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.

Miguel: Hebrew origin: one who resembles God, Part 1

It’s the rainy season, but more so this year than in the past few years.  The rain seems relentless at times.  Downpours last for days at a time, a constant drone on the metal roof.  Roads resemble rivers more so than streets.  Mudslides have replaced villages with mud and boulders and there is a general sense from the populace of a heavy coat blanketing all the senses.  But even with all of the rain a "Buenos Dias" is never far from the lips of all we pass by.
 
Miguel’s parents were up with their child late into the night reflecting on the past few days.  It started as a runny nose, followed by a dry hacking cough and then the rapid breathing, each breath an effort to get more air.  They went to the local health center and received various remedies that seemed to help initially, but now, as their child looked up at them with a plea for help and fear of the unknown, they knew he was getting worse.

They say an asthma exacerbation is like trying to breath through a straw, as it worsens the diameter of the straw grows smaller and smaller........

Jennifer had just laid down in bed during a 24 hour in-hospital call.  She’d seen and treated numerous patients that day.  Routine stuff mostly, but now as she laid down at 4 AM she heard the unforgettable "clack, clack, clack" of the tuc-tuc coming down the dirt road to Hospitalito.  At this hour of the day it could mean only one thing -- a patient in need of acute care. 

She gets up before the guardian can knock on her door, fumbling around in the dark in a place that is becoming less foreign each day.  She hears a rooster crow, a dog barking at some unknown nemesis as she puts on her doctor’s coat --loaded with all the “essential” paraphernalia from 15 years of practice.  She grabs her stethoscope, a close friend since her days in medical school, and heads down the stairs to the ER. 

Andrea, the nurse, had already placed oxygen and gotten vitals when Jennifer entered the room.  Miguel’s eyes were bulging and wide with panic as his chest wall heaved with every breath.  Sensing the acuity of the situation, Jennifer questioned, examined, and gave orders almost simultaneously -- pulse oximetry, intravenous access, nebulizer treatments, I.V. steroids.  With treatment, Miguel’s pulse oximetry began to rise from the low 80’s to low 90’s.  His respiratory rate began to drop from the 80’s to 50’s and his lungs began to open up.  He looked a bit better now.  

It was almost 7:30AM and time for morning report.