TILIF#10: Jury-rigger extraordinaire!

I love problem solving; more specifically, I love finding a way to use a limited set of tools or resources to find creative solutions to problems. I've always been drawn to this sort of activity: assembling custom Lego creations using the pieces from random old sets, building imaginary spaceship instrument panels out of the doodads from my dad's workbench, or playing Minecraft in survival mode where you need to harvest limited resources before you can construct anything.

That limitation fosters creativity and forces you to think outside the box. My favorite real-world example of this is depicted in the famous scene from Apollo 13, where the flight director gathers the smartest engineers at his disposal into a small room and dumps a box of parts on the desk, explaining that they need to find a way to fit a square tube into a round hole with only these supplies and then come up with a procedure so the astronauts can follow those instructions to fix the crippled spacecraft.

The ICU is always pushing the boundaries in medicine, so we often don't have the technology mass-produced to fix the problems we see. Often these kids have very unique problems. One of my favorite examples is chronically trach dependant kids who have a hole in their neck with a tube that goes in and takes a 90° turn into the trachea. As you might expect, such an unnatural connection between a foreign device and the body leads to funky changes to the tissues in the area (think earring hole mixed with a callus). Every tracheostomy tract is a little different and most kids need a custom tube that's a certain width, depth, length, flexibility, etc.

If that tube gets plugged up, suddenly the kid can't breath. Usually you can just replace the tube, but sometimes tissue damage can make that very difficult, so you may have to find creative ways to ventilate the patient. You can try passing a long flexible oral tube through the hole in the throat. You can essentially plug up the hole with your finger and use a bag-mask over their mouth (assuming their upper airway connects, which is not always the case!). You could even put a mask over their neck if you can get a good seal and plug up the mouth and nose. Whatever works!

One of the goals of fellowship is to accumulate a magic show's worth of tricks that you can adapt to any audience. It's amazing to see some of my attendings' ability to pull a rabbit out of a hat, even if they've only managed that trick once or twice... often in their fellowships.

TILIF: "Post-pump slump" is a phenomenon seen after children come off of cardiopulmonary bypass. When you are doing open heart surgery, you need to divert blood to a mechanical pump that keeps the blood oxygenated and flowing until you can put back together and restart the patient's heart. After these kids return to the PICU, you need to watch them closely - for lots of reasons, one of which is a period of low cardiac output that is not entirely understood but seen fairly frequently.