points to oxygen sensing equipment.
Balding Surgeon actually understands the dilemma but was hoping the problem would just "go away".
Goldilocks finds a happy medium and they split the difference. A new tube is put in.
In truth, neither Balding Surgeon nor Anaesthesiologist in a Hazmat Suit are happy with the solution, which ensures that the right decision has probably been made.
Balding Surgeon is surprised to see that one of the things pulmonary doctor originally saw was gone.
Balding Surgeon thinks he might have a chance! He is elated.
Balding Surgeon was sadly mistaken. He sees nothing but a big mess in Really Fat Dude's breathing hole.
Balding Surgeon wishes to defacate, but he realizes that he is not in a good place nor is it a good time for this.
Balding Surgeon uses tricks he learned when he was a P.O.W. at Parkland Hospital, and some he learned along the way, to try to get the big mess out of Really Fat Dude's breathing hole. One is called the laryngeal skimmer, an instrument Balding Surgeon wishes he had invented so he wouldn't have to be working with Anaesthesiologist in a Hazmat Suit on Really Fat Dude's breathing hole.
Every time Balding Surgeon tries to remove big mess from Really Fat Dude's breathing hole, it bleeds. Although it really isn't all that much blood, it is in a critical area, and, to Balding Surgeon, it is not unlike an explosion at the ketchup factory.
Balding Surgeon uses fancy laser (shark not included) with a light pipe attached to bring the bleeding from an explosion at the ketchup factory down to a slow ooze.
Balding Surgeon is worried that the laser (shark not included) might start a fire in Really Fat Dude's airway hole, because members of his tribe have told him stories of such and have even made drawings in their caves describing it.
Balding Surgeon recalls something else from his P.O.W days that can help stop bleeding - chemicals.
Balding Surgeon puts chemicals on "patties" tied to strings, puts them onto the big mess surgical site, and says a prayer.
God takes pity on Balding Surgeon and bleeding continues to slow down.
Anaesthesiologist in a Hazmat Suit, however, is not impressed. She keeps pointing to her machines that make strange noises and are filled with numbers and squiggly lines. She says something, but, again, she sounds like Charlie Brown's teacher to Balding Surgeon. "Something, something, oxygen, tidal volumes", blah, blah, blah, Balding Surgeon cannot take it, too many words!
Balding Surgeon tries to think of something that will prevent another encounter with Really Fat Dude and Anaesthesiologist in a Hazmat Suit. An idea pops into his mind.
Balding Surgeon gets a really long needle, injects steroids into Really Fat Dude's Breathing hole where the big mess was found, and replaces magical chemical patties.
Balding Surgeon takes strings attached to bleeding-stopping, chemical-soaked patties, and ties them to laser tube so that Anaesthesiologist in a Hazmat Suit will not leave them in Really Fat Dude's airway when she pulls out the tube.
Balding Surgeon's trick works - Anaesthesiologist in a Hazmat Suit pulls out tubes, and magical chemical-soaked patties come out as well.
Circulating nurse is pleased that "counts" are correct at the end of the case.
Balding Surgeon takes pictures and sends them to TexAgs poster Marcus Aurelius before posting update.
Marcus Aurelius responds to Balding Surgeon, "Hmmm".
Balding Surgeon is originally saddened by the response, then Balding Surgeon recalls the words of Sir William Osler:
"Look wise, say nothing, and grunt. Speech was given to conceal thought".

Sarduakar said:

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Shark with laser beams would have done the surgery and the post faster and better

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Hmmm. Agreed, but Balding Surgeon is doing his case in 2020, and Sharks with Laser Beams are not yet trained to do this, they refuse to wear N95 masks, and the surgery staff fear them.

Was that your op note??

Kool said:

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aggiemike02 said:

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Dude. So much over my head but you're awesome.

---

In keeping with Page Juan and in order to make suitable for general viewing audiences, we take up where the story left off:

Really Fat Dude isn't getting better.
Really Fat Dude admits that he has rediscovered biscuits with gravy.
Balding Surgeon resorts to the first maxim he learned in surgical training, "When in doubt, cut it out".
Balding Surgeon speaks with Really Fat Dude and Anaesthesiologist in a Hazmat Suit this morning, Really Fat Dude signs a consent.
Balding Surgeon tells Anaesthesiologist in a Hazmat Suit he is going to use a laser to control bleeding, asks for the smallest laser intubation tube available.
While Balding Surgeon is dressing into scrubs, Anaesthesiologist in a Hazmat Suit pulls out a tube that is NOT the smallest available, thinking that Balding Surgeon will not notice.
Balding Surgeon tries to get a look into Really Fat Dude's airway once he is asleep, "Time Out" has been performed, etc.
Balding Surgeon cries a lot, because the tube keeps slipping in the way of his line of sight, so much that Anaesthesiologist in a Hazmat Suit acquiesces and agrees to put in the REAL smallest laser tube available.
Anaesthesiologist in a Hazmat Suit changes to the smallest tube, looks at her fancy monitors, pushes on some kind of green balloon-looking bag, and says something to Balding Surgeon.
Balding Surgeon cannot hear Anaesthesiologist in a Hazmat Suit because he is old and she is in a Hazmat Suit, but Anaesthesiologist in a Hazmat Suit flails arms and points to oxygen sensing equipment.
Balding Surgeon actually understands the dilemma but was hoping the problem would just "go away".
Goldilocks finds a happy medium and they split the difference. A new tube is put in.
In truth, neither Balding Surgeon nor Anaesthesiologist in a Hazmat Suit are happy with the solution, which ensures that the right decision has probably been made.
Balding Surgeon is surprised to see that one of the things pulmonary doctor originally saw was gone.
Balding Surgeon thinks he might have a chance! He is elated.
Balding Surgeon was sadly mistaken. He sees nothing but a big mess in Really Fat Dude's breathing hole.
Balding Surgeon wishes to defacate, but he realizes that he is not in a good place nor is it a good time for this.
Balding Surgeon uses tricks he learned when he was a P.O.W. at Parkland Hospital, and some he learned along the way, to try to get the big mess out of Really Fat Dude's breathing hole. One is called the laryngeal skimmer, an instrument Balding Surgeon wishes he had invented so he wouldn't have to be working with Anaesthesiologist in a Hazmat Suit on Really Fat Dude's breathing hole.
Every time Balding Surgeon tries to remove big mess from Really Fat Dude's breathing hole, it bleeds. Although it really isn't all that much blood, it is in a critical area, and, to Balding Surgeon, it is not unlike an explosion at the ketchup factory.
Balding Surgeon uses fancy laser (shark not included) with a light pipe attached to bring the bleeding from an explosion at the ketchup factory down to a slow ooze.
Balding Surgeon is worried that the laser (shark not included) might start a fire in Really Fat Dude's airway hole, because members of his tribe have told him stories of such and have even made drawings in their caves describing it.
Balding Surgeon recalls something else from his P.O.W days that can help stop bleeding - chemicals.
Balding Surgeon puts chemicals on "patties" tied to strings, puts them onto the big mess surgical site, and says a prayer.
God takes pity on Balding Surgeon and bleeding continues to slow down.
Anaesthesiologist in a Hazmat Suit, however, is not impressed. She keeps pointing to her machines that make strange noises and are filled with numbers and squiggly lines. She says something, but, again, she sounds like Charlie Brown's teacher to Balding Surgeon. "Something, something, oxygen, tidal volumes", blah, blah, blah, Balding Surgeon cannot take it, too many words!
Balding Surgeon tries to think of something that will prevent another encounter with Really Fat Dude and Anaesthesiologist in a Hazmat Suit. An idea pops into his mind.
Balding Surgeon gets a really long needle, injects steroids into Really Fat Dude's Breathing hole where the big mess was found, and replaces magical chemical patties.
Balding Surgeon takes strings attached to bleeding-stopping, chemical-soaked patties, and ties them to laser tube so that Anaesthesiologist in a Hazmat Suit will not leave them in Really Fat Dude's airway when she pulls out the tube.
Balding Surgeon's trick works - Anaesthesiologist in a Hazmat Suit pulls out tubes, and magical chemical-soaked patties come out as well.
Circulating nurse is pleased that "counts" are correct at the end of the case.
Balding Surgeon takes pictures and sends them to TexAgs poster Marcus Aurelius before posting update.
Marcus Aurelius responds to Balding Surgeon, "Hmmm".
Balding Surgeon is originally saddened by the response, then Balding Surgeon recalls the words of Sir William Osler:
"Look wise, say nothing, and grunt. Speech was given to conceal thought".

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This is genius. Austin Powers references and all.

This is the funniest, nerdiest thread I've ever read. And I've thoroughly enjoyed every minute.

I lost my mother to end-state COPD last November amidst a life-long inventory of health issues, including 50+ years of smoking 2+ packs/day, morbid obesity and a terribly sedentary lifestyle. I learned more than I would have ever imagined about pulmonary health and all of the diseases attributed to breathing.

Never in a hundred years would she have survived this pandemic. That said, my mother's case pales in comparison to your patient and everything you've done to keep him alive. Just....daaaaaaannnnnng.

I can proudly say that I've done everything I can to be the opposite of these cases. Thank you for what you do. Even being a "Balding Surgeon" referencing Austin Powers, Seinfeld, etc.


PS - username checks out. literally.

Why not have a little fun? I definitely wasn't having it this morning. I consider myself much more like the Geico Caveman than Kool, but c'est la vie.

It's hard to explain all the different difficulties that his case brought forth, but suffice it to say that it was not the case I was hoping it would be. Which brings me to the point - I am sorry to hear about your Mom, but happy that you aren't following in her footsteps. My wife's aunt smoked years ago and was just diagnosed last month with metastatic lung cancer. It seems like such a waste. We are all going to die some day, but that doesn't mean we should accelerate it or make our living days less than they should be because we neglect our health.

Bit of an update. The patient did absolutely great immediately postop, and stated the following day that he felt normal for the first time in months. I thought I was a genius.

Fast forward another month and he says he can't keep coming off of his steroids and he has increased them on his own. Obviously no good for his diabetes and obesity (BMI now 39).
Two weeks ago, he was getting short of breath again.
He got a dynamic CT chest which showed no significant tracheomalacia. But his subglottic and tracheal soft tissue has reappeared.
Earlier this week he came to my office and was actually stridorous. Ugh, now I'm an idiot Off he goes to be urgently admitted.

We put our heads together and today Pulmonary Critical Care, Thoracic Surgery and I took him to the OR

All the king's horses and all the king's men. Humpty not clearly seen (see, HIPAA):



Did flex bronch working through the LMA and heeeee's baaaack:



Working with flexible cryosurgery wand then rat tooth forceps then a snare:









Erbium laser (again, shark not included) was on standby but not needed.

The "finished" product:



I then did a rigid laryngoscopy and injected the bed with triamcinolone. Sort of. Truth of the matter was that we only had a super-long bronch needle and he is so short-necked and gravitationally challenged that I couldn't hold the scope and inject at the same time. Plus, my arm was still sore from patting myself on the back for curing him two months ago that I had to position the needle while the thoracic surgeon stood behind my shoulder and injected it. But I digress.
30 minutes later and he was in PACU saturating 96% on room air and asking when he can go home.
Great collaborative case today. First try only lasted a while. Hoping this one does the trick.