The Intern Blues(118)

She went for her cath bright and early yesterday morning and she came back at about ten. We were on attending rounds. I saw her for a moment, at about noon. She had fallen asleep in her mother’s arms, and her mom asked me not to disturb her. I told her I’d come back and see her later, after she’d slept for a while. When I came back, she looked a little uncomfortable, but not bad. I got called away to do something else before I had a chance to finish my exam.

At two o’clock we were called to see her because the nurse had noticed she was looking worse. We went in: There she was, pale, tachypneic, with cold extremities. She looked clamped down and shocky. We had a devil of a time getting a line in. Before we did, we got a blood gas: It showed she was quite acidotic, with a pH of 7.21. But after we got the line in, we gave her a small amount of fluid and she seemed to become more comfortable. Her repeat blood gas was improved; she was less acidotic.

A little later we decided we should give her a little Lasix [a diuretic] so she wouldn’t go into congestive failure or pulmonary edema. When I went to give it she looked comfortable, breathing at sixty instead of eighty. I spent the afternoon darting in and out of the room; basically she looked okay. We put her in 60 percent oxygen by headbox to help her out. Her attending also kept coming in and going out all afternoon. He was concerned that she had suffered some sort of ischemic event [damage to the heart muscle due to lack of oxygen], but he didn’t know when. He told me I might have caused it by drawing blood and introducing an air embolus, something I’d never heard of before. That sounded like a really ridiculous idea. He said it might have been that or it might have been the cath, but he sort of kept stressing that I had done something.

Anyway, at about five o’clock he was there, and he chastised Eric. He told him how foolish and unobservant he had been. He told him that the child was in respiratory distress, grunting and flaring, and that he’d noticed it an hour and a half before, but that he didn’t seem concerned. During the afternoon, the baby had spiked to 40.5°C [almost 105°F]. We were very worried, so we got a chest X ray, drew some blood, and started the baby on antibiotics. Her attending told us the fever was just a “dehydration fever.” I saw him put his hand on Eric’s shoulder and say condescendingly, “I’ve been in this business for a long time. I can tell you that’s all it is.” He didn’t want us to start the antibiotics. But we did nonetheless.

At about six-thirty I was writing my sign-out, trying to get home; Eric was with Kelly Jacobs, the other intern, almost at the end of evening rounds. Eric remarked to Kelly that the baby had a “preterminal look.” She had a heart rate of ninety, which is slow. Suddenly her heart stopped, right in front of their eyes, a witnessed cardiac arrest!

When I first heard the scream “Call a code!” I jumped up; I knew it was my baby. I ran into the room; they were starting to position her to start CPR. I turned around and helped the nurses haul the crash cart in. Eric intubated the baby and I took over managing the endotracheal tube while he ran the code. I started ventilating the baby while Kelly started sternal compressions. He was counting “One one-thousand, two one-thousand,” up to five, and I forced a breath in every time he got to five. Meanwhile, the nurses had ripped open the crash cart and people began to fill the room from everywhere. And we began to code the baby.

We did everything we could. We pushed four rounds of meds. Jon, the chief resident, came and stuck a line in the baby’s external jugular vein. We poured in fluid and kept pushing meds. But every time we stopped the CPR and looked up at the monitor, there was nothing. Flat-line. Finally we put her on an Isuprel drip. Even that didn’t work. Then Eric tried intracardiac epi. And when that didn’t work, after twenty-five minutes, they called the code and declared her dead.

At one point, well into the code, I remember looking up and seeing the mother, horror-stricken, with her hands to her mouth, bent at her hip like she had been punched in the stomach, screaming with horror. And then Jon had pulled the curtain so she couldn’t see in. When we stopped the code, Eric pushed me out of the room and told me to tell the parents. He said, “You go first, go tell them.” Just for a moment I stood in the baby’s room terrified that I’d have to go through this experience again; I’ve already had to tell three sets of parents that their child had died. But this would have been the worst of them, because this was my patient, I had admitted her, and because this was a baby who wasn’t supposed to die.

But I was spared giving the news this time. By the time we left the room, the mother already knew. Word got out very fast; one of the nurses had told the baby’s grandmother, and the grandmother had told the mother.