Worms: Part I—worm in the throat
I stepped on the black pad and the frosted glass doors at the entrance of the Emergency Department slid apart into recesses in the wall. It was Saturday morning in early spring 1975. For the last 24 hours I had been on call as the Internal Medical resident at the Toronto East General Hospital, a community hospital in the west end of Toronto. It was in a blue-collar district and otherwise a tough neighborhood. Many of the local people were medical care averse and tended to tough out illnesses until they were over-ruled by their significant others and neighbors, and then were put into an ambulance before they died and sent to the hospital. This resulted in a steady parade of people in extremis being rushed through these frosted glass doors on ambulance stretchers. I saw things in this this hospital—diseases, severity of diseases, presentations of disease, types of people and human stories—every day that most doctors don’t see in a lifetime of practice!
I had one of those ‘up 24 hours running-all-over-the-hospital’ nights. There was me and an intern—an intern!!—covering the whole hospital and the cases coming into Emerg. We spent the whole night chasing dire emergencies, cardiac arrests, septic shock, stroke, diabetic coma and other conditions. The Intern was typically way out of his depth, knowing little about these conditions, having never seen them, much less saw them managed. So was I, by the way. My staff was at home sleeping and of little help, even if I called him/her. They ran lucrative office practices and by the end of the year (as this was), I had actually more experience handling these things than the staff. If I called them, their advice would be suspect as they were remote, didn’t know the patient, and it would have been years and years since they handled things like this. At the end of the day, I was on the spot, I was responsible and therefore I took charge.
Anyway, it was one of ‘those’ nights. And now, it is 08:00, the official end of my call. As the frosted glass doors close behind me, the baton is considered handed over to the Saturday call resident, who was Eric.
I walked through the doors which stayed open while I was traversing the black pad on the outdoor side of the doors. In this interval I heard the alert buzzer from the overhead speaker in the hallway of the ER, and the announcement “Attention please, code blue Emergency Dep..” and the doors closed. I looked at my watch. It was precisely 08:00. I actually hadn’t seen Eric and wasn’t sure he was in the hospital, much less near the Emerg. Maybe I better go back to the resuscitation room and see if he is there.
When I walked into the room, there was full CPR in progress. Eric ordered me to replace the nurse ventilating the patient. I grabbed the self-inflating bag and began ventilation. The patient was a very young man. The ambulance driver said they were called because he was having trouble breathing. He was fine when they picked him up and his mother wanted him taken to Sunnybrook Hospital, an East end university teaching hospital. On the way, his breathing became progressively difficult and they changed course to our hospital which was the closest. On arrival he was blue, and in ventricular fibrillation. The attempts at defibrillation before I got there had failed to convert the rhythm.
I was ventilating him easily and asked for the laryngoscope and endotracheal tube to be prepared. At a break in the chest compressions I inserted the laryngoscope. I slipped the blade under the tongue and pulled up. Rather than seeing the epiglottis and larynx as I expected, I saw a long, flesh coloured worm-like something coiled in the back of his throat obscuring the larynx. What the hell was that?? I tried pushing it away or hooking it with the endotracheal tube, but to no avail: it slinked off the tube and fell back into the throat. I tried another couple of times and returned to ventilating him with the mask. I asked for an urgent call for the anesthesiologist. I tried intubation a second time, but with a forceps in my other hand to grab ‘the worm’. It was too slinky and slippery and I couldn’t grab it.
The anesthesiology resident arrived and also failed to intubate. The anesthesiology staff arrived and between him and his resident they managed to eventually intubate the patient. However the patient’s heart was never resuscitated and he was pronounced dead. Weird, really, but every on-call day I saw such off-the-charts weird stuff in this place.
On the Monday there was an autopsy. It turned out that the ‘snake’ was actually a polyp arising from the epiglottis. This explains why I couldn’t hook it and remove it. This condition is rare as hens teeth and most doctors—even ENT specialists—may never see one (https://www.ncbi.nlm.nih.gov/pubmed/25136930).
So, to string the story together, he had this long polyp which may have been 2-3 cm long, string slender, slinky, hanging over the epiglottis into the pharynx and esophagus. For some reason, it must have flipped to the other side of the epiglottis and fallen down through the vocal cords. The vocal cords would have gone into spasm resulting in a kind of tourniquet on the polyp. This would cause it to fill up with blood and swell. As the tissue is very elastic, it lengthened to the length of my middle finger, and swelled to about the same circumference. As such it obstructed his larynx and choked him. When we began chest compressions it was probably blown out of the trachea and into the pharynx, where I encountered it.
I chalked this case up to one of the unusual deaths that I had in my practice (See series xxxxxxxxx for others). As my residency was coming to an end I was looking at my next gig. I made preparations to go out to Campbelton New Brunswick and open my general practice office (see series XXXXXX). Before I left, I was called down to the administration offices of the hospital and a fellow in a suit said “Dr. Joseph Fisher?”. I said “yes.”. He handed me an envelope. I opened it. It was a notice of the intention of the family of the patient with the worm in his throat to sue me for malpractice.
