I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day.  The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as reassembling an anesthesia machine that fell apart right after intubation (see this story here) or improvising PEEP from some suction tubing and a bottle of water. (see that story here)

But being able to improvise is just as important in the settings of the more modern hospital.

Improvising An End-Tidal CO2 Adapter in MRI

It was our first week in our new hospital and our first general anesthetic in the new MRI scanner. The patient would need to be intubated for airway protection. As we were setting up the equipment for the procedure, we discovered that the adapters that would allow us to measure end-tidal CO2 for an intubated patient with our MRI compatible monitor had not been delivered, and would not arrive until the next day.

MR compatible nasal prongs with ETCO2 sampling tubing for Philips MR compatible Monitor

What we did have were the nasal prongs with a built in end-tidal CO2 sampling line that plugged directly into our MRI compatible monitor.

The case was urgent so delay was not an option. I was loath to proceed without end-tidal CO2 sampling unless it was absolutely necessary.  What to do?

I took one of the nasal prongs and cut the ETCO2 sampling line free. I then inserted that sampling line to one of the ports of a stopcock. I then secured it with our trusty pink tape. I made sure by pressurizing the circuit and performing a leak test that the tape prevented any leaks. It worked like a charm.

Close up of the stopcock and the attached ETCO2 sampling line securely taped to prevent any leaks

Modified ETCO2 sampling line showing the adapter to the monitor as well as the stopcock

We did the case without difficulty. The specific sensor adapters arrived two days later.

Making an Uncuffed Endotracheal Tube Longer

Uncuffed endotracheal tubes (ETT) are designed for smaller pediatric patients. We can use cuffless tubes in young children because the cricoid ring, a round hole, is the smallest diameter of the pediatric airway. In the adult, the smallest diameter is between the vocal cords, a triangular opening requiring a cuff to seal the gap in order to generate the pressure needed to manually ventilate.

However I recently participated in a head and neck surgical case where a small uncuffed tube was the optimal endotracheal tube for the procedure. In this case, the subglottic region was partially filled with a large bilobed mass of granulation tissue. Our surgeon was concerned that the use of even a small diameter cuffed tube might scrape the cuff against the mass and cause bleeding. Our surgeon felt that the bulk of the mass would be enough to seal the gap around our uncuffed 5 endotracheal tube for the brief period of time he needed to position his direct laryngoscope and remove the mass. Once the bulk of the mass was out, we could replace the uncuffed tube with a cuffed one of our choice.

The problem with this plan was that a 5 uncuffed tube is too short for an adult. One of my colleagues had the solution, creating what he termed the Frankentube. We took the 5 ETT and removed the adapter. We then took a 7.5 cuffed ETT and cut it about 4 inches from the adapter end.

#5 uncuffed ETT made longer by combining with a cut 7.5 ETT

The 5 ETT inserted neatly into the cut end of the 7.5 fit quite snuggly. We then wrapped this junction securely with pink endotracheal tube tape. This tape is not quite duct tape but it sticks very securely. Our combined tube was now the perfect length for an adult.

Close up #5 uncuffed ETT made longer by combining with a cut 7.5 ETT

Close up of the junction of the #5 uncuffed ETT with a cut 7.5 ETT showing the tape

The 5 was also big enough to insert a GlideScope stylet. We wanted to use the GlideScope to allow the entire team, including the surgeon, to see the tube slide over and past the mass. We also had just about every other tube we might possibly need, as well as the trach tray and the jet ventilator, available in the OR just in case plan A did not work or we lost the airway.

The plan worked perfectly. I did a combination IV inhalational anesthetic with the patient breathing. After I tested the ability to ventilate, I administered muscle relaxant to avoid having the patient buck on the tube. I intubated easily and was able to ventilate adequately, although there was a small leak. The surgeon removed the mass without difficulty.

Summary

There will be rare times, even in modern well-equipped treatment settings, where you will not have something that you optimally should have. Don’t be afraid to think outside the box and improvise. However, do it safely.

1. Don’t take unnecessary risks. If you think it’s safer to delay, then do so.
2. Always check your improvised equipment thoroughly before you use it on a patient.
3. Always have plan B (and C) ready to go.

May The Force Be With You

Christine Whitten MD, author Anyone Can Intubate, 5th Edition