Chapter 51: Cricothyroidotomy

Professor Choi, the assistant professor of trauma surgery, blinked his eyes wide upon hearing Kim Cheol-su’s question.

It wasn’t the kind of question you’d expect from a mere medical student. It was truly the kind of question one could ask before entering surgery.

The white-haired assistant professor spoke in surprise.

“You seem to be studying trauma surgery harder than I thought. Otherwise, you’d never be able to ask a question like that…”

“Thank you for the compliment,” Kim Cheol-su replied.

“Let me see… yes. Actually, the details about obese patients are so intricate that even I sometimes forget to teach them. Usually, the cricothyroid membrane is visible. But on the neck of an obese patient, it’s not. In such cases, you can use the four-finger technique ((0 na 090 Ｌ 60701946).”

“The four-finger technique? How does that work?”

“If you can’t see the cricothyroid membrane above the thyroid cartilage on an obese patient’s neck, then you have to go lower. Place the tips of your four fingers vertically on the suprasternal notch (5 ni pa 8516102! 001 a)) at the base of the patient’s neck, then spread your fingers. Your index finger will be exactly over the cricothyroid membrane.”

Kim Cheol-su felt how easily he understood the professor’s explanation.

By inserting his fingers into the hollow V-shaped groove below the neck, the index finger would be precisely positioned on top of the cricothyroid membrane.

From his memory, the cricothyroid membrane measures about 10 by 20 millimeters. Now, he roughly knew how to start the surgery.

Feeling the heavy vibration of the chronometer in his pocket, Kim Cheol-su said to the assistant professor,

“I’m really glad to have met you today, Professor Choi. Please take care of your health and don’t skip your annual endoscopy. There might be stomach cancer, you know.”

“What…?! What are you talking about?”

The assistant professor’s stunned face gradually softened like water flowing away.

As if waking from a dream, the space around him seemed to collapse.

Once again, Kim Cheol-su lost his composure.

*****

“Wake up! Lieutenant Kim Cheol-su! Come on!! You can’t die like this!”

“Hmm… Where am I?”

“Lieutenant! You’re alive! Thank goodness! Thank you, really thank you!”

Shin Se-young, tears streaming down her face, calmed herself to speak.

She wanted to confirm the recent situation.

“There’s no time. How long were you unconscious?”

“Not even a minute. But I really thought you had passed away. I was so shocked… I’m glad you came back to us. Did Se-dong give you an epinephrine injection?”

“No… I don’t think so. I just came back because it was time.”

Hearing that he had been unconscious for a full minute, Kim Cheol-su thought.

He was basically clinically dead from a cardiac standstill.

But waking up like this couldn’t be explained medically.

Moreover, the time he’d been ‘dead’ was at least ten minutes.

How on earth did this happen?

There was no time to ponder such mysteries now.

Kim Cheol-su sterilized his hands once more, put on gloves, and said,

“Scalpel, please.”

“Shouldn’t you rest a bit first?” Oh Ha-jin asked worriedly.

Considering that someone who had just died was now awake, forcing the surgery seemed unreasonable.

But Kim Cheol-su smiled and reassured him.

“I’m really fine. There’s no time. If we don’t secure the patient’s airway now, he’ll die from respiratory failure.”

Shin Se-young handed him the scalpel. Though nervous, she knew the best thing was to support Kim Cheol-su.

Wiping her tear-streaked face with the back of her hand, she steeled her resolve.

“Here it is, Lieutenant. Stay strong!”

“Thank you. What’s the patient’s oxygen saturation now?”

“80 percent… 79… 78! Severe hypoxia! What should we do? If we don’t secure the airway quickly, the patient’s in danger! His lips are turning blue from cyanosis…”

Below 80 percent saturation is extremely dangerous. Time was running out.

It was absurd to think the patient could die simply because he couldn’t breathe.

Kim Cheol-su tensed and switched the scalpel to his left hand, raising his right.

“Phew… We need to secure the airway immediately. First, to find the incision point on the neck of this obese patient, I’ll use the four-finger technique.”

Kim Cheol-su placed four fingers vertically into the V-shaped suprasternal notch.

Then, his index finger gently pressed down, sensing the cricothyroid membrane below.

This was where the skin incision should be made.

He used X-rays to confirm the anatomy beneath the skin.

As Professor Choi had said, the cricothyroid membrane was clearly visible.

Although it was possible to rely on X-rays alone during incision, the exact site could be slightly off—too wide or too narrow.

That was why Kim Cheol-su had asked the professor’s advice, which proved helpful.

Fluoroscopy is an excellent skill, but not infallible.

What truly matters for a doctor is knowledge. He’d almost forgotten that such knowledge is what empowers a clinician in the operating room.

“I’ve located the cricothyroid membrane. I’ll adjust the patient’s posture now.”

Kim Cheol-su thought again how remarkable the assistant professor was, as he repositioned the patient.

Because there was no cervical spine injury, he extended the neck (hyperextension of the cervical joint).

This placed the occiput forward, making the surgical position ideal.

If there had been cervical injury, neck extension wouldn’t have been possible, complicating the surgery.

Then, with the patient’s neck in position, Kim Cheol-su drew a straight line with a surgical pen.

This marked the future incision site.

Grasping the occiput with his left hand, his right thumb and fingers pinched the skin over the cricothyroid membrane, pulling it taut.

Now, it was time to begin the incision.

There was a crucial point when cutting the skin—the incision must be made precisely over the midline of the cricothyroid membrane.

If the incision were too low, it could damage the thyroid isthmus.

If too high, the sharp scalpel could injure the thyroid cartilage and vocal cords.

The neck contains many vital structures.

Knowing this, Kim Cheol-su was tense as he began the skin incision.

A single bead of sweat rolled down.

Ji ji jik –

Using the scalpel, Kim Cheol-su made a vertical incision about 4 centimeters long.

The reason for a vertical cut was to avoid damaging the anterior jugular veins that run horizontally.

If those vessels were cut, bleeding could be significant.

A vertical incision was the safer choice.

“I can see the cricothyroid membrane. I will now incise the membrane.”

The cricothyroid membrane, hidden beneath the skin, appeared as Kim Cheol-su carefully exposed it.

Shin Se-young and others held their breath in tension.

Now the real surgery was about to begin.

He needed to open the cricothyroid membrane outside the skin.

Ji ji jik…!

Kim Cheol-su started a horizontal incision through the cricothyroid membrane with the scalpel.

He deliberately preserved the upper boundary of the thyroid cartilage to avoid injuring the superior thyroid artery.

This step was extremely delicate.

If the scalpel went too deep into the airway, it could cause posterior tracheal perforation.

Fortunately, he made the hole correctly.

Kim Cheol-su inserted a (3 a 1631 『100() retractor above the incision to pull the thyroid cartilage upward.

This kept the airway stable and the incision open.

This instrument also served to prevent the tube from going into subcutaneous tissue instead of the airway after insertion.

By pulling the retractor upward and widening the incision, the airway lumen could be seen clearly during the procedure.

“Phew — the incision window is well opened. Before inserting the tube, I will insert a bougie (50496: a thin, long cylindrical instrument).”

It was finally time to insert the bougie, followed by the tube.

Kim Cheol-su carefully inserted a blue bougie dilator toward the tracheal lumen.

He was cautious; if the bougie went into the wrong place, such as under the airway, it could cause a posterior tracheal perforation like before.

The thought of a hole forming in the back of the airway was terrifying.

If this happened, bleeding from the perforation could cause blood pressure to plummet and the patient’s survival would be uncertain.

Thankfully, the bougie went in perfectly beneath the tracheal cartilage.

Following the bougie, he pushed in a transparent tube.

“Silk sutures, please. We need to fix the tube in place.”

“Here you go.”

The skilled surgeon tied the silk sutures swiftly, securing the tube firmly.

The tube inside the incision was stable.

“We’ll start ventilation now.”

“The patient’s blood pressure is returning to normal! Oxygen saturation is climbing. 92 percent! 94! 95!! Oxygen saturation is back to normal range. The patient is breathing again! Lieutenant, congratulations! The patient’s breathing has returned!”

The patient’s condition improved dramatically once he was able to breathe properly.

This patient, who had nearly died from respiratory failure, had survived the crisis.

It was truly a close call.

Because Kim Cheol-su’s loss of consciousness had caused oxygen saturation to fall to dangerous levels.

Had more time passed, the patient would have died from respiratory failure.

Wow!!! What a relief!

The surgical team exhaled in relief and joy.

But this was only the beginning. They had merely secured the airway.

Just because the patient could breathe didn’t mean the carotid artery and occiput injuries would heal on their own.

The carotid artery was still bleeding profusely.

They were transfusing blood, but there was a limit.

As previously mentioned, the carotid artery carries 80 percent of the brain’s blood flow.

If it was not restored quickly, neurological damage could occur.

Postoperative paralysis or vision loss would be tragic after saving the patient’s life.

At least the golden time was secured.

There was no risk of death from airway obstruction anymore.

Haah… haah…

The patient’s breathing settled now that he could breathe properly.

The structure of the human body was astonishing, and the advancement of medicine was miraculous.

Since the patient couldn’t breathe through his mouth, they had cut a hole in his neck and ventilated him artificially.

Thanks to that, oxygen saturation had returned completely to normal.

With 95 percent saturation and above, the crisis was truly over.

The patient’s respiratory failure had been resolved.

Du du du duu

“We’ve arrived at Hampyeong Hospital, sir!”

“Thank you, helicopter pilot. We will transfer the patient from the transport team to the hospital. Everyone, quickly bring the patient to the operating room.”

“Yes! Understood!”

After recovering the patient’s breathing through the cricothyroidotomy, they safely arrived at Hampyeong Hospital to begin the carotid artery surgery.

Yet Kim Cheol-su’s expression was far from bright.

This was his first neck trauma surgery… Would it be successful? Especially on a patient with bullet wounds damaging both the carotid artery and occiput?

The success rate was unknown and the surgery was extremely difficult.

After the exhausting incision, his back, soaked with sweat, grew cold as a chill ran down his spine.

He felt a little afraid.

What if he failed?

But worrying would bring no answer.

So, he could only do his best.

Pushing aside fleeting doubts, Kim Cheol-su hurriedly followed the team out of the helicopter.

With his head down, he quickened his steps.

Tap tap tap

No matter how difficult the surgery was, he would not give up.

Because the patient’s breath was still hanging by a thread.

As a doctor, the only thing he could do was to succeed in this surgery.