It had been a quiet, peaceful summer afternoon and I wan’t really into the chaos that I knew was waiting for me in the ED. Two ambulances were empty with the doors still standing ajar and two more were parked over in the parking spaces. I stopped for one last moment to look out over the harbor, took a deep breath and plunged into the department.
I tried to make a cheerful ‘hello’ to the registration clerk, but her tired business expression never wavered. I tried again with the doc I was replacing and he gave me the same ‘no nonsense’ expression and kept typing madly on the computer. “Just get started” was all he said. Instinctively, like a football player entering the game for the first time, I loosened the muscles in my neck and shoulders, picked up an armful of charts and prepared for the first hit.
Everyone had been waiting several hours to be seen, so they were in no mood for a jovial “Hi, I’m Dr. Plaster.” It was all business from the beginning. The beautiful day was gone. In fact, it seemed to be another life. Soon I was churning 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, then I overheard her saying, “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 needlessly announced to the nurses already moving to the Resus Room. “How old is the child?”
“Three,” was the response.
“Don’t make more than one peripheral IV attempt.” I said. “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 our emotions in 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 as he just shook his head no.
“Continue CPR,” I ordered preparing to intubate the child. “Hold for five seconds,” the tube went well due to the widely dilated vocal cords. “Continue”. It was all by the book, the tube, the lines and the drugs, but nothing was working. We would continue working this code for a long time, but heaviness soon blanketed the room. The shouting was 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 weep 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 professionally 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 masking 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 finally said coldly. I examined the monitor for a 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, 8:17PM.”
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 my team. They were all mothers and fathers and cared deeply about children. But they were able to suppress their emotions in order to do their jobs effectively. “Thank you for your effort,” I said softly.
“I’m sorry, Dr. Plaster, but I think I have to fill out a referral to Children’s Services on this case,” the charge nurse said through gritted teeth.
“Yes, I agree,” I said, “but I’ll sign it.” I was anticipating the firestorm that would follow.
I stopped to smell the wisteria in the arch over the gate as I trudged home that morning. “You seem more tired than usual. Are you OK?” my wife asked as I bypassed breakfast and began trudging up the stairs to the bedroom. I paused for a moment before continuing my silent ascent. I contemplated the deep pain that the story of my night would bring her and thought better of sharing it. Maybe later. Maybe.
“I’m OK,” I said with a solid manufactured smile. “Just a little tired.”
A story that is unfortunately all too common. RIP little Ava and thank you Dr. Plaster and all the other ED physicians who bear witness to a multitude of human tragedies and make so many sacrifices during each shift.