Mikhail BulgakovWe’ve read and heard many accounts of emergency surgical airways over the years. They’re always exciting, and there’s always something new to be learned. Most written accounts are very clinical, so we were thrilled about discovering this story. It’s not new, by any means, but might be new to many of you. Written by Mikhail Bulgakov, one of the great Russian authors, around the 1920s. There’s prose to this account. And thrill.

“I picked up the scalpel, still wondering what on earth I was doing. It was very quiet. With the scalpel I made a vertical incision down the swollen white throat. Not one drop of blood emerged. Again I drew the knife along the white strip which protruded between the slit skin. Again not a trace of blood. Slowly, trying to remember the illustrations in my textbooks, I started to part the delicate tissues with the blunt probe. At once dark blood gushed out from the lower end of the wound, flooding it instantly and pouring down her neck. The feldsher started to stanch it with swabs but could not stop the flow. Calling to mind everything I had seen at university, I set about clamping the edges of the wound with forceps, but this did no good either.

I went cold and my forehead broke out in a sweat. I bitterly regretted having studied medicine and having landed myself in this wilderness. In angry desperation I jabbed the forceps haphazardly into the region of the wound, snapped them shut and the flow of blood stopped immediately. We swabbed the wound with pieces of gauze; now it faced me clean and absolutely incomprehensible. There was no windpipe anywhere to be seen. This wound of mine was quite unlike any illustration. I spent the next two or three minutes aimlessly poking about in the wound, first with the scalpel and then with the probe, searching for the windpipe. After two minutes of this, I de- spaired of finding it. ‘This is the end,’ I thought. ‘Why did I ever do this? I needn’t have offered to do the operation, and Lidka could have died quietly in the ward. As it is she will die with her throat slit open and I can never prove that she would have died anyway, that I couldn’t have made it any worse…”

Doctor turned writer
Bulgakov was originally a physcian, and worked as a doctor before giving it up for his writing. One of his most scary encounters, an emergency surgical airway, is told in his short story The Steel Windpipe.

The story starts with describing the little fear that always nags us at our earliest night shifts, and goes on to describe the fear and ambiguous feeling of stepping over the threshold and performing a potentially life saving – but also potentially lethal – procedure. Alone. In the middle of the night. He also describes the family of the patient, a beautiful little girl, and the rest of the personnel at the rural clinic, a feldsher and two midwives.

The clinical setting is also well know for many of us who’ve performed an emergency surgical airway: there’s blood, you lose sight of what you’re doing, your instruments can’t feel where you are, you’re stressed out.

Techniques and barriers
Of course, Bulgakov should’ve stuck his finger in the wound to find his way, but saves the story by making a blind but lucky slash, finding the windpipe. I’m sure many surgical airways have played out in a similar fashion. Learn the scalpel-finger-tube technique to take out some of the stress – still, the psychological stress and CRM challenges will still be there. Making the decision to cut will often be the highest barrier.


Read the full text of Bulgakov’s eloquent and thrilling account here:
The Steel Windpipe, Mikhail Bulgakov, 1920s.

There was also a short article published on the short story a few years ago. Read the article here:
Facing Fear: Mikhail Bulgakov’s “The Steel Windpipe”, Chest, 2005.

Also have a look at The grumpy Doctors and the Short Story for more tales.

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  1. nfkb says:

    Bulghakovs’ book “A country doctors’ notebook” is great. “Morphine” is also frightening describing opioid addiction.


  2. Agree, it is a great story – I recently learnt of it from James Garvey on the FOAMcc G+ community here:
    All the best

  3. James Garvey says:

    There is a brilliant film adaptation of ‘A Country Doctors Notebook’ called ‘Morphia’. The final scene is dark genius that isn’t in the ‘Notebook’.

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