Monday, May 24, 2004
And of Our own do we give You
Spacefan writes :
Still haven't seen any resus cases, but I'll get my chance soon enough I suppose. A friend attended to a toddler who perished in a road traffic accident, but details are pending and I'm not sure how this event has affected him. Believe it or not, for some reason, I've never witnessed a paediatric death firsthand before, even though I did paeds as an intern ( with a full month in paeds oncology ), and have done quite a number of A&E rotations. Well, it's certainly something I can do without.
*****
He's just leaving as the call comes through. 2.5 year old, cardiac arrest.
Gone, the overcoat, shrugged into a pile at the nurses station. Gone, the sling bag, and the latest squeeze, "Neverwhere" (Neil Gaiman).
Are you staying? One of the other SHOs asks in bemusement. He babbles an answer, but it comes out wrong : I've never seen a paeds resuscitation. It might be good to watch some APLS, learn a bit. And find out if the kid survives. (How cold and heartless that sounded! The other SHO nods... hesitantly. Her eyes betray her doubt. This guy... is nuts...)
What he means is - I must know how the story ends.
There's something cold, and clinical about resuscitations. Adult life support is calm, and professional (In other words, nothing like what you see on ER) and everyone leaves feeling slightly subdued, but slightly exultant even after failed resuscitations, since you feel like you've done everything you possibly could, and somehow, it was taken out of your hands.
The ambulance pulls up. Nothing happens for a while. They're certainly taking their time aren't they, one of the sisters half-jokes.
Then the doors burst open...
...and suddenly the picture changes. Ghostly white arms flop limply off the sides of the trolley, as this pallid doll, arms akimbo is run through the door by the two parameds. He's the colour of death, except for his tiny, cherubic face half-dwarfed by the bag-valve-mask locked in a desperate embrace with it : that (his face) is the colour of his life, running in streaks and pools. Dark red, and sticky. And already starting to crust; making a mask, over the mask that his face will soon become, anyway.
We run through to trauma, where the assembled trauma team stands ready. The anaesthetist begins intubating almost before the trolley comes to a halt. One of the other A&E SHOs is there. She puts two fingers to the child's chest and begins compressions. Faster... faster, I urge her in my head.
I linger in the background. I'm not really here. I'm a fly on the wall, buzz buzz. It's easier to cope somehow, when you stand back and observe. Cold, clinical. Detached.
I glance to my left. Dad has come through with the crew. He doesn't quite seem to get it, he's saying things like oh don't worry about me, I can handle it, I'm not the sort to get unsettled. I pause and think - your child is already dead. But I'm not here. I keep my thoughts to myself, thoughts like - what chance, now?
Because on the screen he's in asystole. Because he's too shut down for access - two paediatricans and our staff grade are trying to cannulate him in three limbs with no success.
There is fear in the air. That's the difference between ALS and ATLS. The smell of fear.
IV cannulation is abandoned in favour of intraosseous access. That's sticking a needle through into the bone of the shin in children, to deliver emergency fluids and raise their blood pressures back to levels that can sustain life. Children have small blood volumes, and what seems a little loss to an adult can be a fatal bleed in a child. The intraosseous needles bend off at crazy angles as the paeds reg struggles to insert them. Bloody cheap NHS equipment, only good for plastic practice dolls.
The 20ml saline boluses just make little subcutaneous pockets in his legs, and some of it actually spurts out through one of the many failed insertion sites. Squirting back out as fast as it goes in, into the paeds reg's face. At another time and place, it would be almost comical, like those fake flowers clowns with painted faces and ridiculous red noses wear on their coat lapels. The reg grimly plugs the hole with his thumb and keeps injecting - not quite life, but maybe, just maybe a chance at it.
The sister in charge starts to become flustered. She's being bombarded from all sides by requests. Blue venflon. Another. Syringe please. Another intraosseous, now. Adrenaline. Atropine.
The fly falls off the wall. I step forward and begin handing out the drugs. It's the least I can do, without getting sucked right in.
It feels like an eternity since we first started. We're still strugging at airway - there is blood coursing up the endotracheal tube. Not red froth - blood. With every squeeze, it vanishes back down into... somewhere. And then floods back up as the bag is released. For the third time now, someone says -in a slightly shaky voice- I can't hear any air entry into the lungs. The anaesthetist says again, it's going somewhere. But where?
He calls for someone to hold the neck while he re-intubates.
An eternity passes, while all around him people bustle studiously on at their little chores, heads down. And suddenly I'm gloved, kneeling down at the head of the trolley and holding his head. The tube comes out, and there's a fountain of blood. Out his nose, out his mouth. And as always, that slight metallic tang to the air; the smell of life, leaking away.
Suddenly, I am afraid. That's how it is when you stop being the fly on the wall and step into the little surreal bubble that surrounds a trauma. From TV camera perspective, to first-person, looking out from the two round holes at the front of your skull.
We plug back up, and the anaesthetist starts bagging again. Did you know that the valves on BVMs aren't quite watertight? I make this realisation as I feel microscopic flecks of blood hitting my face. It's a mercy I'm wearing spectacles.
I step back to revert to being a fly, but the sister, who's taken over from the other SHO is exhausted from the compressions, and so I'm back in again, doing chest compressions.
Somewhere along the way, access is finally established. But every rhythm check (is it just me, or is the paeds reg calling for them more and more frequently? and more urgently?) shows asystole.
And then the final nail in the coffin. Let's reassess... this child has been down for....... I know the drill. We all do. Call it again, Sam.
Gloves are stripped off, almost in disgust. People creak away, shoulders slumped. Backs are turned as the assembled team troops dejectedly out the room.
I watch two nurses clean the blood off this pint-sized waxwork effigy of a child. Dad still stands by, dry-eyed, saying he's all right. He looks slightly dazed.
This is... wrong.
*****
There aren't many nights that I wish I could get drunk. Random fact #12041 about re-minisce. He's never been drunk. Not properly, with the euphoria and stuff. It's a complete waste of money.
But stopping by the corner shop on the way home, he briefly considers buying a large bottle of Absolut, just to give it another shot. (ha, a pune, or play on words)
He doesn't, because he realises that when the words "I need a drink" float into his mind, it's not the drink he craves, but the company that comes with it. I just need to talk.
Funnily enough, nobody in London wants to talk right then.
IRC is a barren, soulless place. That idea goes out the window in a hurry.
And so I write.
Thank You for listening.
(And for wanting to. These were the words that were lost to the cruelty of a moment's drowsiness.)
*****
Does that answer your question, Jen Jen?
Oh, and highway code rule #xxx : don't put your children into motorcycle sidecars. Ever.
*****
It's funny how some stories are experienced in days, savoured page by page, thought by ordered thought, and how others are all over within twenty minutes, and all that remains is a bitter taste in the mouth, the lingering memory of minute, damp wet flecks hitting a face already viciously scrubbed with water, soap and cheap paper towels, and that slightly metallic - almost synthetic! smell of flowing blood.
Still haven't seen any resus cases, but I'll get my chance soon enough I suppose. A friend attended to a toddler who perished in a road traffic accident, but details are pending and I'm not sure how this event has affected him. Believe it or not, for some reason, I've never witnessed a paediatric death firsthand before, even though I did paeds as an intern ( with a full month in paeds oncology ), and have done quite a number of A&E rotations. Well, it's certainly something I can do without.
*****
He's just leaving as the call comes through. 2.5 year old, cardiac arrest.
Gone, the overcoat, shrugged into a pile at the nurses station. Gone, the sling bag, and the latest squeeze, "Neverwhere" (Neil Gaiman).
Are you staying? One of the other SHOs asks in bemusement. He babbles an answer, but it comes out wrong : I've never seen a paeds resuscitation. It might be good to watch some APLS, learn a bit. And find out if the kid survives. (How cold and heartless that sounded! The other SHO nods... hesitantly. Her eyes betray her doubt. This guy... is nuts...)
What he means is - I must know how the story ends.
There's something cold, and clinical about resuscitations. Adult life support is calm, and professional (In other words, nothing like what you see on ER) and everyone leaves feeling slightly subdued, but slightly exultant even after failed resuscitations, since you feel like you've done everything you possibly could, and somehow, it was taken out of your hands.
The ambulance pulls up. Nothing happens for a while. They're certainly taking their time aren't they, one of the sisters half-jokes.
Then the doors burst open...
...and suddenly the picture changes. Ghostly white arms flop limply off the sides of the trolley, as this pallid doll, arms akimbo is run through the door by the two parameds. He's the colour of death, except for his tiny, cherubic face half-dwarfed by the bag-valve-mask locked in a desperate embrace with it : that (his face) is the colour of his life, running in streaks and pools. Dark red, and sticky. And already starting to crust; making a mask, over the mask that his face will soon become, anyway.
We run through to trauma, where the assembled trauma team stands ready. The anaesthetist begins intubating almost before the trolley comes to a halt. One of the other A&E SHOs is there. She puts two fingers to the child's chest and begins compressions. Faster... faster, I urge her in my head.
I linger in the background. I'm not really here. I'm a fly on the wall, buzz buzz. It's easier to cope somehow, when you stand back and observe. Cold, clinical. Detached.
I glance to my left. Dad has come through with the crew. He doesn't quite seem to get it, he's saying things like oh don't worry about me, I can handle it, I'm not the sort to get unsettled. I pause and think - your child is already dead. But I'm not here. I keep my thoughts to myself, thoughts like - what chance, now?
Because on the screen he's in asystole. Because he's too shut down for access - two paediatricans and our staff grade are trying to cannulate him in three limbs with no success.
There is fear in the air. That's the difference between ALS and ATLS. The smell of fear.
IV cannulation is abandoned in favour of intraosseous access. That's sticking a needle through into the bone of the shin in children, to deliver emergency fluids and raise their blood pressures back to levels that can sustain life. Children have small blood volumes, and what seems a little loss to an adult can be a fatal bleed in a child. The intraosseous needles bend off at crazy angles as the paeds reg struggles to insert them. Bloody cheap NHS equipment, only good for plastic practice dolls.
The 20ml saline boluses just make little subcutaneous pockets in his legs, and some of it actually spurts out through one of the many failed insertion sites. Squirting back out as fast as it goes in, into the paeds reg's face. At another time and place, it would be almost comical, like those fake flowers clowns with painted faces and ridiculous red noses wear on their coat lapels. The reg grimly plugs the hole with his thumb and keeps injecting - not quite life, but maybe, just maybe a chance at it.
The sister in charge starts to become flustered. She's being bombarded from all sides by requests. Blue venflon. Another. Syringe please. Another intraosseous, now. Adrenaline. Atropine.
The fly falls off the wall. I step forward and begin handing out the drugs. It's the least I can do, without getting sucked right in.
It feels like an eternity since we first started. We're still strugging at airway - there is blood coursing up the endotracheal tube. Not red froth - blood. With every squeeze, it vanishes back down into... somewhere. And then floods back up as the bag is released. For the third time now, someone says -in a slightly shaky voice- I can't hear any air entry into the lungs. The anaesthetist says again, it's going somewhere. But where?
He calls for someone to hold the neck while he re-intubates.
An eternity passes, while all around him people bustle studiously on at their little chores, heads down. And suddenly I'm gloved, kneeling down at the head of the trolley and holding his head. The tube comes out, and there's a fountain of blood. Out his nose, out his mouth. And as always, that slight metallic tang to the air; the smell of life, leaking away.
Suddenly, I am afraid. That's how it is when you stop being the fly on the wall and step into the little surreal bubble that surrounds a trauma. From TV camera perspective, to first-person, looking out from the two round holes at the front of your skull.
We plug back up, and the anaesthetist starts bagging again. Did you know that the valves on BVMs aren't quite watertight? I make this realisation as I feel microscopic flecks of blood hitting my face. It's a mercy I'm wearing spectacles.
I step back to revert to being a fly, but the sister, who's taken over from the other SHO is exhausted from the compressions, and so I'm back in again, doing chest compressions.
Somewhere along the way, access is finally established. But every rhythm check (is it just me, or is the paeds reg calling for them more and more frequently? and more urgently?) shows asystole.
And then the final nail in the coffin. Let's reassess... this child has been down for....... I know the drill. We all do. Call it again, Sam.
Gloves are stripped off, almost in disgust. People creak away, shoulders slumped. Backs are turned as the assembled team troops dejectedly out the room.
I watch two nurses clean the blood off this pint-sized waxwork effigy of a child. Dad still stands by, dry-eyed, saying he's all right. He looks slightly dazed.
This is... wrong.
*****
There aren't many nights that I wish I could get drunk. Random fact #12041 about re-minisce. He's never been drunk. Not properly, with the euphoria and stuff. It's a complete waste of money.
But stopping by the corner shop on the way home, he briefly considers buying a large bottle of Absolut, just to give it another shot. (ha, a pune, or play on words)
He doesn't, because he realises that when the words "I need a drink" float into his mind, it's not the drink he craves, but the company that comes with it. I just need to talk.
Funnily enough, nobody in London wants to talk right then.
IRC is a barren, soulless place. That idea goes out the window in a hurry.
And so I write.
Thank You for listening.
(And for wanting to. These were the words that were lost to the cruelty of a moment's drowsiness.)
*****
Does that answer your question, Jen Jen?
Oh, and highway code rule #xxx : don't put your children into motorcycle sidecars. Ever.
*****
It's funny how some stories are experienced in days, savoured page by page, thought by ordered thought, and how others are all over within twenty minutes, and all that remains is a bitter taste in the mouth, the lingering memory of minute, damp wet flecks hitting a face already viciously scrubbed with water, soap and cheap paper towels, and that slightly metallic - almost synthetic! smell of flowing blood.
