YOUR FIRST PEDIATRIC INTUBATION | Rachel Kowalsky
First, eat a meal. Then kick your dragons to the curb. The dragons of your self-doubt, my dear! You rode them all the way here. Have you read the chapter? That will help. Let’s go.
1.Dress
in a plastic gown. Gather your endotracheal tube, laryngoscope, suction, stylet, syringe, pink tape. Connect the child to the monitor, the IV to its tubing, face mask to blue bag. Ask for medications early, and dose with care. Never do math in your head.
2.Take your place
as per the diagram. You at the head, team leader at the foot, nurses to left and right. Chest compressor at the chest of course, and hope that you won’t need them. Tech there, clerk there, x-ray here then there, scribe, pharmacist, parents. You’re in a circle of people; at its center, one child. You can process this later.
Or now. You can process it now. Bright room, many people, small child. OK, that’s enough.
3.Position
the airway. Lift the child, slide a towel beneath the shoulders. Ease the head back, chin up, good. Now the airway is ready, sleek and straight as a tunnel. Don’t cut off the clothes, this is not a television show. Ease them off and hand them to the mother. Unless they are bloody, then cut them.
4.Preoxygenate
This buys you time in later steps. Push air through the tunnel to the lungs. Consider your career choice, and what tunnels are for: shelter, escape, crossing.
I crossed too. Story, body, ocean, grief—to get here. Flew in on the back of a dragon.
5.Maintain
situational awareness: you now stand in a circle of love. It’s an awful cliché, but allowed in this context—life and death—another trope we invoke all day. Don’t worry too much about all this, the time-worn language, the circle, mortality. You’re just the airway person.
6.Write
love letters on the walls of the room, the back of scrub caps, the Breslow measuring tape. Take the mother’s hand, draw her closer. Watch for dragons in the corners of the room.
7.Wrangle dragons
I’m sorry to say the dragons are here, those minstrels of your obstinate self-doubt. They’ve been exorcised, banished, left for dead at the side of the road, but this room, the trauma bay, is their last stronghold. Their silver and green scales are stunning, but don’t look. Don’t think about the boys on the bus, the filthy song they sang, or the one who scorned your love. Blow up the song in your mind. This room is a speck on a turtle’s back. Think of the loves you have known.
8.Speak
loudly and clearly: nurses, doctors, faithful pharmacist, we are going to sedate now. Tell the scribe too. It’s a wonderful word, scribe. A listener with a plume in hand, paid to bear witness and write it all down. Where did this story begin?
9.Focus
despite the ghosts who haunt your circle: Noah’s sister, Inez’s son, Sara’s ex. They all hover at elbows and hang on shoulders, it’s a problem. Remember when we talked about (sorry) love? Send some to Noah, Inez, Sara, and obviously the scribe. Ghosts may only speak when spoken to, so don’t do that. The room is crowded now between the people, the dragons, and the ghosts. Focus.
10.Pass
your scope, lift it up, behold the illumined airway. The white V of the vocal cords pops into view. Relax, smile, tell a joke. Dragons hate jokes, they cringe and sulk in their corners. Pass the tube through the cords. Tape it in place with the pink tape. It’s got to be pink, I don’t know why. You’re full of questions. Listen for breath sounds.
You thought you were done, but it’s tricky— such stories don’t have endings. Choose another beginning, like wheeling your patient to the ICU. The ghosts will follow, you know that much. The dragons will try, but they’re too large to exit the room. They live there, in the trauma bay. Like you, they have the inconvenience of a body. The blessing and the agony of a body.
Rachel Kowalsky is a pediatric emergency physician in New York City. She is a Pushcart Prize nominee and winner of the New England Journal of Medicine’s fiction contest. Her work is in The Atticus Review, JMWW Orca, JAMA and elsewhere.