Volume 1, Issue 4 - August 2009
By George Dunea, MD
This dramatic incident must have taken place around 1930, at a time when great controversy raged about the level at which a life-saving tracheotomy should be done. It is an extract from “High Tracheotomy Low Tracheostomy,” a lecture as given by Sir Clive Fitts at the Royal College of Physicians of London in 1967.
It describes a doctor who saved a life while visiting a patient in a dingy tenement, only to be met with contempt by the recently graduated young resident at the teaching hospital.
Then, as now, many hospital doctors, especially the more recent graduates, have tended to look down on the efforts of the “local M.D.,” the general practitioner or primary care physician. They often regard themselves as better educated, more competent, and more up-to-date. They forget that much of their prowess is based on their ready access to the facilities of a modern teaching hospital, whereas the local M.D. is often struggling on his own, left to his own resources.
The reader will also note that in those days hospital beds were scarce. The control of admission to hospitals was left not to a computer or a hospital clerk but to the “admitting officer,” a senior medical resident who zealously guarded the scant resources available at the time and sometimes submitted the referring doctor to a detailed and often humiliating interview in which he would question the need for admission.
I had the privilege of meeting Sir Clive in Chicago around 1978, when he was on a world tour travelling with his daughter. We became friends and he entertained me at the Melbourne club, as well as sending me many of his published and unpublished writings. He was a cultured man, with wide interests and a distinguished career at the Royal Melbourne Hospital. He died in 1984 and his obituary was published in the March 3 issue of The Lancet, page 522.
What follows is Sir Clive's story, an extract from “High Tracheotomy, Low Tracheostomy,” delivered as the Tudor Edwards Memorial Lecture at the Royal College of Physicians, 15 July 1967.1
By Sir Clive Fitts
“Returning to Australia after some years in England the physician found that the final examinations were completed, the summer vacation had begun, there were no students at his hospital and his time was not fully occupied. A friend who had a small general practice asked if he would attend at his surgery from 6 to 8 p.m. on weekdays and answer occasional calls while he took his summer holiday.
One Saturday evening the telephone rang and a woman asked the physician to visit her lodger. Although she said she was afraid that he might choke, she did not sound anxious. Armed with his attaché case containing a stethoscope, patellar hammer, torch, sphygmomanometer and ophthalmoscope he set off by tram, not at that time possessing a motor car. The route lay through a busy suburban shopping area. A walk down a narrow side street brought him to a small weatherboard house about half an hour after leaving home. Two women greeted him and explained that the lodger had come home late that afternoon and complained of his throat closing up. They had decided to call a doctor because at one stage he thought he was about to choke, and they noticed his open blade razor by his bed. This fear had passed but they had taken the razor and hidden it.
The physician was led by the landlady through the kitchen to the patient's bedroom which in former days had been the scullery. Here in bed was a healthy-looking man in the mid-thirties. His breathing was not distressed nor was he cyanosed. He spoke in a hoarse voice. Beside the bed was a bucket containing lysol presumably as a receptacle for sputum.
On examination the temperature was 100.4; the soft palate, tonsils and larynx were much engorged but did not appear to be the seat of a virulent infection. There was no stridor and no sign of pulmonary disease.
In the light of the history the patient was advised that he should be admitted to hospital for observation. There was no telephone in the house and the physician was directed to a public telephone in a confectionery shop in the shopping centre. The telephone was placed behind the entrance door and was not enclosed. His visit to the shop coincided with the interval at the cinema next door and on that hot summer evening all who came to buy stayed to hear. His first humiliation was that the Admitting Officer at the hospital did not seem ever to have heard of him. The wheel had turned full circle he thought, as he remembered the contempt and suspicion with which he, as Admitting Officer at this very hospital, had listened in former days to an unknown doctor pleading for a bed on a Saturday night. He soon realized that no ordinary diagnosis would gain a bed. Acute laryngitis seemed pathetically inadequate. Laryngeal obstruction sounded better but did not satisfy the merciless guardian of the hospital beds. 'What is it due to?' came the question. Of course the physician did not know and could think of nothing better than laryngitis but thought to improve his chances by garnishing this with the adjective streptococcal. 'There is only one bed left in the hospital. Do you think your patient deserves it?' For a desperate man there was only one answer. Then came the last humiliation. 'Send him down and I shall have a look at him but I won't guarantee to take him.'
The physician was in no state to telephone the ambulance. He made his way through the crowd into the peace and quiet of the side street. As he approached the house he heard screams. He hurried through the kitchen into the scullery. The lodger was sitting upright in bed. His face was very deeply cyanosed, his eyes were staring, his neck engorged and his expression was of inarticulate horror. An instant later he fell to the floor, the bucket of lysol overturned and the emulsion ran about the bare wooden floor. The man lay motionless on his side, his head flexed upon his chest.
Some latent primitive surgeon's instinct must have prompted the physician to remove his coat, roll up his sleeves and call for a knife. The women had retreated into the kitchen and were not seen again that evening. A hand came through the doorway bearing a butcher's knife with a short handle and a curved blade of quite exceptional length. Grasping it by the blade, the physician knelt down to perform a tracheotomy but the knife proved inadequate as a surgical instrument. He remembered then to ask for the hidden razor. With this the tracheotomy was easy. Through the opening blood and froth were coughed out and air was sucked in. Then with the next inspiration the flap closed. The incision was enlarged and the physician inserted his left index finger to maintain the airway. In time consciousness returned and the man struggled on to his hands and knees. The women had gone beyond call. The house was silent and deserted. The victim then proceeded to crawl around the floor on hands and knees without appearing to have any sound reason for so doing. The physician found himself astride the wanderer, his left index finger in the trachea and in his right hand the blood-stained razor. He remembered then with some satisfaction that the state of mild mania which engaged the man was akin to Haldane's description long ago of the recovery stage from anoxia. He was awakened from these nostalgic musings by the appearance of a startled man in the kitchen doorway. He was sent to the confectionery shop to arrange for an ambulance When the stranger returned, the patient was able to walk to the ambulance. With the physician's arm encircling his neck and the index finger still in the trachea, they journeyed to the hospital….
The ambulance drew up at the Hospital beyond the range of the lights of the Casualty Department. A dresser came out, for the doctors on duty were busy. He was told that a tracheotomy tube would be needed and he set off for the theatres. Sitting in the semi-darkness of the ambulance the physician's spirits were sinking from neglect. Several recently qualified house doctors looked in the doorway and passed on. Then one, more interested, climbed into the ambulance. He nodded and turned to the patient. 'What is this?' he said, as he flashed his torch on the site of the physician's labours and looked more intently. 'Tracheotomy?' he said. 'You have made your incision too high.' His torch went out and he left the ambulance.
Further comment may seem superfluous… There was little comfort in the thought that from his ivory tower the house doctor could not see the scullery floor….. The trams had stopped running as the physician walked alone into the outer darkness of the hospital drive…. When he visited the hospital on the following Monday, the laryngo-tracheotomy had been closed. The laryngologist had found no gross abnormality and the patient was afebrile. Embarrassed and dismayed by the atmosphere of polite incredulity he made his exit and did not return”.
1. Reprint pp. 15-18
George Dunea MD, FACP, FRCP, FASN is the President and CEO of the Hektoen Institute of Medicine. He serves as the Chief Editor of Hektoen International Journal. He is also a professor of Medicine at University of Illinois at Chicago and the Medical Director of Chicago Dialysis Center and Founding Chairman Emeritus, Division of Nephrology, Stroger Hospital of Cook County.