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Life Lessons in the Pediatric ER
By William Bonadio
St. Martin's Press Copyright © 2000 William Bonadio, M.D.
All rights reserved.
OCTOBER 15, 1998
THE EMERGENCY ROOM
The ER winds down, like a wobbling top. The last patient is discharged home—at least for now. Still six more hours to go on this overnight shift. But for now the lights are dimmed low, as nurses brew more coffee and riffle through magazines to pass the time.
Will I get to rest a bit?
A cold chill always runs through me at about 3 A.M. It's the "night-watch" chill. We all get it. Drags on you, makes it difficult to finish an overnight shift. I can abort it—artificially—by taking coffee. A "caffeine push" is necessary at 3A.M. when the ER stays busy, to trick the gears of your body through it; but you pay a price later on, because then you are nauseated for the next twenty-four hours. Or, the chill will resolve itself—naturally—if I can get some sleep during a lull like this, to let my internal clock reset to a new day.
I move out of the ER arena to the adjoining physician on-call room. Go through an outer door—connected to a short passageway—then through an inner door. Now I am in. It's cold, and darkly quiet inside, with no hint of ventilation. Don't need much to furnish an on-call room—just a telephone, a pillow and blanket on a plastic-lined mattress.
You realize just how tired you are on an overnight shift after closing your eyes in a dark quiet room. It doesn't take long before weariness gives way to subtler shades of drifting. Everything is small, then big. I am joined to it, but not completely gone over yet. Then the boundaries of self begin to merge and fade, like drifting smoke from the lingering ash of a cigarette. ...
And then it was my turn. It was early morning when the nurse came in to get me—I thought it was still night time, with the street so dark and quiet outside my hospital window. Saw her shadow above me rolling back the netting over the bed top, pushing down the side rail. She whispered, It's time to go, today you get your tonsils out. I obediently got upright and pulled the rope belt tight on my pajamas up around my chest, and put on my robe and woolen slippers. Didn't even think about being hungry or tired. Then there were two nurses, and they took both of my hands as we went down a hallway into an elevator. One of them said—Push the button with the 4 on it. We went up fast, and stopped. The doors opened. It was quiet there—quiet and darker; the air smelled antiseptic. The floors were cold and hard, speckled like marble. We walked fast down another hallway; they held my hands tight going through swinging doors into a room with big people all around wearing masks and hats and white robes. I panicked when I couldn't see their faces, kicked hard to get away, but they grabbed me all over and I was floating and laid out flat on a high table. The big silver dish of bright light overhead burned my eyes. There were hands all over me now, holding my arms and legs and head, forcing me. Then a black cone came down over my face, hard and snug, and I couldn't breathe through the bitter hissing gas—I was choking, and it seemed I struggled out my last to get free. And then a man who was upside-down over me said, Don't worry just count to ten. There's a ringing in my ears, like a bell under water. I struggled out my last it seemed, sure that I was going far away alone and would never come back; then it all blurred, and the last of my strength was gone, so I gave in. I gave in. And the last thing I remember is how easy it was, to let go—how peaceful it felt, to finally pass over. ...
Ringing ... in my ears ... like a bell—
"We need you out here—now."
The voice on the other end is ... emphatic about this. I have to stay with it. Yet can't quite place where I am, or how I got here—
"What's wrong?" I ask.
"Motor vehicle accident. Child hit by a car."
Stark consciousness is jerked all the way back. Yet even with my eyes wide open, everything around me is still deep in black. I can't see my hands in front of my face—
"Are they here now?"
"No, not yet—three minutes out," the voice says.
"It's serious—the paramedics sounded panicked over the radio. We only got part of their report."
"What time is it?"
"Just past seven. We need to get set up. Now."
Now ... it echoes like a rifle shot through my brain, as I grope to replace the phone on the receiver. Then pause in the motionless dark. Just past seven. It always takes a moment to accept that yes I do have to get up, it's my shift, my watch ... then recruit the same automatic reflexes to fight back the temptation to doze again.
My neck and back are stiff, as if I've been down a while; I have to push my forty-three-year-old body through it, quickly, but in degrees: Sit up—shoes on—stand, straighten up, steady—shuffle forward—grope for the door handle—open the inner door. I reenter the dark passageway, the floor lit by flames of white light streaming in beneath the outer door. I hesitate to open it, anticipating the painful assault on my unprepared eyes—and then a searing white intensity beats upon my consciousness. ...
There is only one thing I'm looking for—and I spot it, peripherally at first: The pattern made by the hectic pace of others, which indicates an impending crisis is coming—now—from somewhere.
The team rushes to their preassigned positions in the glaringly lit resuscitation room. Nurses, a respiratory therapist, several aides, and a pharmacist all scrambling at their posts to prepare—overhead lights are focused, machines whir into calibration, the cardiac monitor scintillates, IV pumps and tubes and fluids are readied.
The sliding glass doors open down the hall.
"Looks bad—they're moving fast!" someone calls out.
I know what that means. You get an early gauge on the prognosis of an injured child coming at you by the body language of the paramedics. I can see this crew far down the hall, quickly wheeling their load toward us like panicked pallbearers; shuffling sideways, stiffly hunched over their burden, looking down instead of straight ahead. I can hear the thud of their feet running. This is going to be bad. Now going past the empty waiting room area—and it's an all-out sprint. Did something just get worse? I can't tell, looking from this far away. The fluid bags and connecting tubes hanging above the stretcher clank in unison, like rigging on a ship's mast in a heavy wake.
"Should we call for a surgeon?" someone asks.
"Not just yet. Let's wait and see what we have here." You learn the hard way that too many hands can be just as ineffective as too few. There is time to call for their help, if we need it—
A last-second check—all the equipment is set up; everyone is in position. Just a bit longer. ... We stand in place, and wait to take it on. The resuscitation room is warped with tension. I can't feel myself inside the way I normally do. The rhythmic beep of the monitors on the stretcher rolling toward us intensifies. They've almost reached us now ... then we grasp the baton, and run our heat with it.
I scan the faces surrounding me. There is no response to my rhetorical question, since no one knows quite what to expect. We've all been here before; yet each resuscitation is an unprecedented event. Which is why your chest feels tight and your hands shake. All you can do when this kind of reality comes at you from down the hallway is stand in, and take it on.
The paramedics rush headlong through the doorway. It's a young girl lying on the stretcher, wearing what was a white dress. We all strain to see, like wedding guests viewing the processional. Her clothes are sopped thick with blood. She has only one shoe on; the other foot is bare. I can see her left hand lying open at her side—the right is heavily wrapped in red-stained gauze. Surely I've felt tender hands and feet like these many many times before. But this is different—because there is no strength in her limbs, and because of the wet and dried blood staining everything.
The paramedics frantically steer the stretcher carrying the lifeless body up alongside the ER resuscitation table. They dock.
"Make the transfer—let's go!"
Four sets of hands hastily reach in to grab a side of the undersheet support.
"One, two, three—lift!"
Now she has passed over to us.
"Link her up!"
More hands reach in, to untangle the tubes and bags and wires, disconnect them from transport mode and reconnect them to our life-support system.
My first impression of her condition is the most important predictor: Does she have any fight in her? Will the birth-cry force of life reassert itself? But so far there's been no movement to her, none at all.
Despite the frenzy of it, her transfer to us was orderly. Each is doing his or her part, working together. My basic instinct is to jump at it—reach in both hands, take full control of the situation by doing everything myself. But to be most effective, the captain of the resuscitation team must stand apart, stay at the foot of the table—decipher the overall evolving pattern, direct the action and delegate to others.
A nurse with big shears is frantically cutting away the girl's clothing—her dress, tights, T-shirt, underwear drop wet to the floor. The skin beneath is so white, she's bled all the color out of it. No question we need more help—the calls go out: Surgeon, orthopedist, anesthesiologist, radiologist, intensivist—to ER!
The paramedics helplessly stand back against the wall to watch. One gives us report in a trembling voice: "Six-year-old girl—struck by a motor vehicle—crossing the street to school—"
He can barely keep up a full breath through the telling. I can only mind him with one ear, listening for any bit of information that might help to direct our attack, filtering out the tenor of his fearfulness as we continue to press on.
"At the scene she was unconscious, remained unresponsive during transport ... shallow respirations—thready pulses and low blood pressure. Pupils fixed and dilated. Large laceration to the scalp, bleeding from ears and nose, distended abdomen. Major injury to the right hand. ..."
Enough of this. I can see it all before me. I've heard enough to take over. We need to move on.
"The mother was notified by the police and is on her way here."
That sticks deep. And this is her argosy of pearls.
The team needs to be given clear, strong direction. Measurements must be taken; priorities established; therapy administered. There's so much ground to make up here. I check the start time on the clock—
"What are the vital signs?"
I snap out this first order as decisively as possible, to focus the efforts around me into some cohesion. So everyone knows exactly where the orders will be coming from. And to conceal my private misgivings: That there may already be an answer to the question which everyone here is surely asking themselves.
Numbers are the only comfort. They sanitize a medical emergency, allow it to be addressed objectively, dispassionately. I can treat shock more effectively than this little girl's shock. We will do our best for her if we don't feel for her, treat the problem instead of the person lying beneath our hands.
Her chances for survival hinge solely on the arithmetic, so I quickly take measure—heart rate, respiratory rate, blood pressure. I automatically tick it off in my head: Spontaneous movement—none, effort to breathe—none; palpable pulses—none; heartbeat—none. I've seen this null-pattern before—it's very, very bad. But there is a chance—if we can somehow find a way to recruit her languished strength to help us bring her back. It's happened before in this room. We must do it all for her now—rely on the science and medical protocols—then either it is in her, or it isn't.
One at the head of the table pumps oxygen to her shattered lungs through a breathing tube placed in the windpipe.
"Are we ventilating?" I ask.
"Both lungs, equally."
Another to the right of the table manually compresses her chest up and down, to circulate blood.
"Are there pulses with compressions?" I ask.
"Minimal—femoral pulses are barely palpable."
Several others are busy starting an IV.
"How many IVs are in?" I ask.
"Two. Two now. We're working on getting a third. What fluids do you want?"
This girl has lost a lot of blood. Even though her circulation is emptied, she's still bleeding from her mouth and nose and ears. There's no time to do a type and cross-match. She needs O-negative red cells—now.
I order a "round"—intravenous fluid and medications and a transfusion given in proper dosage and sequence, to fill her emptied circuit and charge it back into motion. The pharmacist quickly measures each, draws them up into syringes, passes them to the administering nurse; all are pushed through the IV with trembling hands. Continued ventilation and compressions. In a moment we will withhold support to gauge the effect. Either it is in her or it isn't.
We stop—everything is suspended for a moment—and peer at the monitors: There's no blip across the screen, no beeping sound; and still no movement to her.
We begin again—ventilation, compressions; after a few minutes, I order another round given.
We stop again—still no activity anywhere.
We start again, and repeat—this round, I order ten times the usual dose of adrenaline; a last-ditch effort to reach her stilled heart and jolt it into beating again. It is quickly pushed through the IV. After a few minutes, we hold to reassess. There is nothing, we are nowhere. So we start again.
As brave arms pull, dip and pull the beating oars, a silent black vapor overhead is sweeping the skies. And this young girl's mother is on her way here.
After three full rounds, it's time. For me to move up to the head of the bed. Just her and me negotiating this now. I retract the girl's eyelids; beneath it's lusterless, the eyes are marbled and vacant—raw, like uncut jewels. They move in blank unison like a play-doll's when the head is turned side to side. I focus a light beam into the corneal windows—her pupils are widely dilated, fixed in size—gaping, as if the tenant spirit was already released from within, had already passed. There's a perfume in her hair ... beneath the coagulate her skull bone is crepitant, like a cracked eggshell.
The specter of death is here. It stalks the tall grasses on silent haunches, assured of its speed and strength. Yet we will persevere for the full interval—continue to press with what we know and what we have—apply external pressures and infuse corpuscular blood and artificial chemicals and bottled gases to try to push it back, to at least forestall the pronouncement. ...
We've been pressing hard to bring this little girl back now for over an hour. The first lab reports are just in; a crucial blood test confirms it—that her system has been shut down far too long. After receiving six full rounds of drugs, she shows no sign of any effort to breathe or heart to beat. Her blood pressure has plummeted to zero. The electrocardiogram traces the cold dark line of the horizon.
Individually—silently—collectively—we are resigned there will be no resuscitation here.
But when to cease, and let go? How long to keep at it? If we keep at it, could a miraculous thing perhaps take place? Can Divine Benevolence rectify Its mistake, and enable this young heart to pump out a line of warm red life again?
All of my knowledge and experience says no. Yet we are her only advocates. All are waiting, standing on the line. It's my turn to speak.
"Let's call it."
And with that, the formal pronouncement of death is made. Legally, it is the moment in time at which a licensed physician deems futile any further attempt at physiologic resuscitation. Metaphysically, it is a speck on a continuum; and we are merely porters.
Each of us peers deep into the blank monitor screen one last time, as if it might also tell why. The room is slurred, dimensionless for a moment. Then the certainty of science is relinquished. Surgeon, orthopedist, anesthesiologist, radiologist, intensivist; clergy. Now the individual parts of this case, which we tried to objectively isolate and deal with separately, are coalesced back into a whole.
The monitor scintillation effervesces away. Machines are switched off, disconnected, rolled back into the corner. It seems whenever we reach this point no one looks at each other. Is that broken glass on the floor? You think of the closest thing this could be to you—a neighbor kid, a niece, even your own daughter. ...
Excerpted from Julia's Mother by William Bonadio. Copyright © 2000 William Bonadio, M.D.. Excerpted by permission of St. Martin's Press.
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