I got the call at 0500 from the ER on a peds night where I had finally stumbled into bed at 0-dark-hundred. It was one of my lightest peds call nights all month - only ten children, but those ten filled the last ten beds on the floor. I had counted every empty bed and the nurses and I had rejoiced when there was only one more. To bed, then, and hopefully up early to round.
I know the ER docs by now - know who admits for no reason and who admits for a reason. The one who called admits when he's worried, and perhaps that is the way it should be. His report to me was brief - trached kid on a chronic ventilator, pneumonia, needs to come in. Is this worth our last peds bed? I asked the question - I thought he should know, in case it was iffy. "Yeah," he said, "I think he needs to come in." Send him up. Have them call me.
The time lapse between when a child is admitted and when he or she arrives on the floor is sometimes as many as three or four hours; enough time for me to sleep another hour and regain some coherency before doing the admission. It didn't sound serious. And at 0645 when the transport team passed me on the way up to the peds ICU he looked pretty good. I finished my note and headed over to do the admission.
He was precious, nine months old, twin, bright eyes looking up at me. Home for ten days of his life - down to $childrens_hospital for a heart repair when he was barely out of our NICU and then lung failure after that. Mom related her story - throwing up for a few days, vent alarms, saturation and heart rate (home alarms are not very complicated), loading him into the car with portable oxygen and bringing him in. She sounded together and with it, until we got to medications. "It's all in the book." She handed us the baby's Book of Treatments, which is something you get at $childrens_hospital if you have a chronic kid. We read. We sorted through it. She wasn't sure about some of the stuff, and she wasn't sure about some other things. Maybe that should have been a warning. It might have been a warning as well that when she had been told to bring her vomiting child to the ER three days ago, she hadn't. Would it have changed things?
I talked as I did my initial exam, 0700 on a day I had to leave soon. He was beautiful, even with machinery forcing air into lungs, bright brown eyes, seeming to watch me inquiringly. He didn't look sick. He didn't look sick even as I heard the monitor beep and looked up to see a heart rate around 40. The PICU nurses sprung into action, then. Chest compressions. Getting the code cart. Escorting Mom out of the way. It was surreal, unreal, at first, and then - gradually - things began to come together. This child was trying to die.
I have never before run a code, O Best Beloved. There has always been someone there first. I did not have my code cards, or my algorithms, or my wits about me, but I tried. The nurses did most of the work. We called the PICU attending, reported. He gave orders over the phone - more competent at managing a code from his bedside table than I was from inside the room. Push this. Do that. I'm on my way in.
We drove in IO needles into his legs - if you can't obtain IV access in a pediatric patient (children's veins are tiny, fragile, elusive) you go for the bone marrow, which is rich and vascular, drive a sturdy needle through the bone itself with a twisting, terrible pressure. We called it over the overhead speakers - something we don't usually do for PI patients, because there's usually an intensivist right there to run it. The code siren is a dreadful air-raid quality howl that jars the mind - but it accomplishes its job. The Medicine folks came running. Two third-years. They took over while I, bewildered, panicking, helpless, retreated into my mind.
I held the paddles on his tiny chest and called the chant - Everyone clear? Everyone clear. Shocking. - pushed the buttons, saw him twitch. We had a rhythm, briefly, and then we didn't, wild scribbles of nonsensicality on the EKG, the bedside monitor, the code cart monitor. Again - ACLS protocol is changing: one shock, then CPR, rather than stacked shocks, but we haven't internalized that yet - and again. Something. Maybe.
The attending appeared, did a cutdown for access, barely got anything. Labs finally came up on the computer screen, the labs I hadn't thought to check before my exam and had forgotten about in the meantime. His potassium was high - so high it was practically incompatible with life. We (I say we. I mean everyone there who wasn't completely overwhelmed by shock) pushed drugs to bring it down, rechecked. It was no better. It never did get better. We got blood cultures, more labs. Kidney failure, perhaps. No, definitely. And at last we had him stabilized after a fashion. He was on pressors to keep his blood pressure above critical, he was barely maintaining a perfusing rhythm, but he was stable. And we went to talk to his mother.
It's a blur; the PICU attending, calm, rational, almost inhumanly so at all times - explaining the situation, that he had been very sick, that it was a miracle he hadn't died at home before now. Trying to make her see that he had not, in fact, been fine. She didn't hear it. She thought at first that she'd done something - then that we'd done something - and then, finally, when we brought her back to see the child (the nurses, efficiently, had cleaned up the bed and thrown away the debris of three failed IO lines and an entire code cart's worth of drugs - a clean code, tidy. Movie quality.) she broke down sobbing. She also whispered accusations.
He was fine when he came up here.
He wasn't fine, not in the beginning, not then, and not when he went down to $childrens_hospital for emergency dialysis, coded when he got there, dialyzed and died anyway. He was bacteremic, with gut flora coiling and reproducing in his blood; he was uremic, he was sustaining a level of potassium that destroys the heart's ability to maintain a rhythm. These are not problems that occur within a few moments. Something was desperately, terribly wrong with this beautiful child. Something had already been wrong.
You wonder, after a code, what-ifs and maybes and could-have-beens, as I tossed ten patients to round on at one of the other residents and ran for my car to go to a funeral service two hours away. Would it have made a difference if I had had the lab values going in the door? Would it have made a difference if the ER physician had known about them before sending the kid up. What if he'd come in three days earlier, when the on-call resident had told the mother to bring him in? What if - would it - maybe - could I...
Nothing, said the attending calmly, logically, could have saved this child by the time he was brought in. He came here to die.
And sometimes, maybe, that's the way it is.