It’s wild what you do and do not remember after a trauma or resuscitation. There are a few that I can’t recall whatsoever, which is a little strange in some respects. For whatever reason they didn’t impress themselves upon my mind and make me feel as though they were a part of me. They were “normal.” The first time I ever did compressions on a real person was memorable for just that it was the first, and perhaps that the injuries we later found are explained with no real ease and left the impression that it was intentional. He was 3 months old, and I remember how tired and painful my thumbs were. On small children you do compressions by wrapping your hands around the child’s chest and compressing with your thumbs rather than your palm.
We worked him for nearly 40 minutes, with his little heart wanting to jump start several times after each dose of epi. But each time it would wind down and we’d have to start again. While intubating, our attending doc could feel crepitus at the base of the skull – the feeling of bone on bone, indicating a severe fracture. Basilar skull fractures are rare (~4% of all skull fractures), and even more so in infants. Strangely, he had no outward signs of significant internal injury.
CT revealed that he did indeed have multiple skull fractures – roughly 7-8 that I can recall. Foul play? Most likely. At this point his heart rate (HR) was around 150-160, a little below what we’d expect and desire with the epi dosing he’d taken. The attending’s order was to notify PICU that if he coded again on the way up – it’s a long walk from the ED to the PICU, and an elevator up 6 floors – we would call it and turn back to the ED. Not 30 seconds later his pulse began to drop, toned dispassionately by the Zoll one beat at a time.
I don’t remember his name, though I do remember that mom and dad (who had been watching the kid before work while mom was gone) – when told they could come be with the body but couldn’t touch it, as it’s now a Medical Examiner case – walked by the room and went outside to smoke a cigarette. Rumor was that mom was already suspecting dad as the abuser; imagine dealing with that one. People handle trauma in very strange and unexpected ways, sometimes.
My next round of compressions was a trauma, and I remember nearly every detail of that one. Four year old boy, struck by a pickup at roughly 40mph. Frankly, he was likely dead before he ever hit the ground. The truck then ran over him twice before it could stop. This was witnessed by his entire immediate family, including several brothers and sisters and his parents. Normally, if he were an adult, he would probably have been pronounced dead on scene. The community, however, would probably (rightly) frown on its firefighters arriving in million dollar trucks and just throwing a sheet over a bloody kid. So to us he came.
It was late January and a beautiful day, probably around 4-5pm. I recall precisely the month because I had just gotten my glasses, which would play some part in this later. We were waiting bedside when they arrived, and my first recollection is that the firefighter was doing terrible compressions. For peds, the prescription is between 100-120 beats per minute (a good bit faster than the layperson may realize), and 1.5-2″ or 1/3AP (anterior-posterior depth). He was getting maybe 70bpm at 1″ (if that), and with one hand. Now, I understand what he was seeing on scene and on the ride to us, but the parents are with you and, though they will likely remember very little from that day, at least look like you give a shit. Pretend, until you get to us. Nothing will stoke my ire like EMS coming in half-ass – whatever chance a kid had is now likely gone if you’ve done improper compressions for the better part of half an hour. Just do it right or don’t do it.
But like I said, I understand his thinking: he was gone the moment he stepped in the street. Now I’m standing over the top of him, my face just a couple feet from his, my hands square over his sternum and my eyes locking on the Zoll to establish proper rate and depth. The Zoll will show both, and even speak to you; very helpful in a room full of chaos. Just lock on and keep up. Once I found it, I began to look around to see what else could be done. There is usually one Looky Lou tech standing near the door, and while it’s technically forbade, he or she can be helpful to grab if you need something done right then. Maybe a cup of ice for the lactic blood labs. Or point-of-care (POC) testing (HemoCue and glucose) that can be done in the room without going to lab.
So I’m on target and looking around. Dad is with the social worker at the door, probably 20 feet away from the bed. As a “rule,” we don’t allow parents in the room during workups. The caveat is if they insist. I cannot imagine what it must feel like to watch your lifeless child bleed out in a room full of strangers in what appears to be disorganized chaos. But there dad is, his shirt covered in his son’s blood. And I have a view, on my pedestal, of the entire room. It’s hotter than Hell (nearly quite literally; the room is heated to mid-80s since bodies experiencing trauma are less able to maintain homeostasis), we’re all wearing lead gowns to protect from radiation exposure, beneath our PPE gowns and gloves. Then my glasses begin to slide. I’m covered in blood from my elbows down, since our kid, now intubated, is expelling blood as quick as we can transfuse it, from his nose and right ear with each squeeze of the ambu bag. His left ear is nearly detached, and there is a 60cm x 30cm gash out of his right forearm, down to the muscle sheath. We get a nasogastric tube in, and the return is feces. At this point it’s nearing flat-out disgusting. And my glasses are sliding down my nose. All I can envision is them falling onto his blood-covered body, and likely onto the floor where they would be destroyed, never mind becoming an absolute bio-hazard. I look around; who can help me? Everyone bedside is covered is as much blood as I am, and I don’t want to make a scene about such a small thing. But it’s getting critical. Across the room is another attending doc, and we make eye contact. Bingo. She laughs to herself and obliges, saving a small tragedy from accompanying the major one before us.
And the show continues. I see dad, near the door, crying and covering his eyes, but looking up every few seconds, hoping against hope that something can be done. But I can tell by his tears and his expression that he knows what we all know, already. His handsome little boy is gone.
The sight gets even worse, with blood now cascading off the bed and pooling on the floor. He is bleeding so profusely and violently from his head that we cover his face with a blanket, just to protect us from the spatter. I was ready to quit. Enough is enough. By now his testicles are blowing up, nearly the size of a softball which, in case you aren’t familiar with 4yo boys, isn’t normal. It means the air we are putting into his lungs is making its way to his testicles and beyond – his thoracic cavity is trashed, his vital organs have no integrity. The trauma doc immediately performs somewhat sloppy but clinically effective bilateral chest tube placements to evacuate the air and restore “normal” internal spacing. But at this point it’s all gone, and I just want to stop compressions. The trauma doc holds out, and it’s getting worse. Thankfully, a distinguished-looking older physician whom I had never seen before was standing next to our trauma doc, and professionally and tactfully but assertively tells him he needs to call this and stop it. Now. Trauma doc thinks for a few moments, and is admonished again. I’m watching, silently begging him to listen. One more: “You need to stop.” He’s the PICU doc, he’s salty and knows when to quit. Trauma finally relents, and my hands are off the chest before he finishes his sentence.
“Time of death is….”
We clean up, both the room and the body as much as possible. The injunctions we put in the body – IVs, airway, NG tube, chest tubes – have to stay in for the ME, but we can make him a little more presentable for the family, and mayyybe skirt the rules a little. For instance, the rules say that you can’t take a locket of hair from the deceased, for the family, but…what ME don’t know won’t hurt. The families don’t remember a lot of what we do; they’ll never know about the technical aspects, never appreciate our sweat and the battle we fought. But they’ll remember the small things forever, and those are worth it all. His mother, I found out as I walked by, was just down the hall in the family room with her other kids during the whole ordeal. She was covered with more blood than dad.
Her son’s name was Kevin.