Prologue

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InIt was an uncommonly difficult intubation. Ian's left arm burned and ached from fighting with the laryngoscope; the only time he had thought he'd seen the vocal cords, his only landmark in this red, slippery mess, they had immediately dropped from sight; and when had he passed the tube anyway, it had not gone into the trachea; it had gone into the esophagus. Twice he had had to go back to using the BVM, the Bag-Valve Mask to ventilate his patient, to force air into her unbreathing lungs, and into her stomach as well, for the mask could not discriminate between the two. And here was Death, standing over his shoulder again, impatient with him to be done with it already.
In"Okay," Ian nodded to the firefighter working the BVM, and as the firefighter lifted the mask from the patient, as the EMT stopped her chest compressions, Ian went back to the soft, cramped, wet tunnel of his patient's throat. He had changed his straight, thin Miller blade - supposedly designed for this type of patient but for some reason useless here - for a wider, curved Macintosh blade, and with this he swept the patient's tongue to the left, lifted her jaw open and her head up as he resumed his search for the vocal cords. The cords guarded the entrance to the trachea - the windpipe - and unless he saw them he couldn't be sure that he wasn't in the esophagus again. Indeed, he was more likely to be in the esophagus, as that was where the anatomy naturally led.
In"Crichoid pressure," he said, and the EMT - Karen, for that was her name - leaned over and pressed softly down on the hard cartilage of their patient's Adams Apple, forcing the trachea down toward the searching laryngoscope and at the same time squashing the esophagus closed. Still, the cords refused to appear. He struggled with the anatomy for another moment, then shook his head and withdrew.
In"Screw it," he said, tossing the laryngoscope aside and twisting himself around to kneel beside the patient's head. He stuck his gloved middle and index fingers into her mouth. In his mind, he watched his fingers creep along the patient's tongue and beyond, slipping on the floppy half-rigid form of her epiglottis (kind of like a wet ear, thought the part of his mind that wasn’t taken up with the dire nature of the situation), and lifting it open to reveal her trachea. With his other hand, Ian threaded the tube into her mouth and between his fingers, against the epiglotis and down. Holding the tube still, he removed his hand from her mouth.
InAn umbilical cord ran from the tube to a small blue pilot balloon, about the size of a dime. Earlier, Ian had stuck an air-filled syringe into a port on the balloon; now, as the firefighter fumbled to disconnect the BVM’s bag from the mask in order to connect it to Ian’s tube, Ian squeezed the plunger into the syringe, inflating the pilot balloon and inflating the cuff around the far end of the endotracheal tube, deep in the patient’s throat, and sealing the tube in place.
InThe firefighter was already squeezing his bag. Ian pulled the syringe free from the balloon and glanced at the index numbers printed along the side of the tube: number 21 rested against the patient's lower lip. The tube was size seven; three times seven was 21; the tube was probably in as far as it should be. Nevertheless, he leaned over the patient with his stethoscope, listening at her stomach for the gurgling that would mean the tube was in the esophagus: the abdomen was silent; then over each lung for the movement of air.
InHer lungs sounded clear and equal, and Ian taped the tube in place. He glanced at the heart monitor, which still showed the angry picket-fence pattern of ventricular tachycardia; checked his IV; and felt again at the patient's neck for a pulse: nothing.
InThe defibrillator was already set to 360 Joules (its highest setting) from his earlier attempts at defibrillating the patient. He charged it and pressed the paddles against the patient's chest and began his chant: "shocking. I'm clear," he glanced down to see if he was touching the patient. "You're clear," the firefighter had disconnected his bag and squatted safely away. Karen stopped her compressions and backed off. "All clear," he checked himself again, then "shock 360," and he pressed each of the ‘shock’ buttons, one on each paddle, discharging the defibrillator into the patient's chest. No change on the heart monitor. Even as she arched her back and lay flat again he was pressing the charge button and recharging the defibrillator. "Shocking," Ian said again, "I'm clear, you're clear, all clear, shock 360."
InDeath had started to pace between the far corners of the bedroom; this was taking far too long. But Ian was not ready to give up. "Shocking," he said for a third time. "I'm clear, you're clear, all clear, shock."
InAnd the third shock did it: the tracing on the EKG monitor changed, and suddenly everyone heard the loud, incredibly loud "beepbeep, beepbeep, beepbeep," of bigeminy – not a normal rhythm, but ten times better than the pulseless v-tach he had started with.
In"Is there a pulse with that?" Ian shouted over the beeping, not waiting for an answer before pressing his fingers against the patient’s throat. Her carotid artery throbbed against his fingers, two beats at a time, in time to the beeps of the monitor. It was not strong, but it was definitely there. Was she breathing? He watched her chest for motion; turned his cheek, held low over her mouth and nose for the soft movement of her breath, and listened for the sound of moving air: nothing.
InIan shook his head and sat up. The firefighter reconnected his bag to the ET tube. "One out of two isn't bad," Ian said, turning to the monitor to reduce its volume and finally sitting up in bed, fumbling for the alarm clock, and turning it off. The sound was reclassified: it was the clock, of course; and Ian dropped his feet down to the floor, rubbed his eyes, and held his head in his hands. It was time for a new day. It was time to go to work.

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