One of the gloves tore when he stripped them off, and the hair on his forearms was speckled with blood up to the line of the cuffs. He pedaled the sink into life and then scrubbed and rinsed, leaning over so the water would fall away from the wrists and sluice down to the elbow. The desire to scream was still there: pressure just behind the nose and throat but fading. During intense stress he was most aware of himself separating into layers. Fear flattened the mind, but urgency unfolded it, so all the pieces were laid out to use.
The mouth of the body in the bed teemed with dark blood and spongy ropes of clot. Ten minutes ago, he had seen the ICU fellow frantically opening the airway cart in the hall while he pushed his own patient into the room two doors down. There was no one to meet him. He stood, squeezing the bag, and a respiratory therapist came in.
“Here. He’s completely stable. Thirty percent, PEEP of five. Sixteen, four-fifty. I’m going next door. I’ll be back.” He slipped around the threshold and straightened.
“Do you need my help?”
The fellow tensed, looked up, and relaxed. “Yes. Right-sided small cell lung cancer that was responding to treatment. He got a leg DVT so we started heparin. Now he’s having hemoptysis.”
A thin man, naked to the waist, was sitting up in the hospital bed behind him and coughing into a basin lined with phlegm and blood. A nurse stood beside him, holding the basin and repeating “it’s gonna be okay.” The man coughed and spat out a large, red mouthful, and the nurse looked up and indicated the patient. “This is Peter.”
“Hi, Peter. I’m from anesthesiology. I’m here to help.”
He turned back to the fellow. “Bronch team?”
“Coming.”
“Allergies or other major medical problems?”
“Uh, no. No issues. Heart’s fine.”
He picked up a blade and handle from the open tray on top of the cart, pulled out tubes, syringes, and stylets from the next drawer, and plucked a long, honey-colored bougie in its sleeve from the bin on the side. “Do you have drugs?”
“Etomidate and rocuronium.”
“Fine. Calcium and epi too?”
“I’ll get some,” said the fellow, but a hovering nurse was already moving toward the pharmacy station.
He shuffled between the wall and the column of outlets and gas valves that supported the telemetry monitor and squeezed past to the head of the bed. Another respiratory therapist was setting up the ventilator. They nodded in recognition.
“Hey. Until I look, I won’t know how large a tube I can get in, so if I ask for the eight, hand me the eight. If I ask for the bougie, give it to me and then take the stylets out of the tubes before you hand those over.”
“Okay.”
He turned to the monitor and tapped the volume until he could hear the tone of the pulse oximeter, then turned to the nurse. “What kind of access–” and the patient in the bed fell back. He didn’t cough, or convulse, but his mouth overflowed with blood.
“T-burg, T-burg!” He groped for the release lever and let the head of the bed drop flat. The nurse was already working the bed controls to raise the feet. He snatched up the suction and pulled the tip off, slipping the thick tube directly into the patient’s mouth. After an initial rush of blood, the opening clogged. He reached in to clear it, turning the patient’s head to the side and hooking out gore with his fingers. He opened the laryngoscope blade and slid it around the tongue, lifting the man’s whole head from the mattress. There was nothing recognizable, and then an arch and a bubble limned out of the red mess.
“There. Can I get some pressure? Eight-five, please!” Someone reached down and pressed on the man’s neck just below where his hand had been, and a breathing tube was placed in his hand. The tip made it between the vocal cords before sticking, but with a little twist it scraped forward.
“That felt good. Cuff’s up,” said a voice. He relaxed with the blade. The respiratory therapist attached the bag to the tube, the fat carbon dioxide detector interposed between them, and started to squeeze. The little paper in the detector faded purple-to-yellow, purple-to-yellow. Blood and vapor fountained up in the tube with each breath. The fellow was shouting for fluids. A resident he did not recognize applied a stethoscope to the man’s chest.
“Bilateral.”
“Do we still have a pulse?” someone called.
“I have a femoral!” said another nurse with her hand pressed into the patient’s groin.
The respiratory therapist handed him a flexible catheter, and he attached it to the main suction line. He pulled the bag off the end of the breathing tube and pushed the catheter in, covered the thumb port, withdrew it, relaxed his thumb, pushed, covered, withdrew. Blood came, but it didn’t seem nearly enough. He reattached the bag and let the therapist squeeze it again. The fellow was still at the foot of the bed.
“You said it’s on the right side?”
“Yes.”
He could hear the descending tone of the pulse oximeter and looked up at the monitor. Seventy-one percent. Sixty-nine. He pulled the long bougie out of its sleeve and turned it in his fingers so the little bend at the end faced left.
“Stop bagging for a second.”
He pulled the bag connector free from the breathing tube and pushed the bougie in, taking care not to let it rotate. When it met resistance, he grabbed the breathing tube in his other hand and pushed it forward until it too would go no further. Then he drew the bougie out and reattached the bag. The respiratory therapist squeezed. He put his own stethoscope on the patient’s chest. Nothing on the right side, but there was a coarse rush on the left. Okay. I hope this works. He looked up at the pulse oximeter on the monitor. Fifty-four percent. Fifty-three. Fifty-four. Come on. The man’s heart was slowing down. Ninety-nine beats per minute. Seventy-one. Forty-one. No, no, no.
“Pulse?”
“I don’t have it anymore!”
“Start chest compressions.”
“Wait! We can’t!” said primary nurse. “Peter has a directive: intubation’s okay, but no compressions.”
Everyone stopped, and his mind went very still. Then, feeling like he was on a stage and very self-conscious, he reached down and felt along the man’s neck. “I don’t have anything here.” He looked up at the fellow standing by the other end of the bed. “Then we’re done. I’m sorry.”
The fellow nodded. “We’ll call time at eight thirty-two.”
He straightened up and took a deep breath. “Thank you everyone.”
There was a ragged toccata of thank-yous from the other people in the room, and the crowd began at once to dissolve. He gathered up the tools and stepped behind the utility column to get around to the door. For a moment he was hidden. He did not kick the trash can, because it would have made too much noise.
