It had been a quiet, peaceful summer afternoon and I wasn’t really looking forward to the chaos that I knew was waiting for me in the ED. Two ambulances were empty with their doors still standing ajar and two more were parked in the parking lot when I arrived. I stopped for one last moment to look out over the harbor before entering the ambulance doors. I took a deep breath and plunged into the department like a fresh substitute in a football game.
I tried to give a cheerful ‘hello’ to the registration clerk, but her tired “don’t-talk-to-me-unless-you-really-have-a-problem look never wavered. I tried again with the doc I was replacing but he never even looked up from the computer, which he was pounding away on madly. “Just get started” was all he said without breaking his train of thought. The set of his jaw told me he had been qui- etly struggling for hours. Instinctively I loosened the muscles in my neck and shoul- ders, picked up and armful of charts and prepared for the first hit.
As I surveyed the ED the looks on the patients said everything. Most had been waiting several hours to be seen, so they were not in the mood for any pleasantries. It was all business from the beginning. The beautiful day was gone. In fact, it already seemed like a dream, or a past life altogether. Soon I was churning robotically through the charts making my best effort to appear really caring.
“We’ve got a kid coming in from a private pool,” announced the nurse handling the radio calls. I didn’t really respond. You never know if these calls will mean anything. Then I overheard her say, “Continue doing CPR and we’ll see you in 3 to 5.” I felt my teeth clench as I fought to keep my exterior calm. Who is swimming with a little kid at this hour, I foolishly thought.
“Get out the Pedi crash cart and the Broselow tape,” I announced barely ahead of the nurses already moving to the Resus Room. “How old is the child,” I said mechanically.
“Three,” said Anita with glistening wide eyes.
“Don’t make more than one peripheral IV attempt. We’ll go right to an IO to save time.” My cold calmness seemed to focus her thoughts. But my internal thoughts went immediately to our own three-year-old grandchild. I felt myself physically shaking my head as if to drive that thought away from the moment.
It was clear as soon as the paramedics burst through the ambulance doors that it was going to be hard to keep control of this team effort. “Down time is unknown. The adults were partying and didn’t notice the kid come out of the house,” the medic shouted as they whisked into the room and put the child on the gurney in one fluid movement. They were using a bag-mask while doing CPR.
“Did you get much when you did the abdominal thrust?” I asked the medic as I looked at the lifeless child. He just shook his head.
“Continue CPR,” I ordered, preparing to intubate the child. “Hold for 5 seconds.” The tube went in well due to the widely dilated vocal cords. “Continue.” It was all by the book – the tube, the lines, the drugs. And it all wasn’t working. We would continue working this code for a long time, but a heaviness began to blanket the room. The shouting was all gone, replaced by the beeping monitor that was picking up the chest compressions and the whooshing of the air in the tube. I heard one of the nurses begin to cry softly off in the corner. I turned to engage her eyes and waved her out of the room with my head. There was no time for that tonight. This room was all business.
Then the mother burst into the room, still wearing a swim suit. “Where’s my baby?” she wailed. I turned and blocked her vision of the child with my body while I walked over to comfort her. Who wants to see their precious child with tubes coming out of every orifice while a paramedic is mechanically crushing her chest. “Is she OK? She’s OK, isn’t she?” she repeated pleadingly. I knew that most likely I was eventually going to tell her a crushing truth. But I wanted just a few more minutes to determine if the child’s fate was sealed. So I engaged her in a bit of distraction. It was something I’d learned long ago about how to soften bad news.
“Let’s step out in the hall while the team continues their work. I’ve got a few questions.” I put my arm around her and turned her away from the scene. She resisted but my firmness gave her the impression that I was in control of the situation. “How long was she in the pool before you discovered her,” I asked as calmly as I would ask about the progress of abdominal pain. It was then that the sorrow and pity that I was mask- ing turned to furious, boiling anger. The mother smelled strongly of alcohol.
“I told her to go to bed,” she slurred. “She must have come outside while I was fixing the drinks. I don’t know how long it was. We weren’t in the pool until later.”
“Who found her?” I asked through gritted teeth.
“My boyfriend,” she cried softly. “My ex is going to kill me,” she said, changing her demeanor. “He loves little Ava. She’s going to be OK, isn’t she?”
I just shook my head silently. “I’m going to go back in there and check on her. But I think you need to prepare yourself for the worst. Depending on how long she was underwater before she was found will determine if she is permanently injured or whether she will survive at all. If you need to call family members, there is a phone. I’ll send someone in to sit with you. We’ll do everything we can, but truthfully, I’m not hopeful.”
She stared at me through drunken, blood shot eyes. I turned to leave the room lest I deviate from my professional responsibilities and become an overprotective, angry father. I walked back into the room. “Any improvement?” I asked the charge. “She’s been asystolic the whole time she’s been here. We took the liberty of icing her head on the odd chance that she comes back with a rhythm. But I don’t think we are going to get her back.” I took a long time to examine the rhythm on the monitor. “Hold CPR,” I said coldly. I examined the monitor for another long moment, hoping for any sign of electrical activity, even as the nurse printed out a long strip anticipating my next words. “Stop CPR,” I said with a defeated sigh. “Time of death, 8:17 PM.” I bowed my head in silence to pray for understanding. The questions of why and how were floating up in the air like Chinese fire lanterns as they accompanied the soul of little Ava. I finally turned to face my team, who appeared to be in shock. As I looked from face to face I realized how proud I was of them. They were all mothers and fathers and cared deeply about children. But they’d held back their emotions in order to do their jobs effectively. What was the toll, I wondered, of hiding your heart behind a cold professional exterior. My only answer was a soft “Thank you for your effort.”
“I’m sorry, Dr. Plaster,” the charge nurse said through fierce eyes, “but I think I have to fill out a referral to Children’s Services on this case. This wouldn’t have happened with proper supervision. It might be just an accident. But it might also be a pattern.”
“I’ll sign it. But you shouldn’t run point on this,” I said, anticipating the firestorm that would follow.
************
My shoulders were just beginning to loosen as I smelled the wisteria in the trellis over the gate leading to the house. “You seem more tired than usual,” my wife said over breakfast. “Are you OK?”
“I think I am,” I said, looking at my plate. I thought of the pain that little Ava’s story would bring her and decided to lock those demons away, at least for a while.
“I’ll tell you later,” I said with a solid, manufactured smile. “I’m just a little tired.”
