When Tom Kuczenski woke in the middle of the night on April 2, 2014, with half his tongue swollen, neither he nor his wife panicked.
“I assumed it was a spider bite,” Kuczenski says, “which I’ve gotten before while sleeping in bed. My wife said to take some Benadryl and go back to sleep.”
But there was no Benadryl in the house, and Kuczenski, then 49, thought he should seek medical help in case the swelling progressed. So at 3:45 a.m. his wife, Carolyn, drove him the three and a half miles from their home in Madison to the Yale New Haven Shoreline Medical Center in Guilford.
Alison Hayward, MD, MPH, one of Yale Medicine’s emergency medicine specialists, was the sole doctor on duty that night. Her last patient had just left, and she and the nurses were chatting when the security guard rang to say that a man had arrived with tongue swelling.
“I wanted to immediately see what the patient looked like because that’s such a serious symptom,” Dr. Hayward says. “I saw this cheerful, jovial man walking toward me who looked absolutely healthy, and I breathed a sigh of relief.”
Kuczenski smiled, then opened his mouth, revealing that half his tongue was three times its normal size. Dr. Hayward instantly recognized the symptom as angioedema, a swelling that can manifest in the tongue, mouth and throat. If it progresses, it can close up the throat and block the airways, potentially leading to asphyxiation.
“I said, ‘I see why you’re here, and I bet I know what caused this problem already. Are you on an ACE-inhibitor called lisinopril?’” recalls Dr. Hayward. In five years she had seen about 10 cases of angioedema that turned out to be a side effect of this common blood pressure medication.
Kuczenski told Dr. Hayward that he had taken the drug for more than 20 years without any negative side effects—at least until that night.
Kuczenski recalls how calm Dr. Hayward was. “And I was being calm back,” he says.
Preparing for the worst
With Kuczenski resting comfortably in the examining room, Dr. Hayward left to order the medications typically used to treat angioedema, which can also be related to life threatening allergic reactions called anaphylaxis. To address the possibility of allergic angioedema, patients can be given epinephrine, Solu-Medrol (methylprednisolone), Benadryl and Pepcid (for its antihistamine effect rather than its reflux aid). When angioedema is caused solely by an ACE inhibitor, however, Dr. Hayward knew that it might not be possible to treat the reaction medically. If the reaction progressed, she would have to maintain the ability to get oxygen into the lungs by any means possible to keep Kuczenski alive until the reaction spontaneously resolved. Her plan was to administer the medicine, then transport him to Yale New Haven Hospital, a 20-minute drive, where he would have access to the hospital’s full range of medical care.
On her way back to Kuczenski, Dr. Hayward asked the nurse for what is called a cricothyrotomy kit, which she might need if her patient were struggling to breathe. If she could not fit a breathing tube down his throat because it was too swollen, she would need to insert a tube through an incision in the neck (a procedure called cricothyrotomy). She stopped briefly to check the contents of the kit. She had never performed the procedure but wanted to be prepared.
“It’s a superstition in emergency medicine that if you prepare for the worst, it won’t happen,” Dr. Hayward says.
Rapidly worsening symptoms
When Hayward returned to Kuczenski a few minutes later, her patient’s condition had completely changed; he was in acute distress. Feeling the swelling in his throat, he was spitting into a basin, an indication that he couldn’t handle his saliva. He could speak, but his voice had changed, which meant the angioedema was affecting his vocal cords.
“Obviously this situation was changing rapidly,” Dr. Hayward said. “I was getting extremely nervous, but I didn’t want to frighten him or his wife.” She willed herself to stay calm.
Kuczenski felt no fear, however.
“I had no doubts to entrust my life with the team that made me feel safe and in competent hands, having no fears whatsoever,” he says. “I was amazed that Dr. Hayward understood that the medication had a rare side effect that I was experiencing.”
Transporting Kuczenski to New Haven was no longer an option. Dr. Hayward moved Kuczenski from a regular room to the resuscitation room. She told his wife to drive to the main hospital, saying that her husband would be brought there soon.
“I didn’t want to say, ‘Hey, say goodbye in case something goes wrong here,’” Dr. Hayward says. “That would have made it even more stressful.”
A race against time
To prevent Kuczenski from dying of asphyxiation, Dr. Hayward knew she had to get a breathing tube into his airway before it closed completely. She also knew it would not be easy, especially with no other doctors or surgeons to back her up. She began by administering the standard medications used for an intubation: etomidate, a sedative, and then succinylcholine, a paralytic that relaxes the muscles, which would give her the best view of his vocal cords.
Ideally, Kuczenski would have been given oxygen, which would have helped his body remain in balance without breathing. But Dr. Hayward knew there was not enough time. Kuczenski’s tongue was so swollen it was coming out of his mouth. Still attempting to get a breathing tube down his throat, which was severely swollen on one side, she tried to find the vocal cords with a Glidescope, an exploratory device which has a camera on the end of it, but her view was obstructed.
“At this point, I’ve been looking for a couple of minutes, and his oxygen levels are starting to drop,” Dr. Hayward says. “With only a side view, I tried to put the breathing tube in, but it didn’t go into the right place.”
Kuczenski’s oxygen numbers were dropping by the second, from percentages in the 80s to the 70s to the 60s. (The average healthy person has a blood oxygen level of 95 percent to 100 percent.) Dr. Hayward would have to perform her first cricothyrotomy—and fast—if her patient were to survive.
“I said to the nurse, ‘Hand me the scalpel,’” Dr. Hayward says. “I remember the moment really clearly, because it was absolutely terrifying.”
A dramatic, life-saving procedure
Kuczenski’s neck is thick, which made it difficult for Dr. Hayward to feel the anatomy. She began to cut, and blood spurted everywhere. By this point, everyone in the building, from non-medical staff to ambulance personnel, had gathered in the room. Everyone was eager to help, but none could. Kuczenski’s oxygen levels were now in the single digits, putting him at risk for brain damage. As Dr. Hayward worked to make the correct incisions, he began to turn blue.
“He looked like he was dead already, and I was thinking, ‘How am I going to tell his wife this news?’” Dr. Hayward recalls. She had spent only a few minutes with her patient, but she really liked him. “You could tell he was a wonderful person. I was screaming, ‘No! No!’”
Kuczenski began to go into respiratory arrest. Typically a person’s heart rate speeds up when the body’s oxygen is dropping, but his had started to slow down.
“He was about to code,” Dr. Hayward says. “Then, right as I hit his trachea with the scalpel, I knew I was in the right place.” She made the incision and worked to insert the breathing tube quickly. “I looked up at the monitor, it was 6 percent,” she says. “We hooked up the bag valve to oxygen, and started squeezing it to inflate his lungs.”
All eyes were on the monitor. The oxygen numbers began to rise, and Dr. Hayward could see the wave of relief sweep over the room. “It was such a moment,” she says. “I could breathe again, too!”
With blood still pouring from Kuczenski’s neck, Dr. Hayward concentrated on stitching him up so he could be taken via ambulance to Yale New Haven Hospital. Kuczenski had been stabilized, and for Dr. Hayward the ordeal was over. Her work was done.
‘He was himself again’
About 7 a.m. the ambulance arrived at the hospital, where Kuczenski was met by a huge medical team and taken to the operating room. There, for 90 minutes, Wendell Gray Yarbrough, MD, section chief of otolaryngology in the Department of Surgery, worked to revise Dr. Hayward’s cricothyrotomy into a more complicated yet stable tracheostomy.
The next day, Dr. Hayward visited Kuczenski in the intensive care unit. This was unusual for her, but she felt that she had to see him again.
His transformation was “just amazing,” she says. “He was awake, he was smiling,” Dr. Hayward says. “He was trying to talk to me, but he couldn’t. He could sort of whisper, but he couldn’t speak. I felt so relieved that he was doing so well. No brain damage from low oxygen numbers. He was himself again, with no complications from the procedure.”
Kuczenski left the hospital five days later, with no further issues. His internist prescribed a water pill to lower his blood pressure, because he would no longer be taking the Lisinopril.
A patient’s tribute to his doctor
As soon as he recovered, Kuczenski says, he started “to think about a way to pay it forward.” He did some research and learned that Dr. Hayward was involved with Uganda Village Project, a nonprofit that promotes public health and sustainable development in southeast Uganda. He made a large donation.
That was not all he did. Deeply grateful to the Shoreline team for saving his life, Kuczenski sent the staff a card with this poem about his experience:
Life Saving Music
By Tom Kuczenski
Singular notes strand together
Tell a story that impacts forever
Your path happens all on its own
Mine crossed by chance before the sun shone
April shares many points in time
The 30th is my birthday but the 2nd is now sublime
It may just be another day to some
I see it as having a new vocal to become
That spring morning took my breath away
The team had trained for this that day
No time to prep it became clear
Second nature actions is the reason I’m here
My lungs now fill with air and I have a voice
I am thankful for your profession
And with your choice
Numerous lives are now touched and stitched along
We have each other to sing our beautiful song