EditorDrs Cooper and McClure rightly highlight the worrying re-emergence of unrecognized oesophageal intubation as a cause of death in Why Mothers Die 20002002.1
I gave my first (supervised) obstetric anaesthetics in 1963. Detailed anaesthetic records were not kept routinely but I was taught to use the record card, designed (I believe) by Dr Michael Nosworthy, whenever problems arose. This masterpiece of compression provided a time chart for vital signs with preprinted options for selection denoting drugs, techniques, complications, etc. I asked my consultant what was meant by under mask in relation to tracheal intubation and was told that before proper connectors became available it was customary to assist ventilation by placing a face mask over the endotracheal tube. Obviously the ventilation route would be oropharyngeal if the tracheal tube was wrongly sited. I used this system in certain circumstances when I had doubt about the correct placement of a tube but had had such difficulty with laryngoscopy that I found myself reluctant to remove a tube. I have subsequently always rejected the simplistic maxim when in doubt, take it out in debates on recognition and management of airway problems.
Years later this method saved a patient's life when I was called by nursing staff to a theatre where a patient was clearly in extremis but a colleague would not entertain the possibility of a misplaced endotracheal tube. Patency had been checked and bronchodilators given. Disconnecting the breathing system from the tube, adding a face mask and using this to hand ventilate transformed the patient's colour and chest movements. Diagnosis and treatment were simultaneous.
It would have been psychologically (and hence physically) extremely difficult to have used any other approach and I believe the psychology of this type of situation has been seriously neglected. The mortality report comments in all these cases, there appeared to be a major reluctance on the part of the anaesthetist to consider the possibility that the oesophagus had been intubated in error. One had hoped that the introduction of reliable monitoring (one of the constant joys of my later days in anaesthetic practice) would have eliminated these problems, nevertheless information is only part of the battle, a manouevre that simultaneously diagnoses and treats a problem is worth remembering.
References
1 Cooper GM, McClure JH. Maternal deaths from anaesthesia. An extract from Why Mothers Die 20002002, the Confidential Enquiries into Maternal Deaths in the United Kingdom. Br J Anaesth 2005; 94: 41723