“Grandpa, take this cord off! Take it off!” In the past few days, whenever I checked on this little girl in the ward, she said to me with a begging, pitiful look. Today, at the door of the ward, I said to the junior doctor, “Remove the stitches on the little girl’s chin.” She must have heard my words. As soon as we entered, I saw her with a big smile on her face, her hands dancing and shouting, “Grandpa, thank you, this time it’s really removed for me!” It was a life-saving thread, and at the end of the surgery, in order to prevent the head from being tilted back, the chin was sewn to the skin of the front chest with a tenth-gauge thick silk thread to keep the patient’s head down. For more than half a month, only those who have experienced it can truly appreciate the unbearable feeling. It was very hard to even cough and extremely inconvenient to eat and drink. Her name is Xiaomeng, 12 years old, a fifth grade student in elementary school, is as innocent as a flower age. She was in a coma with encephalitis in April this year and had to be put on a ventilator with a tracheotomy 10 days later. 2 weeks later, she was awake, but the tracheotomy couldn’t be removed. After the extubation, she had high difficulty breathing and had to have a tracheal stent put in as a last resort. The stent was removed until 7 months after the onset of the disease. However, due to the narrowing of the tracheal scar, suffocation occurred several times. Xiaomeng’s mother said that she had suffocated more than 10 times since the onset of the disease, and the most serious one was before she was transferred to our hospital, she suffocated when she couldn’t get a mouthful of sputum, and “nothing (breathing and heartbeat) was left”. Finally, he was saved again. Before surgery, the trachea had to be dilated every 3 to 4 days, more than 10 times before and after, and if it was not dilated for 3 to 4 days, asphyxiation would occur. The feeling of death by strangulation was so horrible that Meng woke up at night from nightmares after the surgery. Her parents both work outside the home to pay for her schooling. The family has spent hundreds of thousands of yuan for treatment. When she talked about her daughter, her mother cried bitterly. Seeing no hope, and not wanting her to die like this. The discussion before the surgery was of course very fine. The middle part of the trachea was about 3.5cm long stenosis, and we were sure of removing 4~5cm with open-heart surgery. But the experience of tracheal surgery tells us that the preoperative examination, is not absolutely accurate, and anything unexpected can happen on the stage. The risk is great, and in case the experience tells the doctor that the family speaks well before surgery, disputes often still occur once the accident occurs after surgery. Which is more important, vocation duty or self-protection? The scales eventually tipped in favor of saving lives. But on the operating table, as it happens, there are unexpected complications and even catastrophic situations. It is difficult for a wise man to think about a thousand things without making a mistake. This is the most difficult part of being a good doctor. How can the social environment understand and forgive what-ifs? Do doctors have to get into trouble for not saving lives? The routine pre-surgical examination and discussion are done step by step. The child had been to several hospitals, had undergone several CT and tracheoscopic examinations, and the CT and tracheoscopic examinations showed a thickened and irregularly narrowed lower and middle tracheal wall of about 3-4 cm. open-chest surgery to remove and perform a one-stage anastomosis was not too difficult for us as a surgical team. Based on previous experience, we even thought about what if we found intraoperatively that we needed to cut longer and could not connect the severed trachea. We prepared several options. Two uncommon CT manifestations were also noted preoperatively: first, the thoracic vertebra corresponding to the stenotic segment of the trachea was significantly anteriorly displaced and ossified, a phenomenon that can be seen in the case of a slipped lumbar spine, but this was a thoracic spine, where slippage is almost impossible. Secondly, the lower end of the stenotic segment to the tracheal bifurcation (called augmentation in medical terminology) is not a normal image of a segment of trachea about 2.5 cm long, not garden-like, but dumbbell-shaped and continuous downward with the left and right main bronchi. It was not described and diagnosed in several CT reports. We thought it was due to a higher tracheal bifurcation. Due to severe tracheal stenosis, general anesthesia intubation with the thinnest 5-gauge tube still could not pass the stenosis, so it had to be placed above the stenotic segment. After opening the chest, it was found that the tracheal wall of the stenotic segment was highly thickened. The posterior wall was so tightly healed with the ossified vertebral body that it could not be cut, and the scalpel could not be cut. This section of the tracheal cartilage ring had all been broken into fragmented segments, which were embedded in each other and healed malformed. When the healing part of the trachea and vertebral body was opened with scissors, it was found that the posterior wall of the trachea was completely defective into a large hole, and the anterior wall was completely replaced by thick scar tissue. Without resection, the stenosis could not be resolved by dilation or other means. The 4-cm long diseased trachea was removed. The upper and lower trachea sections were then anastomosed together. The anastomosis was good and the anastomosis was very satisfactory. However, it was suddenly discovered that the 2 cm long trachea between the anastomosis and the ramus was a wide ligament, and when pinched with the fingers, it was a “two-layer skin” with no lumen! This is obvious tracheal softening! At this point, I realized that this was a big disaster! I also realized that the dumbbell-shaped trachea that I saw before surgery was actually a section of the tracheal cartilage ring that was completely broken off from the anterior midline! There was already softening and stenosis before the surgery! After removal of the 4cm tracheal stenosis, the lower trachea was stretched after the upper and lower ends were pulled together, so the softening and stenosis was even worse. What to do? We encountered a completely unexpected situation! Of course, no further resection was possible. If resected, the total tracheal defect of more than 6 centimeters long would be irreparable in any case, and the patient would not be able to get off the operating table! No way to survive! The best thing to do was to place a stent. But can a girl of only 12 years old get off the operating table with a stent, but can she live for the rest of her life? The stent would produce granulation and would require constant tracheoscopic freezing or laser treatment. After talking to the family, they also repeatedly pleaded to not put the stent in if they could. After careful observation and design, I finally came up with a solution. Let’s give it a try, and put in a stent if it doesn’t work. So I sutured the right posterior lateral wall of the trachea to the vertebral body periosteum and suspended one side of the trachea to the vertebral body to create an artificial lumen. A total of five stitches were placed, and when I looked again, the lumen came out, which was not as good as a normal trachea, but should be sufficient for ventilation. To ensure safety, the anesthesiologist first stopped the ventilator and allowed the child to resume spontaneous breathing. Because only in the case of spontaneous breathing, the trachea is negative pressure, so that we can test whether there is obvious tracheal softening and whether the child can really breathe normally. The result was successful! To ensure safety, even though the line was not immediately extubated, we took the tube to the ICU and connected it to the ventilator. We prepared for a day of transition, and the tube was removed tomorrow morning. Unexpectedly, the next morning, when the tube was removed, there was an even bigger accident! Vital signs were stable overnight, the ventilator was discontinued in the morning, he breathed on his own, and the tracheal tube was removed an hour later. After 10 minutes, the child suddenly had obvious breathing difficulties, and when he inhaled, his sternum sank sharply, as if his inspiratory efforts were completely ineffective and he could not inhale air. The oxygen saturation of the monitor dropped rapidly, from 100% to 90%, 80%, 70%, 60% in two to three minutes. The heart rate also dropped from about 100 to 80, 60, 40, 30. It is foreseeable that the heart will stop beating soon! The reason for the sudden difficulty in breathing, of course, the first thing to think about is whether the softening of the suspended trachea does not achieve the desired effect, and the occurrence of tracheal softening? The trachea must be intubated immediately. But at this time, intubation was extremely difficult because the patient had a long tracheotomy and needed to maintain a low head position with a flexed neck, and intubation required the head to be tilted back, which would severely crack the anastomosis. After discussion among the experts, the tracheal tube was immediately inserted using tracheoscopic guidance. Sputum was aspirated, and there was not much sputum. Positive pressure ventilation was connected to the ventilator, and with resuscitation drugs, everything soon returned to normal again. The ICU director, the chief of respiratory medicine, the chief of anesthesiology, the chief of thoracic surgery and the young doctors were all at the bedside, witnessing and participating in the thrilling resuscitation. After the child was stabilized, the tracheoscopy showed that the lower trachea had not collapsed. But at this point, no one dared to mention extubation again. If it was considered that the lower trachea was softened, the tube could no longer be removed and only endotracheal stenting could be used. So we communicated with the family several times. The family was told that the specific situation of the child was the safest to be treated with stenting and that the tube could be removed. But the family panicked, “Don’t put the stent in again, it’s going to grow granulation again and there will be no peace.” However, if you don’t remove the tube and ventilate, it’s safe, but the child can’t carry the ventilator forever! Not to mention the many complications over time. The child is only 12 years old and cannot be stopped, how to live. If the stent was released, the ventilator would be removed, but the child would still not be able to survive for a long time! I was struggling fiercely in my mind and suffering in my heart like I had not done for years. The tracheal wall had been sutured and suspended on the operating table, and the tracheal lumen had opened up significantly, but had the sutures completely fallen out in less than 24 hours? A few hours passed, and I was at the child’s bedside observing and pondering. Suddenly a thought came to my mind, and it occurred to me that the tracheoscopic view of the lower tracheal lumen should be similar to that before surgery, both dumbbell-shaped and seemingly wider than before surgery! It should not be tracheal softening! If not, then it should be possible to extubate! To verify whether this feeling was accurate, I reassured the family and hurried back to the thoracic surgery ward to review the pre-surgical tracheoscopic photos. As the photos showed, this was the shape before the surgery. It was so exciting! I hurriedly communicated with the directors again. Finally, at around 1:00 pm, the tracheal tube was successfully removed and the child was taken off the ventilator. The subsequent recovery was smooth sailing. Such a complicated patient was completely saved! Every day since then, we have seen a bright smile on the little girl’s face, but she was stuck with the stitches between her chin and forehead, which prevented her from raising her head and sleeping peacefully, and sometimes she felt pain from pulling on the stitches. Today, the annoying stitches were finally removed, and the little girl’s smile is even brighter! Note: She was discharged from the hospital and went home for the New Year. I can’t count the number of times I died in Beijing, stent placement, stent removal, tracheoscopic cryotherapy, and tracheoscopic dilation. I can’t count how many times I have suffered. This time, she is finally relieved! Back to normal life and study. I would like to wish little Meng Meng health and happiness from now on! 10 days later, Xiao Meng and her mother came to the hospital by subway to visit everyone and to see Xiao Yi, who later operated on the same age and in the same ward as her. What a healthy and lively child! Who would believe when looking at her that 1 month ago she had to undergo bronchoscopy every 3 days, dilate her trachea, choke many times and was on the verge of death? As a doctor, it is infinitely more gratifying to see such a scene. At the same time, it also strengthens our determination to take risks for our patients and treat them to save their lives.