June 28th, 2005

Nescafe rabbit


So Monday was the first day of PALS - Pediatric Advanced Life Support. It's much better than ACLS, everyone said to me. Just remember, oxygen and fluids.
Kids are funny things, O Best Beloved. They're small, they have different physiologies, and if one of them falls over of cardiac arrest there's less than a 10% chance of getting them back with neurologic function intact. For a kid in asystole, there's not a whole lot you can do - you give epinephrine (0.01 mg/kg) every 3-5 minutes, you do chest compressions (infants with two fingers if you're alone, with both thumbs if you're not; 1-8 with the heel of one hand; 100 times a minute either way) and you breathe for them while you're at it. And that's it. All the ACLS algorithms in the world can't do any better than chest compressions, rescue breathing, and epinephrine. That's it. And after 20 minutes or so, it's okay to give up, because if you ever get anything back it's going to be a vegetable.
It's okay to stop CPR on a child. This is a concept that takes me several minutes to type out, let alone contemplate putting into practice. Our instructor looked at me with real compassion when I asked her how long was "long enough", and she told me four rounds of epi (that's about twenty minutes) was probably a good effort, but that pediatric codes go on for hours sometimes. She told me about the staff attending, a good doctor, so much experience, who looked at her when she asked if he didn't think that it was time to stop, and said I can't stop. She's only three years old.
We are healers, doctors, teachers, nurses, we heal and we preserve life and as a family practice doctor, as a pediatrician, we perceive children as the most valuable asset the world can posess. And if that child is only three-years-old, and if that child was found face-down in a swimming pool, and if that child is dead, O Best Beloved, not "gone" or "passed on" or "beyond us", if that child is dead then sometimes all the epinephrine in the world will not change that simple fact. And someone has to decide to stop. Someone has to say the words. Someone has to tell the parents, and sign the death certificate, and someone has to look at that tiny white face and know in their mind that I gave the order to stop trying to reknot the strings that held the semblance of life so close.
We focused on prevention.

I have seen two pediatric codes run in my career thus far, O Best Beloved. Once in my second year and once in my third. Both times, the child was an unrestrained passenger in a MVC. Both times, the child came in already dead. Both times, we ran a full code anyway. If you haven't read those two entries they're probably worth going back to if you have someone you love to come and hold you afterwards. Children are hard.
Even in a mockup scenario it's hard, O Best Beloved. I got picked to run the ED mockup of meningococcal septic shock, and my heart was pounding a thousand miles a minute by the time I said "And I'm calling Peds ICU with an admission" as I looked down at a plastic torso with an interosseus needle stuck in its leg.

Two more days. Tomorrow we wrap up PALS, Thursday we wrap up orientation, and Friday I meet at 0715 on Labor & Delivery to start being a doctor in truth. Saturday I'm on OB call. We have our schedules for the year - in four-week blocks, mine looks as follows :
OB --- ER --- Med --- Peds --- Rural --- Med --- OB --- Med --- Peds --- Pulm --- Med --- Surg --- Med
Boldfaced blocks are call blocks. From November to March I doubt I'll see the sun much - that's that Med-Ob-Med-Peds sequence there. Medicine is q4-5 call, Peds is q3-4, OB is q3. Boomboomboomboom. And Angel, bless his heart, is just as ready as anyone can really be.

I just hope I am.