"Ronnie," I say, a little louder than is natural, "Ronnie, I'm going to brush your teeth now."

Ventilator-associated pneumonia is a big (in the words of Joe Biden) fucking deal. It can be prevented with careful deep suctioning and good mouth care. And good mouth care is what I'm doing now.

Once during the shift, I use a toothbrush connected to suction. Twice during the shift, I deep-suction and swab.

This patient is younger than I am, with no risk factors for laryngeal cancer. The surgeons had gone in, expecting to take a biopsy, but had ended up having to take her whole larynx. She was a singer, before. I was a singer, before.

I shake off the associations and continue. I've already turned up her paralytic drip so she won't bite down on the brush. "Ronnie, here comes the brush. I'm just brushing your teeth, okay?"

I hate it when nurses end their sentences with the word "Okay?" I prefer statements: We're doing this, NOW. You're going to get out of bed. I am going to brush your teeth. But this time, I say, Okay?

She grimaces, but she doesn't have the coordination necessary to bite down on the toothbrush. For a long two minutes, I scrub: it's important to get the mouth bacteria off the teeth before I suction, to make sure they can't migrate past the endotracheal tube cuff and into her lungs.

"Ronnie, I'm going to suction you now. If you cough, that's okay; I can take care of that. Go ahead and cough. That's right; good cough. Give me another."

I suction under and behind her tongue, then grab the suction connected to the ET tube to suction down further, where her cough might've brought up some garp.

There is a boom-box in the corner playing her favorite music. She was a contralto, unlike me: I sang early music, with the occasional foray into Britten and the moderns. She sang the Magdalen in cantatas and led her church choir's alto-section woodsheds. I sang songs that nobody really knew the rhythm to, they were so old. She sang songs that had been written down long after the ones I sang had passed on.

They took her larynx, and left her her life. Whether or not it's a life she would want, not being able to sing, is not my problem. It is not my problem. I shake off the associations and move on.

There's a lot of crap in her lungs. I get a whole load of it out, then give her a break. I turn up the Versed, so that she won't remember any of this, and get the hell out of the room. I don't sing to my patients any more; they're generally not sick enough.

Back in the day, when I was in school, I sang to premature babies. It was my last semester, and I was constantly exhausted. The nurses would find me a pair of twins, or a baby who was so premature he looked like a monkey, with hair all over, and I would button them or him into my uniform top and lie back in a rocking chair. I'd sing them to sleep, and myself to sleep, with songs from "Jesus Christ Superstar" or "Fame" or the things the troubadours sang in the 1300's.

Since then, I have sung once, to one other person, outside the hospital. "Oh, wow, man/I ain't complainin'/Only thinking out loud/My life would've been different/If I knew then what I know now..."

I hope she can turn her singing voice into something else.