"Please not yet! I'm scared!!!"

Those were the last words my patient spoke before we induced her and intubated her. The first patient of my call day last Sunday, she was a transfer from a small rural hospital. Like other unfortunate transfers I've received from this hospital, this one was in a state of "crumping." Her worsening repiratory distress and acidosis meant we didn't have long to get the breathing tube in her. But she was emotionally distraught and just wanted us to wait for her daughters to arrive. In this situation, emotional distance from the patient allowed us to save her life while we could: within seconds, the sedating medicine coursed through her veins and she drifted off to a peaceful sleep.

But the intubation wasn't to be that simple. After another intern tried twice unsuccessfully, the pulmonary attending stepped in with an armament of fiberobtic equipment and years of experience. I knew we were in trouble fifteen minutes later when he stepped back, looked at me, and said, "Hey Jonathan, do you want to try this?" Sure, he knew I was going into anesthesia and had slipped a breathing tube down many a patient's trachea, but this was an attending stepping aside to let the low man on the medical totem pole try! Despite my best attempts at laryngoscopy, all I could find was swollen soft tissue, bloody secretions, and a floppy epiglottis. An hour after we induced the patient, we finally secured the airway by using a device called a "fast-track laryngeal mask airway" which allowed us to blindly place the breathing tube.

I quickly slipped in a central line, and around the time we were going to check the patient's central venous pressures, she went into a pulseless ventricular tachyarrhythmia. Four shocks and an amiodarone bolus later, we had a rhythm and a pulse. Not quite what you see on E.R., but close.

The nice thing about a private hospital is the ease of recruiting specialists' expertise. In addition to the primary team, within a couple hours we had the assistance of pulmonary, cardiology, and renal services. Within a day, thoracic surgery and hematology/oncology were lending a hand.

The problem with the patient? It was a football-sized mass growing next to her heart. After we'd stabilized the patient, I went out to visit with the ten or twelve family members in the ICU waiting area. I stressed that at this point, we were doing everything we could just to help her live through the night. We could make no guarantees. This was their mother, their sister, their wife, and with tears in their eyes they accepted that she might die that very night. A niece caught me by the hand as I turned to leave the room. She looked into my eyes, and then studied the floor as she spoke, "Excuse me, doctor, but are you, um, a believer?"

"Yes, I am a Christian," I told her. Realizing that this family was teetering with their loved one on the precipice at the edge of life itself, I stepped back into the room. I told them I believed in a God who is both loving and who is in control. And holding hands as we formed a circle, I prayed with them. I could offer little hope, but I could point them to Him who could. I could make no promises and offer very little assurances, but I could turn them to the source of peace in the valley of shadows.

* * * * * *

Today, two days later, I found out the tumor is an aggressive cancer. The pulmonologist called me at home to let me know. I don't know what the coming days or weeks hold, but I suspect she may never get off the ventilator. And I think back to those first moments when the patient was alone without her family and frightened. Her last words still echo in my memory: "Please not yet! I'm scared!!!"