Saturday, January 07, 2006

Not After That

It wasn't the first time that I'd worked with this little girl. She came in several times a year, around holidays when school was out, but not always. Her mother would accompany her, as did her younger sister, who was about half the age of the girl herself. She was maybe twelve years old then when I last worked with her.

Her sister was about six but suffered a developmental delay. She had a little PEG tube in her belly because she could not swallow. She also could not walk and she was small for her age despite chubbiness. They wheeled her about in a baby jogger.

We used to have a really nice baby jogger for our little one, but at about age four she was too big and she could outrun us, anyways, so we gave it to a neighbor.

This twelve-year-old always came in with the same complaints. Stomach upset and vomiting, her mother would say. I asked the girl if she had been sick a lot and she would say "I don't know."

"Any pain?" I'd ask her and she would reply "No, not really."

Dr. Fisher, the general surgeon, decided we needed to put down a nasogastric tube to see if there was anything interesting in her stomach. I had started an IV on the girl and she took that very well, tiresome and uncomfortable as that was for her. Dr. Fisher decided to stay around and help put down the little 12-French tube, all the while silent as a stone in moonlight.

He didn't talk much. I was used to this, but the mother of the girl had a thousand questions. Not spoken questions, but the kind of questions that you can see on a person's face.

We inserted the tube and I knew the placement was okay because we could easily aspirate a little nice green bile stomach contents from it, and it auscultated appropriately for position. On behalf of the mother, I asked Dr. Fisher "what is that?" and he replied with one word: "Fluid," which did nothing really to allay the mother's concerns. I wanted to ask him if he could be just a little more vague.

We ran tests, did abdominal films and an ultrasound, and a day or two later the girl would feel better and we would send her home. Happened every time. We'd find nothing really wrong, but a few weeks or months later they would come to the hospital again.

I would ask her if she was sick again and she'd say, "I don't know," or "not really" but her mother would affirm that she had been vomiting at home and maybe at school, too. The little sister would sit in her baby jogger sucking on a pacifier. We would do bloodwork and films again, hold her for a day or two of IV fluids, then send her home again.

Then it happened.

This time it was her younger sister that was sick. Fever, vomiting, dehydration. Poor little sweetie. We had her bedded down quietly in the intensive care unit. At 2 a.m. she developed some respiratory distress and we suctioned her and called the doctors. Then her color turned dusky and she got sweaty but cool. Her blood pressures went down.

When the doctors arrived we were coding her and hanging fluids and calculating vasopressors for her slight weight. The E.R doctor had difficulty intubating her. Due to her developmental idiosyncracies, her airway was crooked. But the vascular surgeon Dr. Riley, who just happened to be up, got one in quickly enough. Not that it did much good.

We never got her pressures back up, and her blood gases were crappy, and eventually her rhythm decayed. It was a long code. One of the other nurses had called her family. When they all arrived, mother, father (it was the first time, over all the years, that I had met him,) and sister, it was approaching 3 a.m. and we were going at it tongs and hammers.

The attending doctor stepped away and talked to the parents while the surgeon, the E.R. doctor and all the rest of us bagged and pumped and gave drugs. It came to a moment when I asked if they wanted more epinephrine and the doctors said "no."

I heard the mother sobbing, and one of the other nurses cried along with her. Through the windows out into the main part of the unit I saw the older sister clinging to her crumbling parents. We quickly cleaned everything up. I left the room while they entered to say good bye for the last time.

After they all left and we had taken the girl out, we spent the last couple hours of the shift in an exhausted fog. I went home and slept for a while but I was awoken by the sound of rain around noon so I did laundry.

The older sister never came to the hospital again after that. Once in a while I would see them at the grocery store or the library, and we'd exchange hellos.

1 comment:

Eric said...

I've never had to code a child. Can't imagine what that would be like. What gets me through most of my codes is the belief that many would be better off not surviving the code. Our medical system is based on the idea that the balls need to be kept in the air for as long as possible, which can be a dis-service. I have not had to face that point with a child.

Although, in the end, we are all children again.