Holding his hands up, Noah began scrubbing his forearms as the final part of the process. He was close to finishing when the intercom system suddenly came to life. A disembodied but urgent voice called out: “Code blue in OR number eight!”
Nearing the end of the scrub process but continuing to keep his hands aloft to avoid any potentially contaminated water from running down onto them, Noah took a step back from the sink so he could look in the direction of OR 8. Almost immediately, a couple of anesthesia residents appeared, running toward the room in question. One was Dr. Brianna Wilson, pushing the cardiac crash cart with a defibrillator as well as a collection of medications and other equipment. The other resident was Dr. Peter Wong, who pushed a second cart that Noah was later to learn was specifically for difficult airway-management situations.
By reflex born of a willingness to help in any emergency, Noah tossed his scrub brush into the sink and took off toward OR 8, realizing that it was one of the rooms in which Ava was supervising either a resident or nurse anesthetist. He hoped that she wasn’t involved directly in another major complication, knowing just how emotionally traumatic the Bruce Vincent case had been for her.
Using his shoulder to push through the OR door, Noah kept his scrubbed hands raised just in case he was called on to jump into the operation. Just inside the door, he paused to assess the situation. The ECG alarm was going off and the monitor showed ventricular fibrillation. The pulse-oximeter alarm was also going off, adding to the cacophony in the room and urgently announcing the blood oxygen was low.
The patient was a significantly obese Caucasian woman who Noah would later learn was a thirty-two-year-old mother of four named Helen Gibson. Instantly, he could tell it was an emergency trauma case. There was a compound fracture of her right lower leg, suggesting an auto accident of some kind. A bit of bone protruded through the skin.
Ava stood at the head of the table. She was struggling with an advanced video laryngoscope, trying to intubate the patient, who Noah could tell was not breathing. To Ava’s right was a first-year anesthesia resident named Dr. Carla Violeta, who attempted to aid Ava by pushing down on the patient’s neck at the point of the cricothyroid cartilage. Normally a bit of pressure at that location would make the entrance to the trachea easier to see. The problem was that a second anesthesia resident was giving external cardiac massage by forcibly and rapidly compressing the woman’s sternum, causing the entire body, including the head, to bounce around. Getting an endotracheal tube into a difficult-to-intubate patient under such conditions was almost impossible. Noah could tell the patient fit the difficult category by her head being tilted forward rather than back, suggesting a cervical neck problem.
The anesthesia residents who’d rushed in with the two carts were busy getting the defibrillator prepared. Standing to the side all gowned and gloved and ready to operate was Dr. Warren Jackson. Noah knew him all too well. He wasn’t quite as bad as Dr. Mason, but he was no polished gentleman, either. He, too, was an old-school, demanding, and temperamental surgeon who had trained back in the good old days when he apparently had been abused and now felt it was his duty to abuse. Noah could sense the man was irritated, as usual.
By some coincidence, the circulating nurse was Dawn Williams, who’d been in OR 8 on the Vincent case. Seeing Noah burst in, she immediately rushed over. “We got another doozie of a problem,” she said. “The first-year resident went ahead and tried to intubate the patient before Dr. London got in here. Dr. London was supervising another intubation in the next room.”
“Let me guess,” Noah said. “Dr. Jackson pressured her.”
“You got it,” Dawn said. “He was really on her case something awful.”
“Okay, clear,” Dr. Wilson called out. She was holding the paddles of the fully charged defibrillator and moved to the side of the patient. The resident giving the cardiac massage lifted his hands in the air. Ava stepped back from the head of the table, and Carla stopped pushing on the woman’s neck.
There was a distinctive thud as the defibrillator discharged. Simultaneously, Helen’s body lurched on the operating table as the electric charge spread through her and caused widespread muscular contractions. All eyes were glued to the ECG monitor except for Ava’s. She immediately reinserted the tip of the video laryngoscope and went back to trying to get an endotracheal tube placed.
Noah hurried over to Ava’s side while a subdued cheer arose from the residents who’d brought the crash cart. The fibrillation had stopped. The patient’s heart was now beating with a normal rhythm.
“What’s the problem?” Noah quickly asked Ava.
“We can’t respire this patient,” Ava shouted. “She’s paralyzed and can’t be bagged for some reason. And I can’t get an airway because I can’t see what the hell I’m doing.”
“It looks like her neck is flexed,” Noah said.
“It is, and it’s fixated. In terms of visibility of the trachea, it’s the worst I’ve ever seen: Mallampati Class Four Grade Four.”
“What the hell is Mallampati?” Noah said. He’d never heard the term.
“It’s a grading system for visualization of the trachea,” Ava snapped. Then to Carla she said: “Try pushing on the neck again. I almost had it a moment ago, before the shock.”
Feeling a rising panic, Noah glanced at the ECG monitor. He didn’t like the looks of it, fearing the heart was about to fibrillate again. He looked at the pulse-oximeter readout, whose alarm was still sounding. The oxygen level in the patient’s blood had barely changed. In fact, the patient’s color, which had been a slight shade of blue when he’d arrived, was getting worse. There was no doubt in Noah’s mind that the situation was rapidly deteriorating. To his right was the second cart, with various laryngoscopes, tracheal tubes, and other intubating equipment, plus an emergency cricothyrotomy kit that contained the paraphernalia needed to create a new opening into the lungs through the neck, bypassing the nose and the mouth.
With the same resolve that Noah had demonstrated when he’d stormed in on the Bruce Vincent case, he suddenly knew what he had to do. He snapped up the cricothyrotomy kit and tore it open. Without taking the time to put on sterile gloves, he grabbed a syringe outfitted with a catheter from the kit’s contents, pushing around to the patient’s right side, crowding Ava and Carla out of the way. Angling the tip of the catheter toward the patient’s feet, he placed its needle end into the depression below the patient’s Adam’s apple and decisively pushed it directly into the patient’s neck. There was a popping sound. When Noah pulled back on the syringe’s plunger and the syringe filled with air, he knew he was in the right place. Quickly he passed a guide wire through the catheter, then a dilator to enlarge the opening, and a moment later a breathing tube.