Part 3

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.