Do No Harm

David reached for a scalpel, fingering beneath Nancy's larynx for the cricothyroid membrane with his other hand. He cut lengthwise along the membrane, opening up a surgical airway in her throat. Diane had the three-pronged retractor in his hand immediately; he slid it into the cut and it opened like a tripod, spreading the hole. Feeding a 4.0 ET tube into the hole, David plugged the other end into a ventilator hose. The ventilator breathed for her, pushing air through the tube into her lungs.

Her chest started rising and falling, and her oxygen saturation climbed slowly back up past ninety. Airway secured. Now he'd have to identify the offending agent.

He glanced up at the nurses. They were moving a little slower than usual, still shell-shocked. A lot of looks to Nancy's face.

"I know this is hard," David said, gently yet firmly, "but right now we're just dealing with an injured body, like any other body. Have you drawn blood?"

Pat nodded.

"Send off a CBC, a chem panel, type and screen, and get a rectal. Does someone have my pH strips?"

The black-haired nurse slid a gloved hand between Nancy's limp legs.

Someone handed David a yellow pH strip and he laid it across Nancy's cheek. It dampened quickly, but did not change. He threw it aside. "Not an acid," he announced. Pat was ready with the red strips; he laid one on Nancy's forehead and one just beneath her eye. Almost immediately, they turned a glaring blue.

David cursed under his breath. A base. Probably Drano. Acids are nasty, but they attack tissue in such a way that the skin scars quickly, usually protecting healthy underlying tissue. Alkali, on the other hand, produces a liquefaction necrosis, saponifying fats, dissolving proteins, penetrating ever deeper into the tissues. Unlike acid, it keeps burning and burning, turning flesh to liquid. Same way it opens clogged drains.

Diane glanced at the blue pH strip and immediately began dousing Nancy's face with saline.

"Follow her lead," David said. "Irrigate the hell out of her." He raised one of Nancy's lids with a thumb and stared at the white cloudy eyeball. Corneal opacification. More bad news. He picked up a little 250-cc saline bottle and flushed the eye. "Someone find me some Morgan lenses." Each of the hard Morgan lens contacts connected to a tube that could continually flush the eyes with saline. As they were seldom needed, he hadn't used Morgan lenses for about ten years.

The blistering lips and swollen throat indicated that the alkali had gone down Nancy's throat. If it had burned through her esophagus, letting air escape into her chest cavity, he would have to get her to the OR immediately. If it hadn't fully penetrated, then the alkali remained on the esophageal walls, eating through additional tissue, and there was very little they could do about it.

He slid an X-ray cassette, encased in a dull silver case, beneath Nancy's body. "Everyone in leads!" Everyone present threw on lead aprons as Diane positioned the X-ray unit over Nancy's body and threw the switch. Quickly, they repeated the procedure until they'd completed serial chest and abdominal films. A lab tech slid the final cassettes out from beneath Nancy and handed them off to the radiology tech, who scurried from the room.

"Check for free subdiaphragmatic air, mediastinal emphysema, and examine lung parenchyma for signs of aspiration," David yelled after the tech. "Did he hear me? Someone make sure he heard."

Several nurses and lab techs were spraying down down Nancy's face with saline bottles. Water and runoff drenched the gurney sheets.

"Should I get ready to drop an NG tube to lavage the stomach?" Diane asked. "Dilute the alkali?"

"No, it's contraindicated," David said. "It can cause retching or vomiting, and the alkali could migrate back up the tube, reexposing tissue. Plus, you could drop the thing right through a weakened esophagus wall into the mediastinum. Getting her stomach pumped isn't worth the risk of boxing her."

A nurse's hand appeared seemingly out of thin air, handing Diane another saline bottle.

Carson Donalds ran in, breathing hard, and shot looks around the room with the mixture of anxiety and disorientation typical of a medical student. He ran a hand through his mop of curly blond hair, his eyebrows disappearing under the front line of his bangs. "I heard you have a pretty gnarly alkali burn." He saw Pat's face, then glanced at the body and took a step back. "Fuck. Is that Nancy?"

David's bottle spat air, so he tossed it into the bin, grabbed another, and continued irrigating the eyes. "Dr. Donalds," he said, taking a calm, didactic tone, "why don't we use emetics for alkali ingestions?"

"Because she's paralyzed and tubed and the last thing you want is her barfing up and asphyxiating," Carson said.

"How about if she wasn't tubed? Would we use an emetic then?"

"No. You don't want to reexpose the esophageal tissue to offending agents on the way back up."

"And?"

Carson shook his head.