When everything has been done that could have been done – Vital Signs

When everything has been done that could have been done – Vital Signs – column

Perri Klass

The good thing about pediatrics is that almost all of your patients get better. The bad thing is that sometimes they die.

When I started my internship, I had never seen a child die. Not up close, anyway. Even in the hospital, children just don’t die all that often. My third or fourth night on call, I ended up at a code. There wasn’t much for me to do, since the little girl was already surrounded by seven doctors by the time I got there; I had been called to bring a new electrocardiograph machine, since the one they had was malfunctioning. So I wheeled the machine in, and then I hung around on the sidelines, wondering whether I could be of any help. But the work was all being done by experts; surgeons were putting in the IV lines, an anaesthesiologist was preparing to put in a breathing tube, a cardiologist was watching the electrocardiogram. There were other people hanging around, unwilling to leave while the child’s fate was still undecided, and it was from them that I got the story.

Six-year-old girl run over by hit-and- run driver. Brought into emergency room. Very badly hurt but seemed stable. They were taking her up to the operating room and she coded in the hallway. The resuscitation effort was heroic. Everything was being done that could possibly help, and we all knew why. A couple of hours ago, this was a healthy six-year-old with a life expectancy of seventy or so more years. Not something to let go of lightly. And therefore the code was prolonged well past the point where anyone believed it was really going to help. But there was finally an end; there was no bringing this little girl back. The machines were turned off. The doctors moved away from the bed and a couple of nurses came and cleaned up the body, pulled out all the tubes, wiped away the blood. ”Are her parents here yet?” one of them asked. ”No, she was brought in by ambulance,” said one of the surgeons. ”Her parents were called and they’re on their way to the hospital.”

And there we were, looking at a child’s face, at blonde hair with a red plastic barrette in it. I had never seen a child die before. Everyone was upset; everyone had to go back to work for the rest of the night. Some people talked for a minute or two about what had happened medically — why had she suddenly coded? Other people talked for a minute or two about what they would’ve liked to do to the hit-and- run driver. ”We could have another code,” one of them said. Eventually, the little group of doctors and nurses gathered for the code dissolved; I went back up to my floor and sat in the on-call room, and tried, you might say, to process the experience. It was two a.m. I have various close friends, but none of them, I suspected, really wanted to be awakened at two a.m. to hear the details of a child’s horrible death. Finally I called a friend in California, where it was only eleven. A doctor friend, so I could go into medical detail. And after all, I thought, thank God I didn’t even know the other kind of detail: what her name was, what she liked to play, what she was afraid of, even what she wanted to be when she grew up. Thank God it wasn’t me waiting downstairs to meet the parents, I thought, knowing it would be me one of these days.

Nobody can watch a child die, I suppose, and take it calmly. It’s unnatural for children to die. When I did adult medicine, many of the deaths were such evident and overwhelmingly merciful releases that it was possible to accept them calmly. Doctors often got frustrated because they felt they had lost a battle, that the patient’s death reflected some failure of medical skill. But you could feel medical defeat and human acceptance, or something like that. With children, except in the rare cases of chronic, merciless disease, it isn’t like that. In fact, it’s just the opposite; you may feel able to accept the sequence of events from a medical point of view, understanding that the child was too badly hurt to live, but you still feel outraged.

When I started my internship, I had never seen a child die. Obviously, I had also never been the doctor standing by the bed when a child was getting sicker. I worried a lot about what I would do when that happened. During orientation, we got various bits of advice: Give the kid oxygen. Call for help. Try not to faint. We got a basic CPR course, practicing on lifelike plastic dummies. And then I waited for the worst to happen.

I listened to the scare stories. ”I know this guy, in a pediatrics program in another hospital. And his very first night, his very first admission was a little boy who suddenly started to bleed out of his mouth and nose while the intern was talking to him.”

”Oh, my God! I wouldn’t have the faintest idea what to do! What did this guy do?”

”He cranked up the bed so that the little boy’s feet were higher up than his head, and then he went and sat outside in the corridor and cried.”

”Are you kidding?”

”No, that’s what he did. And actually, it turned out to be a good thing to do, because he attracted a lot of attention, and some senior residents came and helped the kid out.”

”O.K.,” I said, relieved to have one possible course of action all mapped out. Feet- higher-than-head, cry- in-corridor. I ought to be able to manage that. But I was lucky. It didn’t happen to me my first night, and by the time it did happen, I had seen enough to know what to do. I gave oxygen, I called for help. I gave some extra fluids. I asked the nurses to get some important medications ready. And then my help showed up, and the child, of course, pretended he hadn’t been the least bit sick. But I know what to do if they look as if they might be dying. That, however, is different from seeing them die.

Late one night I was in the intensive care unit. A baby was close to dying, and two doctors much senior to me were trying to bring her back. They asked me to give chest compressions while they handled the medications and all the rest of the resuscitation. I put my hands around the baby’s chest, my ingertips meeting behind her back, and with my thumbs I pressed down on her chest, counting inside my head, trying for 120 compressions per minute. I had done it on a plastic doll. I had done it on an adult. But never before on a real baby. The heart monitor showed what I was doing; I could see the heart action I was generating with my compressions, and I could see it trail away to nothing when I stopped so the other doctors could check the pulse. I concentrated on that baby’s chest, on the feel of flexible bone going down under my fingers, on the perfect waves of activity I was generating on the monitor screen, on the rhythm I was counting. I didn’t try to get to know the baby. I saw details, of course; I saw the recently cut umbilical cord of the newborn and the dark fine hair and the tiny perfect fingers. ”Ten fingers, ten toes,” I remembered assuring parents in the delivery room, and I wondered whether someone had said that to this girl’s parents — before it became apparent that other, more important things, were wrong inside.

I continued the chest compressions. Medicines were given, blood samples were sent, results came back from the lab. My thumbs began to ache, and someone else took my place, and then later on I took over again. I knew that I would absolutely know for the future, with or without a cardiac monitor attached, how to compress a baby’s chest. And I was the one who was doing the compressions when the code ended, when they called it off, when they gave up. Again, it had gone on well past the point where anyone believed it would work. When a baby is born with a badly malformed heart, when that heart cannot pump enough blood to vital organs, and several body systems fail at once — well, there are sometimes situations where there’s nothing anyone can do. Still, I was the one who stopped compressing the chest.

The nurses came to clean the baby up. One of the doctors went off to call the parents. The other went over all the details of the code with me, teaching me and also reassuring me, and himself, that everything had been done that could have been done. There wasn’t any hit-and-run driver to be angry with. If we could have pulled that baby through, we were both thinking, maybe some of her problems could have been fixed, maybe she could have gone on to grow up. That’s worth fighting for, right? So you fight for it. And sometimes they die.

COPYRIGHT 1986 Discover

COPYRIGHT 2004 Gale Group