Do No Harm

A clerk ran from the room. Two nurses dashed in, pulling on latex gloves and snapping them at the wrists.

"Was it an explosion?" someone asked.

"Doubt it," Pat said. "Nancy walked in herself-it must've happened right outside. Security's already contacted the police."

"She's working hard," David said, glancing at the skin sucking tight against her ribs and around her neck. "Supraclavicular and substernal retractions. Let's get ready to tube her."

Nancy tried to sit up, but Pat restrained her. Nancy's breath came in great heaves. "Dr. Spier," she said. Her voice was thick and rough, tangling in the swell of her throat.

David leaned over Nancy's face. The skin around the blisters was whitening, contrasting sharply with the red bulges. She appeared to be trying to go on speaking.

His hands fluttered near her jaw, ready to check her airway. "I'm right here, Nancy. We're gonna get you taken care of. Can you tell us what substance we're dealing with?"

IVs being hung, pulse ox sliding on the finger, scrubs cut free from her legs and tossed into a trash bin. Cardiac leads plunking down across her chest like bullet holes.

Nancy coughed, contorting on the gurney.

"Heart rate's one forty," someone said. "O-two saturation's low nineties and dropping."

David leaned closer. "Nancy, can you tell us?"

The green line on the EKG monitor showed tachycardia, the peaks and valleys getting mashed closer and closer. Her arm rose, a hand pawing limply at air.

No more time. He pulled her jaw open and peered down her throat. Ulceration of the oropharynx, subacute airway compromise from edema. Whatever had gone down her throat had irritated the tissue, causing massive swelling. He needed to secure an airway quickly before her throat closed off.

David tilted her head back to give her throat maximum patency. "Push twenty mgs of etomidate and one hundred of rocuronium," he said, his voice ringing sharp and clear even to his own ears. The drugs would sedate and completely paralyze Nancy. She'd be unable even to breathe unless they could get a tube down in her to do it for her. "Laryngoscope," he said.

The L-shaped tool slapped the latex covering his palm. Positioning it in his left hand, he then slid the blade down along her tongue, using the small attached light to guide it past the epiglottis. The laryngeal swelling was bad, even worse than he'd noticed at first glance. He couldn't see the vocal cords between which to guide the endotracheal tube.

He glanced up at Diane, who was performing the Sellick maneuver, applying pressure to the cricoid membrane beneath Nancy's larynx, trying to bring the vocal cords into view for him. It wasn't working.

"Someone get on the horn to anesthesia and see how long it'll take to get a fiberoptic scope down here," David barked. If the swelling got too bad, he could look through the thinner scope and maneuver down the trachea.

He repositioned Nancy's head and tried again, but still couldn't make out the vocal cords behind the swelling.

"Crich her?" Diane asked.

David shook his head. "Not yet. Before we cut, I'll try to tube her blind and see if we get lucky." Though the swelling prevented him from eyeing the anatomical landmarks, he began pushing the endotracheal tube, tracing a path along the underside of the laryngoscope blade down Nancy's throat. He pulled the laryngoscope from Nancy's mouth. The clear ET tube remained, protruding a few inches from the line of her teeth. David removed the metal stylet that ran down its length and inflated the cuff at the other end, which was buried somewhere in Nancy's throat. He popped the end-tidal carbon dioxide monitor on the end of the tube, then attached the oxygen bag valve atop the monitor.

Diane pulled her stethoscope from across her shoulders, cleared her hair with a head jerk, and positioned the plugs in her ears. She listened over the lungs, then switched to the stomach, as David pumped the bag with his hand. "I'm getting a gurgle," she said.

The ET tube had wound up in the esophagus rather than the trachea, the usual result of tubing someone blind. Diane was picking up stomach noises rather than movement through the lungs. The monitor reading showed high carbon dioxide-Nancy still wasn't breathing.

David pulled the endotracheal tube from Nancy's mouth; it swayed beneath his fist like a bloody snake.

"Her O-two sat's dropping… " Pat said, a note of panic creeping into her voice.

Nancy's flesh was going from white to blue.

"Is the fiberoptic scope here?" David asked.

A clerk leaned into the room. "Not yet, but anesthesia said it's on the-"