A Tracheostomy Is Urgently Needed, but You Have Never Done One

You are called stat to the Cath lab for a patient who has developed sudden difficulty in breathing. You find a 73-yr-old woman with her neck and face severely swollen. She is unresponsive, with shallow, rapid, and labored breathing. She is receiving nasal oxygen at 4 liters/min, and the oxygen saturation is 86%. She has a diagnosis of a superior mediastinal syndrome. In an attempt to investigate this, the radiology staff sedated the patient with fentanyl 100mg IV and midazolam 4mg IV. With the patient adequately sedated, a Shiley catheter has been placed in the right subclavian vein. They inform you that the subclavian artery has also been hit several times, and there is now a large hematoma compressing her trachea. You listen to the chest, but can hear little air entry. You assist ventilation with 100% oxygen via an Ambu bag, to no avail. You attempt to intubate the trachea with a Mac 3 blade, but see nothing. You feel that succinylcholine will not be helpful, as the patient is now relaxed and completely unresponsive. A two-person mask ventilation with a large oral airway is unsuccessful. The laryngeal mask airway (LMA) that you called for has not arrived. The neck is so swollen that you dismiss the use of a cricothyrotomy. A tracheotomy set is produced and an ear, nose, and throat specialist is called for, but you are informed that he can only be there in 10min. The oxygen saturation is now 76%, and there is a dramatic decrease in her pulse rate and blood pressure. Everyone is looking to you as the senior anesthesiologist. You know that you have never done a tracheotomy before under these circumstances, but feel that this is the only option for this woman. You grab the scalpel and feel a great sense of insecurity and dread, but you have committed yourself. How will you quickly secure a surgical airway?