[Doc Dutch]

You are on-call all night and you get paged to the L and D suite emergently. There you find a mother who has just delivered a 32 week old premie. The nurse practitioner goes to intubate the premie due to a low APGAR and discovers that there is a mass off the left tongue which has grown into the roof of the mouth, occluding 2/3 of the oropharynx, with leftward tracheal deviation of the upper trachea by the cricoid cartilage but mid-line just above the sternal notch by palpation. Astutely, the NP abandons the oral ETT route and goes the nasopharyngel route hoping to have a straighter shot at the vocal cords. Saturations that had dropped into the 50's are no hovering in the low 80's to upper 70's. Temporarily satisfied, the child is moved to the NICU (neonatal intensive care unit). On arrival the saturations are noted to have dropped into the 60's but with agrressive bagging the saturations come up into the 70's.

Now, anesthesia arrives. They take a look and cannot see the vocal chords around the mass orally and do not want to dislodge the nasopharnygeal ETT already in place although clearly it is not in. There are bubbles from the mouth and if you close the mouth the saturations improve slightly. The NICU attending tries to intubate orally and cannot pass the tube, even with position change of the level of the head and back. Suctioning the mucous causes desaturations. There is the tiny ETT that the NP had placed initially which is really a nasopharyngeal airway, even an LMA if you will, at best. The anesthesiologist again tries to pass a small ETT (uncuffed) orally but fails. Now the airway is getting "bloody". The premie has destaurated into the 40's and the HR drops into the 60's as well. There is one IV access route. We are able to bag up to the 60's with a flicker of 70 on the SaO2 monitor with a return of the HR into the 130's. Again, the intermittent suctioning leads to bloody output mixed with mucous and greeted with desaturations. The pediatric surgeon has been called in but is 30 minutes away at least.

Anesthesia and NICU physicians try again and again the SaO2 drops. Only able to bag up into the low 50's to high 50's. The premie is bradycardiac and there is cardiac ectopy. The pediatric bronchoscope will not fit down the nasopharyngeal ETT.

The pediatric surgeon will not make it in time for this one and something must be done as they cannot keep the saturations up and the bradycardia becoming more persistent. There are about 25 various well-intentioned health-care practitioners gathered around now looking at you with that look: The look of, "Do something now . . . please!!!"

Now, what?

Remember this is a 32 week premie airway with a mass that goes from the tongue to the roof of the mouth and posterior to who knows where and the trachea is deviated. The chest x-ray which is really a baby-o-gram does not reveal much diagnostic information.

So, where would you go? (This happened last night.)

DM