Did I Kill a Girl and Liked it? Part 2/2
By Rick Fischer.
The UERC responded quickly, for a change. The course was laid. The objective: to deliver the patient at Junta city in St. Michael’s Hospital. Three hours of mud-trail and another 3 of paved roads were ahead. Dr. Sanchez and Don Anselmo found no way of loading the incubator in the ambulance. The mother's body heat and some blankets will be the child's life support. Esmeralda, the ambulance's nursing assistant would be in the back of the ambulance with the mother and the child checking the child’s breathing and pulse. Don Anselmo at the helm and Dr. Sanchez as copilot.
When he used to drive his motorbike in the overcrowded streets of Santa Fe he would always joke about how listening to power metal made him ride faster. This time the tex-mex music of Don Anselmo's choice would only remind him of how far he was into the country-side. The first three hours went down surprisingly well. He had thought upon departure that the girl would not make it to the town's entrance. Two towns ahead the knocking from the ambulance back was the signal for Don Anselmo to stop, and for Sanchez to go to the back and check on the patient. The mother was laying on the ambulance’s gurney with the baby girl lying on her chest both wrapped around several blankets. The baby had lost the red skin tone she had upon departure and was turning pale blue. That's why Esmeralda had called him.
The girl was doing small episodes of apnea. Her breathing was stopping sporadically. He checked the girl's chest. "The heart is still pumping though. That meant the cause was most likely low blood sugar. The baby hadn't been fed. Of course there was no way a baby this early could be breastfed. The muscles in her throat weren't strong enough. And without venous access she it couldn't be supplied in any way... don't think about it! Just keep going and deliver the patient" he thought while getting the mask-bag ready. He would have to mask-bag her all the way to Junta city. He also started showing Esmeralda how to do it. He knew if the baby's heart stopped she would have to be the one doing the ventilation.
He told Don Anselmo at the beginning of paved roads to drive as fast as he could. The back of an ambulance is a cruel and unforgiving place. Everyone in the hospital always wondered how it was that Esmeralda never got dizzy. After the first 30 minutes Dr. Sanchez was starting to get a little light-headed when he noticed the heart of the baby girl stopped and she started to turn blue again. He checked with his stethoscope, nothing. This was it. The baby girl was clinically dead. According to the country's law the ambulance was an extension of the hospital. Legally they were in his hospital. He could declare the patient dead and turn back home. Fill in the death (and birth) certificate and call it a night. "I didn't bring this girl all the way here to surrender in the way" Once he had decided to leave his hospital he was determined to go to the last consequences. "She's coding. Esmeralda, ventilate when I tell you." He said as calmly as he could. He wrapped his hands around the little baby girl's torso connecting both his thumbs over her sternum in the center of her chest. And his other four fingers connecting in the back of her spine. "One, two, three, ventilate!" He said pushing the baby girl’s chest one and a half inches each time and waiting for Esmeralda to ventilate. Miriam, the mother, started crying as her daughter was being given CPR right on top of her chest. He told Don Anselmo to take a detour to El Bocado a nearby town with a hospital fitted with an OR. Though it didn't have a NICU. They had a pediatrician and a transport incubator. And they were one and a half hour away from their position, one hour less than Junta city.
He remembered he had told Don Anselmo not to enter the hospital with the siren on. When he was an intern the sound of the siren of and ambulance approaching the ER would cause stress in him and his co-interns. Which then would be followed by anger when they realized it wasn't a critical patient. In his OSS, when he delivered stable patients he tried to avoid angering this colleagues from the receiving hospital. It would make both his and their job easier. This time he told him to enter the hospital sirens blazing. This was as bad as it could get. "One, two, three, ventilate." He kept directing.
All of the sudden the girl started turning red again. "Oh my God!" he thought. He stopped compressions. Her little heart was moving. "Holy shit it actually worked!" he thought. Though she wasn't breathing. Her heart was pumping again. She was back. He went back to ventilating as Don Anselmo said "we'll be there in ten minutes"
When the ambulance stopped in the ER Sanchez told Esmeralda "go to the CPR-room and very calm and softly tell them we have a coding patient". He had always hated the shouting a CPR could cause. It only stressed the team further.
After he got the patient off her mother and into a CPR-room gurney. The first thing he saw was an eagle-eyed young physician staring him down from the other side of the room. "Is it alive?" he said with a very incisive tone. Sanchez simply pointed at the moving heart in her chest. The physician signaled the rest of the staff to come. They plugged the heart monitor into the baby. They did have the right equipment to do it. The physician looked at Sanchez "Will you intubate her, or shall I?". His face did all the talking. Sanchez signaled for the laryngoscope. "1100 grams that's as small as they get... It was the first time he intubated a pediatric patient, much less a newborn, much less one of this size. But he was at the helm he was responsible. He hadn't snatched this baby girl off of Death's hands to pussy out in the last minute. At the first attempt he saw the vocal cords and placed the tube. The respiratory therapist helped him fixate it.
The pediatrician got a venous access and started IV nutrition. She covered her body in pressed cotton and laid her in a bed of microwave-heated saline bags inside the transport incubator. "Fuck! I could have done that" he thought. They left the mother in that hospital for further tests. She was probably going to need a couple days of IV antibiotic. They provided Sanchez and his ambulance crew with a neonatal pulse-oximeter. He could now know how much oxygen the girl was getting and her pulse. At about fifteen minutes past midnight they left for Junta city.
The trip to Junta city though uneventful, was no leisure ride. They had to stand up all the way there because of the height of the incubator and take turns at mask-bagging when their hands got tired. Sanchez saw the lights of the city and thought that she could actually make it. Though he didn't want to think of the consequences of severe oxygen deprivation in such a young brain. He was starting to believe she could make it.
Next thing he heard in the dizzy haze the back of the ambulance had gotten him was Don Anselmo's voice. "We made it, Doctor!" As they arrived in St. Michael's ambulances parking lot. He told Esmeralda to go get some help to unload the incubator, it was heavier than an adult patient. Yet she obtained no response. Don Anselmo asked for help as well but to no avail. The baby's oxygen saturation was dropping, she was getting less oxygen. Sanchez thought he and Don Anselmo could get the incubator down while Esmeralda minded the patient and helped from the inside of the ambulance. The incubator was heavier that he thought and he had overestimated his strength. The incubator lashed as it was being brought to the ground. But he just kept moving it towards the hospital. The beeping of the pulse-oximeter let him know what has happened. He went to check the equipment and realized the tube was outside the baby. Despite the fixation done in "El Bocado". In the backlash getting the incubator down from the ambulance he had extubated the patient. Oxygen saturation lowered to 72% and Sanchez turned white as paper. He simply couldn't believe it. Everything turned to slow motion. He wasn't really listening to the people around him. "YOU HAD ONE FUCKING JOB SANCHEZ!!! As if the baby girl hadn't gone through enough already, you dipshit!" He thought as he entered the ER with his patient. He could only see the ER physician yelling at him in slow motion. Her plump face, her brown hair, her green eyes, her short stature, her bewildered expression, and the sweating in her forehead as she yelled at him. "I accidentally extubated the patient while unloading the incubator from the ambulance. No one came to help us. We had to do it ourselves" He said in a flat manner still white as snow. The entire ER staff stared at him in disapproval. He continued mask-bagging the patient.
Five minutes later were the Neonatologist and her resident there. Both young tall white skinned and black haired they looked like older and younger sisters. They were the only ones not to stare-down Sanchez with contempt. Their expression was compassionate, almost maternal. They intubated the patient again. Actually had to do it twice since the first time the tube was too small and air leaking could be heard. He saw the pre-readied tube fixings they had handmade themselves. Preparation was the key to success. After the baby girl was intubated she was moved to the NICU and the resident proceeded to ask Sanchez for the patient’s history. He explained all that had happened. She showed empathy towards him and treated him very nicely, almost maternally. She congratulated him for his ordeal and thanked him for the information.
They left around 2am. They had to go back to El Bocado and return the incubator and other equipment to the hospital. And then ride through the mud-trail back to Tizquezoque. Sanchez briefed Dr. Joy his boss, the hospital administrator, on the way. She cancelled his consult for the next morning. She was the best administrator he had seen in his short career. Most administrators would have expected him to arrive and do normal consult duty. But Dr. Joy wasn't the case she led by example and did so humanely. Just the fact that she was up at the time and ready to answer the phone was prove of her uniqueness among those of her rank.
They arrived at Tizquezoque at 8am. Sanchez fell asleep in his Inn room immediately. Next thing he heard was the ringtone of his on-call cell-phone still with him. It was 1pm already. "Sanchez here, hello" He said still barely awake. "Dr. Sanchez, I am sorry to wake you but we need you to log the patient’s birth certificate into the system, they are discharging him from St. Michael's" Said Dr. Joy. "Discharging?" Replied Sanchez. "The patient passed away, Doctor" said Dr. Joy, in the usual niceness of her voice with an undertone of sadness. "Oh, OK. I'll be right there." Said Sanchez blandly.
Perhaps he himself killed that patient the moment he decided to take her in, instead of fighting over the phone with that physician from Murcia. Perhaps she killed her when she decided that she was Sanchez's patient not hers. The Scientific-Technical Committee (quite the euphemism for a kangaroo court) will conclude that it was Sanchez's inexperience with Pediatric Advanced Life Support and improper neonatal patient transportation skills that were to blame for the patient's death. But this conclusion was merely technical neither legal nor disciplinary action was taken, just an "improvement plan" was suggested.
"Medicine is a profession of means" he remembered. The patient was dead. Yet he felt happy. He felt fulfilled. He had the reassurance of having done everything. He had offered his best. Yet it meant nothing. His best efforts made no difference. But despite that he felt happiness.