The falsehood escapes you and you are beguiled
You trust me, believe me, escape for a while
The brutal clutches of truth, my love - you're soothed, my love.
I paged R to find out where he was. I've got a kid in status in the video EEG lab, R says. Come on down when you're done. I went down.
It's morbid and a little frightening to note that we as medical students cannot help but be interested and intrigued at things that one is not normally excited about. You know, O Best Beloved, you have seen, that I have compassion for my patients. But as I scampered out of the stem-cell unit and headed for clinic, four floors down and at the other end of the hospital, I was excited. Status Epilepticus: a seizure or series of seizures without a return to baseline consciousness, lasting more than 30 minutes. Practically speaking, it's status after five. And it's an emergency, and emergencies are things that you don't see very often.
I could have done without this particular emergency.
I got to clinic just as they were finally breaking her out of her status, a tiny fragile creature lying there on the bed. I "excuse me"'d my way past a man and a woman, glanced around. R had stepped out for a moment; I caught my breath.
Babies in the EEG room look like aliens; at least a dozen wires sprouting from their heads, tape everywhere. She was no exception, skin translucent, dark lashes crescent-moons over her cheeks. She will be beautiful, someday, I thought to myself. She is beautiful now. And she was, even with the sprouting wires and the dimmed lights of the room, even with the faint trembling that indicated the electrical maelstrom taking place in her head. She was beautiful.
R came back in, looks around, says "I sent dad and aunt out to the lobby, we can talk." That was when I knew, suddenly, that something was terribly wrong. So I asked the fateful question:
What's her story?
The nurses and techs looked at me. A silence hit the room like a ton of bricks before one of them spoke:
"Shaken baby," she says, softly. In a flash, everything changed.
The head of a one-year-old infant is something like 75% of the size of an adult's. It's disproportionately large and heavy, and it's supported by a short, flexible neck with muscles still developing. If you hold a child by the ribs and shake him or her, that huge wobbly head snaps back and forth, causing rotational injuries to brain and blood supply. It snaps the little veins in the back of the eyes and causes hemorrhages. It can ruin a child forever.
In one single shaking episode, O Best Beloved, permanent damage can be done.
Baby came to the ER because she fell out of her high chair, threw up, went limp, and scared the daylights out of the babysitter. She came in with a subdural hemorrhage, a red-flag sign that triggers a child-abuse workup. Opthalmology says she has the worst retinal hemorrhages they've ever seen. They brought her back a second day to see if they might've been mistaken, despite the pictures they took - pictures that show retina peeling from the back of her eyes in one place, folding, pictures that would make the uninitiated wince. They hoped they would clear up. I have seen them, in the EEG lab; I brought the other students to see them. R told me to look, with my Pan-Optic, the wonder-scope that shows a wider field and greater magnification than the hand-held opthalmoscopes. I wished I had had the other. I looked, O Best Beloved, and the "O, my God" was ripped from my lips before I had a chance to silence it.
Across the back of her eyes, in place of the red-orange field laced with cinnabar vessels, the fine golden lines of the optic nerve, in place of the things we have worked so hard to see and name, was a patchwork of crimson blotches, almost completely obscuring the normal architecture of the fundus. A leopard's-skin of an eye, and the other the same. I had to struggle not to drop the opthalmoscope.
In my opinion, these findings (the opthalmology note says, in writing carefully made clear, double-spaced,) are not consistent with accidental trauma.
There are websites for defence lawyers which will enumerate cases where children got retinal hemorrhages from CPR, from falling off playground equipment, from any number of things. Ten cases here, half a dozen there, but they exist. Perhaps 2% of children with the pathognomonic features of child abuse are not child abuse victims. I tell you this, O Best Beloved, so you understand: perhaps she is not a shaken baby. I hope. O God, I hope. To know that the mechanism of this child's injury were tragic accident would be a wound in my heart healed.
Unfortunately, O Best Beloved, it is not likely. There is fair evidence from the babysitter's report to suggest that the baby was seizing before she fell out of the high chair. And her father keeps asking strange questions, starting with asking whether the skeletal survey ("We don't want to miss any other injuries by focussing on her head") would show "old injuries". It will. It showed none.
Nursing focus: Father asked about security on the unit, whether it were possible for someone to remove the baby from her room and take her out of the unit without an alarm going off. This RN explained that the monitors would alarm if she were disconnected from them. Father continued to ask questions. This RN informed father that not even he would be able to take the baby off the unit without her noticing.
Nursing focus (later that day): Parents asked if it would be possible to disconnect the baby from the monitors so that they could hold her. This RN informed parents her condition would not permit that.
And so on. Dad hovers, keeps asking when she's going to wake up, why won't anyone tell him his baby is going to be all right?
Because she's not going to be all right.
Developmental milestones prior to admission: normal. She could sit up, play with toys. She liked country music and rolled over both ways to get around, they couldn't leave her alone. She was a social baby. There are pictures on her crib now of her, smiling, being hugged by her older brother. At the foot of her crib are cutouts of Johnny Depp and Brad Pitt from magazines, a card - "get better soon."
I pray she does.
My note today: Baby is sedated, unconscious, and minimally responsive to stimuli; will grasp lightly when moderate pressure placed on palm. Hypotonic, no reflexes noted. Pupils with brief constriction to light. Verbalizes moans when stimulated. No purposeful movement noted. Parents report she occasionally opens eyes, moves spontaneously. No clinical seizures.
Plan: continue phenobarbital and dilantin as scheduled. Baby to MRI today; will discuss with neurosurgery.
Neurosurgery stopped us in the hall. "You're consulting on Baby N, right?" Their words? She looks like crap.
We wonder if she'll be able to see again, or feed herself, or grow up to watch Nickelodeon. We wonder if she'll ever be more than minimally responsive to stimuli again. When is she going to wake up?
We don't know.
And I am watching a pale and fragile infant, her head today bare of the tiny wires that monitored the neuronal activity of her battered brain. She had an EEG this morning. There is brain wave activity - mostly on one side - in response to flickering light; the pathways that transmit signals from bleeding retina to battered occiput are still transmitting. There is no rhythm of underlying consciousness on the EEG; she is on phenobarbital, a drug which should produce a sort of background static at greater than 14 cycles per second, and there are no barbiturate spindles to be seen - just a slow and undulating delta-pattern, occasionally rhythmic, flattening across her occipital lobes to a subtle wave. The reading indicates severe encephalopathy, no seizures. We have done our part of the equation, she is not seizing any more.
I am watching a child with half-moon black lashes, hair so pale and fine it makes her seem nearly bald, skin a translucent pale peach. I can indeed place my finger in hers and elicit the faintest fraction of a grip, and I fight to prevent myself from latching onto that brief reflex as a sign of healing. It is a reflex. She looks like she is sleeping, tucked under her blankets. It is coma. I brush her hair back and find it still sticky with the electrode glue. We cannot wash her, there are skull fractures.
I give her father, always at the bedside - this is still alleged, no culprits named, and he is not denied visiting rights - a sad and sympathetic smile. "We'll let the neurosurgeons know she's not seizing. That should let her brain rest some. Let us know if you have any questions, all right?" And I walk out of the door, hearing his thanks echoing hollowly in my ears and falling, acidic, on my heart.
If you shake a baby once, O Best Beloved, just once in that fit of sudden frustration and anger, you can transform a happy and healthy seven-month-old girl into a mannequin in a hospital bed. You can change a child's life forever. If there is one thing - one single thing - that you take away with you from reading these words, I beg of you, remember this: