Gregg Hurwitz: Do No Harm

He repositioned Nancy's head and tried again, but still couldn't make out the vocal cords behind the swelling.

"Crich her?" Diane asked.

David shook his head. "Not yet. Before we cut, I'll try to tube her blind and see if we get lucky." Though the swelling prevented him from eyeing the anatomical landmarks, he began pushing the endotracheal tube, tracing a path along the underside of the laryngoscope blade down Nancy's throat. He pulled the laryngoscope from Nancy's mouth. The clear ET tube remained, protruding a few inches from the line of her teeth. David removed the metal stylet that ran down its length and inflated the cuff at the other end, which was buried somewhere in Nancy's throat. He popped the end-tidal carbon dioxide monitor on the end of the tube, then attached the oxygen bag valve atop the monitor.

Diane pulled her stethoscope from across her shoulders, cleared her hair with a head jerk, and positioned the plugs in her ears. She listened over the lungs, then switched to the stomach, as David pumped the bag with his hand. "I'm getting a gurgle," she said.

The ET tube had wound up in the esophagus rather than the trachea, the usual result of tubing someone blind. Diane was picking up stomach noises rather than movement through the lungs. The monitor reading showed high carbon dioxide-Nancy still wasn't breathing.

David pulled the endotracheal tube from Nancy's mouth; it swayed beneath his fist like a bloody snake.

"Her O-two sat's dropping… " Pat said, a note of panic creeping into her voice.

Nancy's flesh was going from white to blue.

"Is the fiberoptic scope here?" David asked.

A clerk leaned into the room. "Not yet, but anesthesia said it's on the-"

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.

"Dr. Trace?" David said. He didn't look up from the eye he was spraying, but he sensed Diane's head pivoting.

She switched the saline bottle to her other hand, squinting as a wayward squirt caught her across the brow. "Increasing intraluminal pressure generated by emesis is speculated to increase the risk of perforation when the tissue is markedly weakened. Carson, get your ass over here and give us a hand."

Carson lunged forward and grabbed a saline bottle. Diane nudged him with a shoulder. "What are the three reasons we don't use charcoal to soak up alkali in the stomach?" she asked.

"Four reasons," David said.

Diane grimaced at being corrected but didn't look up.

Pat switched IV bags, then checked Nancy's blood pressure cuff, her face stained with grief and shock. With twenty-three years as an RN under her belt, Pat was the den mother of the ER nurses; that's why she'd followed Nancy in here, probably sending one of the more junior nurses out front to triage. Her crew cut was shot through with sweat.

"I don't know any," Carson confessed.

David raised an eyebrow at Pat. "Pat?"