The trip from Santiago to Solola at any time of the year can be difficult, but especially this time of the year with mudslides and road closures. Brent is elected to go with Miguel. Diego, a new nurse to Hospitalito, is assigned to go, as well, and along with Miguel, his parents, the bomberos and Brent, they begin their journey.
After about 15 minutes, Miguel’s father is dropped off in Cerro de Oro, the village where they live, to tell relatives what is happening and to get money to help pay for their expenses in Solola. The hospital in Solola is a public hospital so the care is free, but there are costs for the parents to eat, etc.
Every jolt and bump seems to tug on the endotracheal tube and Brent and Diego look at one another hoping not to have to re-intubate on the way, but each tug confirms the nurse’s taping job was excellent. Brent is providing Miguel’s respirations methodically reciting “squeeze, rest, rest, squeeze, rest, rest...” trying to maintain 20 - 30 breaths a minute and watching Miguel and the pulse oximeter. The pulse oximeter has been going down 99, 95, 90, 88. Brent notices the bagging becoming more difficult and gives a dose of albuterol (a medicine that helps to open up the lungs) via the endotracheal tube. This appears to help as the oxygen monitor increases to 97 again. The bomberos note another one to one and a half hours to go.
Diego observes Brent looking queazy and offers to take over the ventilations. There are so many 180 degree turns on the road that you begin to wonder if you are really going forward and not just going in circles. Brent is reminded of a similar curvy road growing up, the Green Springs, and the many times his father pulled over for him!
Diego sees the oxygen saturations dropping again and a quick look at Miguel shows him moving his mouth, a sign the paralytic agent is wearing off. Another dose of that, his saturations increase, and he is resting again. They finally arrived to the Pan American Highway and a direct shot to Solola.
Arriving at the National Hospital in Solola, a team of Guatemalan physicians greet and attend to Miguel and his mother. The Hospitalito team stays with Miguel and his mother until they feel comfortable with the change over and begin their journey back home.
Miguel did well during his hospital stay there, was extubated (endotracheal tube removed) after three days, and after 8 more days in the hospital he returned home.
Thinking now of our time with Miguel and the people he brought together from different parts of the world, working together for a common good, his name seems fitting -- one who resembles God.
Morning report is a time to review, with the other doctors working in the hospital, the patients admitted and seen in the ER during the day and night before. Jennifer quickly reviews the patients and then focuses on Miguel. Brent arrives at 7:40, a bit late, but in time to hear Miguel's story. The doctors then go down to see Miguel and the other patients.
Miguel is now breathing 50 times per minute, but his oxygen saturation has again dropped into the 80s. His pulse is 180 and his lungs are tightening up again. He is shows signs of tiring and is not able to maintain his oxygen at appropriate levels as his respiratory rate slows.
The team this morning includes doctors from Guatemala as well as from Spain and the United States. Many specialties are represented including obstetrics, family medicine, and gastroenterology. They realize Miguel will not be able to keep this up much longer. They begin working in unison: continuous nebs, a phone consult to a pediatric intensivist in the US, comforting the parents, and preparation for intubation.
Rapid sequence intubation is a process of giving sequential medications that paralyze the patient and allow for placing a tube into the trachea. This then allows the physician to take over the work of breathing for the patient.
Assignments are given, drugs prepared, high flow oxygen started. All drug dosages checked and double-checked.
The ER this morning is a cacophony of sounds -- the bubbling of oxygen, the drone of the suction machine, voices of physicians and nurses and the labored breathing of Miquel.
The medicines are given and Miguel stops breathing on his own......
Seconds seem like hours during this moment as all attention is focused on placing the tube into the trachea.
When intubating a patient you are always told to have a backup plan. What will you do if you are unable to intubate the patient? The last patient, Brent had intubated, was 6 years ago while working in an ER in Northern California. Brent ran through the different options in his mind -- bag, bougie, laryngeal mask, needle cricothyroidotomy.
The first attempt is met with coughing, signifying Miguel is not completely paralyzed. Another dose of the paralyzing agent is given and this time the endotracheal tube is passed without difficulty and taped into placed. Oxygen is hooked up to the bag and one of the doctors rhythmically compresses the bag which now does all the work of breathing for Miguel.
Miguel’s oxygen saturation increases rapidly to 99%. He appears at rest now after working so hard for so long.
The local volunteer bomberos (firefighters/paramedics) are called and Miguel is prepared for the 2-3 hour trip around the lake to Solola, the national hospital where specialists and ventilators are available.
Diego sees the oxygen saturations dropping again and a quick look at Miguel shows him moving his mouth, a sign the paralytic agent is wearing off. Another dose of that, his saturations increase, and he is resting again. They finally arrived to the Pan American Highway and a direct shot to Solola. 
Arriving at the National Hospital in Solola, a team of Guatemalan physicians greet and attend to Miguel and his mother. The Hospitalito team stays with Miguel and his mother until they feel comfortable with the change over and begin their journey back home.