When I’m done, I go home to a cup of Sleepytime tea and the most indulgent nap on the softest, cotton candy pink organic sheets. When else can an adult intentionally sleep the day away and be called responsible for doing so?
Later, at 4:30 p.m., the alarm on my phone will chirp, and it will be time to get up, as my next night shift begins. I’ll walk through the hospital doors just before 7 p.m., in time to see the big smile on the face of the doctor at the end of the day shift. Things always start the same way: I consult the “sign-out,” a list of the outstanding tasks the day physician couldn’t resolve during her time on, and begin digging myself out of a hole. It never matters if the sign-out list contains two items or ten; it always feels like too many given the inevitable backup of patients currently waiting to be seen and the steady influx of new patients arriving over the course of the next twelve hours.
On one particular evening, I was the sole physician in the ED and was sharing the shift with the night nurses Crystal and Deb. It’s always a blessing to have a strong and amusing team when you’re on nights. When everything is stripped to bare bones, it’s a boon to have a sturdy foundation. I notice that the nurse Pam is on, too, and I tell myself that you can’t expect everyone on the team to be great. Pam is reasonably intelligent, but her clinical insight is often hampered by a bizarre emotional instability. I couldn’t figure out how she’d ended up in emergency medicine, but why she hadn’t been fired was obvious: Pam was committed to nights. The committed night crew is untouchable. Hospitals need them to reliably absorb the burden of the shifts other nurses don’t want to do.
We chugged along uneventfully until around 1 a.m., at which point we heard an ambulance backing into the ambulance bay. Then EMS rolled in a CHFer (our abbreviation for heart failure patients) puffing away on a portable BiPAP (bilevel positive airway pressure) machine. A plump elderly woman dressed in what looked like a housecoat lay on the gurney. The nurses established intravenous lines and informed the woman that they wanted to administer the medication Lasix into her vein to help her urinate the extra fluid backing up into her lungs, as the respiratory tech switched her over to the hospital’s BiPAP face mask to help her breathe. I leaned over and asked her, in a voice raised just enough to overcome the blowing of the BiPAP machine but not quite approximating a yell, “Ms. Yang, how are you feeling?”
She smiled behind the mask as the forced air made her cheeks flap, then flashed a thumbs-up to let me know she was improving. Her EKG and physical exam indicated that her heart was stable, so we were on autopilot for now. The EMS team headed back out the door, and then one of the EMTs returned to give us a heads-up that we might be getting a pediatric code. He said he had been listening to the radio and had heard a call about a baby not breathing and he wanted to alert us in case it was coming our way.
“I certainly hope not! Last thing I need in the middle of the night,” Pam said, loud enough for all twelve beds in the ER to hear.
My physician assistant had just left, there were six patients in the ER, one had just been brought in, and three more were in the waiting room, so the news of the baby wasn’t something I was enthusiastic about either. The truth is, there is never a good time for a pediatric code. When an adult gets sick, we can reason about how or why. After all, Grandpa has to die of something. And if Dad binge-drank every week for the past forty years, we’re not shocked when his liver fails. If Mom was a diabetic who loved to smoke, we understand when she has a heart attack. Even in cases of seemingly random illnesses, such as breast cancer in a thirty-six-year-old man, while these are painful and difficult to absorb, we can concoct for ourselves a kind of piecemeal comprehension to get through somehow. But when a child is brought in with a critical illness, such as cancer or organ failure, we experience a different kind of suffering. Because we see them as both innocent and invincible—too young to justify the affliction and certainly too perfect to succumb to it—it is that much harder to wrestle with.
I moved on to Mr. Nuñez, in Bed 3, while I awaited Ms. Yang’s test results. Depending on her labs, I would admit her to a regular floor bed with heart monitoring, or to the cardiac intensive care unit for her CHF exacerbation. While I assisted the tech in splinting Mr. Nuñez, who had come in with a wrist fracture, the alert came through.
Pediatric code blue. ETA five minutes. Pediatric code blue. ETA five minutes.
I knew it was too much to hope for that we’d be spared.
I asked Crystal to place Mr. Nuñez in a sling and quickly printed his discharge papers. Deb’s phone rang. One of the medics was calling with an update—a benefit of having someone on shift who is friends with a local paramedic.
“Doc, neonate not breathing,” Deb said when she got off the phone. “They coded in the field ten minutes, couldn’t intubate, but have IV access. They’ll be here any minute.”
Ms. Yang, the CHF patient, was doing well. A quick look at the computer revealed that her labs were coming back normal. It was likely that she hadn’t had a heart attack, just a serious flare-up of her congestive heart failure. I asked the clerk, Wendy, to call the hospitalist, the doctor overseeing the medical admissions for the shift, and put the patient’s name in for a bed. We needed to admit her immediately to clear the decks. There was no telling how long a baby code would take.
I took a quick inventory of the status of the remaining patients. Mr. Nuñez was going home. The three waiting room patients had normal vital signs with no life-threatening complaints, so they could wait. Two patients had already been admitted to the hospital and were just waiting for beds to open up. Two more patients were waiting to go to Radiology for CT scans.
“Okay, let’s prep the Resuscitation Room,” I said, heading there with my crew of nurses. “Crystal, can you please make sure we have suction? Make sure the code cart is at bedside. Let’s bring out the neonate tray. And let’s lay out the Broselow tape here,” I directed. “Who’s gonna write?” I asked the crew.
“I will,” Pam responded, already wheeling over a bedside table with a code sheet, the document that records a chronology of all resuscitative efforts during a code in hand.
“Excellent. Okay, are the meds there? Ready with the pediatric pads?” I asked.
“Yup,” said Mark, the tech, holding up the pads for pediatric defibrillation from the pediatric code cart.
“Let me grab my mask and gloves. Miller and ET tube ready.” Then I noticed something. “Wait, there’s no Miller zero in the department? All I have is a one. Good to have a zero in case the kid is small,” I said as I laid down the Miller laryngoscope, the tool used to open and visualize the airway, and the endotracheal tube, which is inserted into the trachea for ventilation, both at the head of the bed near my right hand.
Mark looked around the code cart, grabbing different trays—to no avail: There wasn’t a size zero to be found in the ER.
“Well, then, this will have to work!” I grabbed the Yankauer, the long plastic suctioning tip used in various oral medical procedures, and tested it against my gloved hand. “Suction is good,” I said, tucking it under the mattress head. “Ready!”
Then we stood there staring at one another.
The hardest moments are those right before the code arrives, when the air is thick with anticipation of all the terrible things that could happen and we have time to wrestle with each grisly scenario. I secretly preferred it when the EMS team rolled a patient in unannounced. Sure, we would whine and moan because we had to scramble to prepare everything while treating the patient at the same time, but in reality, such a scenario afforded us the opportunity—really, the luxury—of just being in the moment, of doing our job without getting tangled up in the story of the job. Most of the time, though, EMS teams have the courtesy to call ahead. So we stood around the stretcher, reminding ourselves to breathe.
“What a shitty thing for a Wednesday night,” Pam said.
A cascade of beeps broke the silence. A conveni
ent feature of this resuscitation room, apart from being spacious, was that it offered a clear view of the ambulance entrance. We stood there at attention as the ambulance backed up to the ER, flashing lights that whirled across the bay doors and floors in a dizzying rotation. Then, with a whoosh, two medics swooped in, pushing a small gurney with a tiny patient swathed in white.
“Newborn baby, twelve days old,” the first medic reported. “Called for not breathing. Not breathing on scene. No pulse. CPR started. Family is on the way. We didn’t get the baby’s name; we just got to work. Family can fill in those details when they get here.”
“Okay, we’ll just register him as Doe, like we always do,” Pam interjected.
They parked the gurney next to our stretcher and transferred the baby as one medic continued to ventilate the patient by securing the bag valve mask over his face while squeezing the little chamber of air connected to it in order to deliver oxygen to the baby’s lungs.
“How long was the baby down?” I asked.
“We don’t know. Parents went in to check on him and found him like this,” he responded.
“How long were you coding in the field?”
“Ten minutes at the scene. About six minutes en route. No return of circulation.”
“Okay. What did you give?”
“Three rounds of epi. Accu-Chek eighty-two, so no need for glucose. IO left lower extremity. Unable to tube in the field.”
As the medic and I talked, Deb was frantically connecting leads from our monitor to the infant. Placing my fingers on the inner aspect of the baby’s upper arm, I noted no pulse at the brachial artery. Moving my fingers to the crease at the upper thigh on the same side, I noted no pulse at the femoral artery. Shifting my gaze to the monitor briefly, I saw no shockable rhythm on our monitor. The skin was warm and soft. So smooth—just like a baby’s. I listened to the chest to observe that nothing was moving. There was no heartbeat, no sounds of breathing.
“Mark, please start chest compressions,” I said, bracing myself and trying to sound calm.
Mark placed what seemed like a giant’s fingers on the child’s tiny sternum and began to rhythmically press.
“Okay, another dose of epi,” I instructed. “Pam, please let me know when it’s time for another. Just give a heads-up about the epi at five-minute intervals,” I requested. “Can we just confirm that blood sugar? And I’ll start intubating.”
I looked down at the little boy’s face for the first time. Dark eyes that were wide-open. Beautiful brown skin with a bluish cast. If this child had still been alive, he would have borne a strong resemblance to my sister’s infant son, Eli. He was the specter of the child I didn’t have, the ghost of What Might Have Been. His beauty welled up in my eyes, and I had to blink myself back to reality. This was little angel Doe. At first glance it was impossible to tell if his eyes were black or merely dark from the pupils being fixed and dilated; in either case, there was nothing behind them. His little purple, pouty lips were half-parted where he’d exhaled good-bye long ago. His face was still encircled by the white of the baby blanket that crowned his head. There was no baby here, just a blanket around the body of a departed cherub.
I looked up at Deb. She knew it, too. Everyone around the stretcher knew. We know when a lifeless pod is brought through the door, but we’re supposed to make heroic efforts at resuscitation as they do on TV, when the body is already stiff and blue, but the family is not ready; when arms that have lost the current of life fall limp to the side rails. Still, we push several rounds of meds into them, just to document to the family, peer review boards, and the courts what we already know to be true.
I took a deep breath as I positioned the baby boy’s tiny head and gently placed the Miller blade between his lips. The blade seemed far too large for his mouth. As I advanced the laryngoscope and lifted it up to expose his vocal cords in order to insert the breathing tube, there was tension at the corners of his lips from the size of the blade. I withdrew, opened his jaw, and advanced again. Again, the blade seemed too big. I didn’t want to force it through his mouth.
I couldn’t believe what was happening. Shortly after starting this job, I had completed Dr. Rich Levitan’s difficult airway course, in which this renowned guru of emergency medicine gave us his pearls of wisdom regarding endotracheal intubation. The chairman of the hospital’s emergency department had been kind enough to send any interested faculty members to the lab Rich ran in Baltimore to attend this class. Even before the course, I had never missed a pediatric intubation during my residency. Outside of some anatomic abnormality, children were the easiest to intubate. Because the pediatric airway is shorter and more anterior than in adults, the epiglottis, the landmark we often use to locate the vocal cords for endotracheal intubation, is typically so easily visible that you can see it when kids laugh. Given that you didn’t usually need a blade to see their epiglottises, technically speaking, there was nothing to most pediatric intubations. And yet now I couldn’t do it.
My heart pounded in my fingertips, and I could feel everyone’s eyes on me as I struggled to avoid harming the baby. I knew he was gone, but I couldn’t bear the thought of making one tiny cut or scratch on this immaculate little being. I couldn’t mar perfection.
Resuscitations can be brutal: Ribs are broken with chest compressions, skin is contused, mouths bloodied, even teeth knocked out, for God’s sake. And then, only rarely, after all this medically induced trauma, are people electrocuted back from the dead.
I had long been inured to the assaults that medical teams perpetrate on patients for what is considered the greater good—until now, when the thought of rendering the tiniest blemish on the body of this dead infant made my hands seize up.
“Is there a smaller blade? Do we have a Miller zero?” I asked again, muting my panic. It was an absurd question, as I already knew the answer.
The nurses scrambled to search the cart again, but still found nothing. We continued the resuscitation, with me holding the mask over the baby’s face, squeezing the bag of oxygen to ventilate the child until an advanced airway could be secured with an endotracheal tube.
“I’m going out to the truck. I’m pretty sure we have a smaller blade, Doc,” said one of the medics who had hung back to watch the code and help out if needed.
In seconds, he returned with a Miller 0. As I began again, I thought to myself, This has to be better. Certainly, now I could advance without breaking his little baby jaw. I gently inserted the blade, and still it seemed too big. I met resistance right at the tongue. I couldn’t stretch the mouth. I couldn’t bruise the gums. I couldn’t force the blade back and up. Once again I tried, and once again I failed.
“Doc, do you mind if I try?” the same paramedic inquired. I didn’t look up. I just stepped aside.
“Pam, what’s the time?” I asked.
“Time for another epi, Doc. Ten minutes.”
“Okay, please give another,” I directed.
I asked the medic if he was ready to try for the tube, and he said yes. “Please hold compressions one moment for intubation,” I announced to the crew.
The medic drove the blade between the jaws and cranked forward. The corners of the mouth stretched taut, the skin ripping at both corners, thereby permitting the blade. In the same swoop, the neck craned forward, allowing the passage of a small breathing tube. At the medic’s first attempt, the tube was in.
We continued the fruitless attempts at resuscitation for another ten minutes.
It was finally time for the inevitable end to the code (one that could easily have been called soon after the infant’s arrival), wherein I pronounced the time of death. The code had, in actuality, ended long before the baby was rolled into the department. The child had died at home. The time I called in the ER would simply be a formality.
I looked around at the team and said, “Guys, this kid is really gone. Does anyone have any further
ideas before we call the code?”
“No, Doc. There’s nothing else to do,” one of the nurses said.
One by one, the members of the team shook their heads.
“Any objections to my calling the code now?” I asked. I got a chorus of “No, Doc.”
We took our hands off the baby, the bed, the monitors. I checked the nonreactive pupils and the chest—no breath sounds, no heartbeat, no life.
“Time of death, one forty-one a.m. Thank you, everyone. Thank you for all the hard work. Is the family here?”
“They’re out in the waiting room,” Pam said.
I sighed and shook my head. “Okay, so who’s gonna go out with me?” I threw off my gloves and mask as I exited the room.
Deb stepped forward and rubbed my arm, signaling support for my efforts and that she’d be the one. The doctor typically doesn’t speak with the family alone. They often need more time and support than any ER physician is able to give between patients, so usually a nurse or hospital staff member comes along for the discussion. During the day, it’s nice when a chaplain or social worker is available.
Now we were heading into the hardest part of the code, the part that had no algorithm, no script, the raw part that never feels good.
“By the way,” I said, as I stopped and turned back to the group. “Did we ever get a name on the baby?”
Wendy got up from her desk, which was situated at the front of the ER between the Resuscitation Room and front entrance just kitty-corner to both, to answer, “Baby Christopher Tally. I verified it with the parents. Everyone’s out there. Want me to go get them? You could take them to the back office to talk.”
“Thanks, Wendy. It’s okay. I’m going out.” Then Deb and I headed to the waiting room.
The Beauty in Breaking Page 5