Chapter 3 - UNDER THE VENTILATOR
The monitor alarms chimed in harsh, irregular bursts.
"Oxygen saturation dropping," Marcus called out, his thumb resting on the three-way stopcock of the central venous line. "Seventy-six percent. Heart rate is spiking to one hundred and thirty-eight. Sinus tachycardia."
"Push the rocuronium," I commanded, pulling the pillows out from beneath Lauren's neck to align her oral, pharyngeal, and laryngeal axes.
Within fifteen seconds, the paralytic took hold.
The frantic, agonizing heaving of Lauren's chest abruptly ceased. Her muscles went completely limp, her jaw relaxing as the chemical agent severed the communication between her motor nerves and her diaphragm. The terrified expression on her face vanished, wiped clean by pharmacological paralysis.
She was completely helpless. She couldn't blink. She couldn't swallow. She couldn't pull a single molecule of air into her dying lungs on her own.
"I'm taking over ventilations," the respiratory therapist said, sealing the silicone mask over Lauren's mouth and nose, rhythmically squeezing the self-inflating bag.
Squeeze. Release. Squeeze. Release.
"Laryngoscope," I said, holding out my gloved left hand.
Marcus slapped the rigid composite handle into my palm.
I stepped into position at the head of the bed, my feet planted shoulder-width apart. With my left thumb and forefinger, I scissor-opened Lauren's lips. The tongue was dry, swollen, and cyanotic.
I inserted the curved blade along the right side of her tongue, sweeping it to the left, and advanced the camera into the posterior oropharynx. On the high-definition color screen hovering six inches from my face, the anatomy of my sister's throat appeared in vivid, terrifying detail.
Her epiglottis was beefy, red, and swollen with inflammatory fluid. Thick, purulent green secretions pooled in the vallecula, completely obscuring the vocal cords.
"Suction," I said.
The plastic Yankauer tip hissed as I cleared the airway. The camera cleared.
Beneath the secretions, her vocal cords were two thin, pale bands, locked in a tight, spasmodic adductive state.
"Grade three view," I said, keeping my pulse steady beneath my latex cuffs. "Give me a seven-point-zero cuffed endotracheal tube with the stylet."
The plastic tube felt feather-light in my fingers.
This was the exact mechanical procedure that had saved my life twelve years ago while my sister stood outside the curtain, rolling her eyes and checking her purse. I had replayed that afternoon a thousand times in my nightmares—the sensation of plastic invading my larynx, the suffocating terror of losing control of my own breath.
I did not hesitate.
I guided the bevel of the plastic tube past the swollen arytenoid cartilages. With a gentle, deliberate flick of my wrist, the tube slid cleanly between the pale vocal cords and descended into the trachea, stopping exactly two centimeters above the carina.
"Tube is in," I announced. "Inflate the cuff."
Marcus injected five cubic centimeters of air into the pilot balloon, sealing the trachea against gastric aspiration.
"Connect the ventilator circuit."
The respiratory therapist snapped the ribbed plastic tubing onto the end of the endotracheal tube. The ventilator let out a high-pitched electronic confirmation chirp and immediately began its mechanical cycle.
Hiss. Click. Exhale.
Hiss. Click. Exhale.
I grabbed my stethoscope and listened to both sides of Lauren's chest.
Bilateral breath sounds were present, harsh and filled with coarse rhonchi, but air was finally moving through her lung fields.
"End-tidal CO2 is forty-four," Marcus said, looking up at the colorimetric capnography square turning bright yellow. "Saturation is climbing... eighty-four... eighty-nine... ninety-three percent."
"Good," I said, stripping my bloody gloves and tossing them into the red biohazard receptacle. "Start a continuous infusion of propofol at twenty micrograms per kilo per minute. Keep her sedated. Titrate the fentanyl for a RASS score of minus three. Start broad-spectrum coverage with vancomycin and cefepime immediately. Get a post-intubation chest X-ray and an arterial blood gas in thirty minutes."
"Understood, Dr. Santos," Marcus replied, already typing orders into the mobile terminal.
I stepped back from the bed.
Lauren lay completely still now. The clear plastic tube protruded from the right side of her mouth, secured to her cheek with thick white adhesive tape. The ventilator hummed beside her, its mechanical bellows rising and falling with mathematical precision, forcing oxygenated gas into her infected alveoli.
She looked small. Stripped of her posture, her expensive clothes, and her biting sarcasm, she was just another failing human body fighting an overwhelming microbial invasion.
The glass door slid open behind me.
Nurse Manager Sarah Jenkins poked her head in, looking pale. "Dr. Santos? The patient's emergency contacts have arrived in the ICU waiting area. An older couple. They're demanding to see the attending."
My heart hammered against my ribs, heavy and slow.
"Did they give a name?" I asked.
"Arthur and Beverly Santos," Sarah said. "The mother is in hysterics. She says her daughter is an executive and can't possibly be on life support."
I pulled a fresh disinfectant wipe from the dispenser on the wall and methodically scrubbed the black tubing of my stethoscope.
"Tell them Dr. Santos will be out in five minutes," I said.
May you like
Sarah blinked, glancing at the nametag on my chest, then back at the patient's chart on the monitor. Her eyes widened with sudden, unspoken understanding.
"Yes, Doctor," she whispered, and quietly pulled the glass door shut.
