Finalist, 2017 Remember in November Contest for Creative Nonfiction
My pager alarms and the number in the display is one I’ve never seen before. The white-coated audience members reflexively check their own pagers in response to the familiar buzz. I lean over to the person next to me at Grand Rounds and show him the number. “That’s the transfer center,” he whispers. As a new faculty member in my first job out of fellowship, I am still learning the hospital protocols. I try to make a discreet exit from the darkened auditorium, but the heavy door slams behind me with a thud. I find the house phone just outside the auditorium and dial the number flashing on my pager.
“Hello, this is Doctor Erkonen returning a page.”
“Thank you. Please stay on the line to get report on a transfer coming to the PICU.”
“Sure.” Listening to the classical hold music, I assume this is a child with an asthma attack or seizures. Or maybe it’s a kid with respiratory failure from a bad pneumonia. I have trained for this moment for ten years. Four years of medical school, three years of pediatric residency, and three more years as a pediatric critical care fellow. My time as a medical apprentice is done. I no longer have an attending physician to help me with my decision-making. I am solely responsible for my patients. Shit, I start to worry, I hope this is something simple.
“Hi, Doc,” I hear a young voice through the static of the radio line. “This is Jake with the Med Force transport team. I have a 20-month-old child with an estimated 85 percent body surface burns.”
Not so simple. Pediatric burns to that degree are almost always lethal. The poor connection distorts his voice, and I strain to hear. My heart rate jacks up and I feel a chill come over me.
“We are about ten minutes out. I have her on our transport vent, but she has ashes and soot coming from the endotracheal tube so I stopped her IV fluids. Her blood pressure is low, and I started some dopamine. What else should we do?”
I picture a 20-something guy scared to death in the back of an ambulance trying to manage a very ill child. He has limited experience, equipment, and help. I hear my heart pound in my ears. He needs to keep giving her fluid even though her lungs are sick and he has to increase the pressure on the ventilator.
“OK,” I take a deep breath and instinctively start giving him orders. I try to use a clear, cool voice to keep him calm. “Restart her fluids and increase her PEEP (positive end expiratory pressure) on the ventilator.”
“We’re not supposed to do that without an order.”
“Go ahead, it’s a verbal order,” I reassure him.
He then gives me a set of dismal vital signs and other pertinent information about the medications she has received. I have never cared for a burn by myself, and I feel a pang of panic. I long for the safety net of a supervising physician to help me care for this baby.
Shit, shit, shit.
“I’ll meet you guys in the trauma bay,” I reply calmly. Oh my God, I hope he gets her here alive.
I hang up the phone, and immediately realize I don’t know where the trauma bay is, and I am in dress clothes. I find my charge nurse, Tammy, in the PICU, and she directs me to the locker room. I pull on a set of scrubs, then ask her where the ER is. She gives me a knowing laugh, and says she’ll come with me. I feel like the emperor with no clothes, a fool about to be exposed to everyone.
Turns out we have to go to another hospital a few blocks away since they are handling all traumas this month. A tall, handsome paramedic who looks like he just graduated from high school is waiting for us in the ambulance bay. We pile into the back of the rig and arrange ourselves on the narrow metal benches devoid of seatbelts. The ambulance takes off with a lurch and each turn sends us sliding into one another. The nurse and paramedic chat and let out an occasional “Whoa,” while I try to remember the Parkland formula for estimating fluid needs in a burn patient.
The driver pulls the ambulance into the large parking lot attached to the neighboring hospital’s emergency room. We tumble out, and someone points us in the direction of the trauma bay.
“The patient just got here about twenty minutes ago,” he informs us. I walk into a large room where I see a surgery resident hovering over a small child on a gurney. A nurse and a respiratory therapist stand nearby. The vital signs on the monitor are ominous: Elevated heart rate. Low blood pressure. Oxygen saturations in the 80s.
“Hi, I’m Doctor Erkonen with the PICU. Can I help?”
“Oh great, this kid is super sick,” the surgery resident replies with rapid, pressured speech. He looks cool and in control with his hands folded across his chest and a broad-based stance, but I can tell from his shaking voice he’s not sure what to do. Like a gentleman opening a door for me, he steps away from the child. The room is filling with medical students, surgery residents, and ER nurses–but everyone is taking on the spectator role.
“What’s happened?” I ask him.
The resident starts to rattle off the salient points of the trauma as I begin to examine the child. “Twenty-month-old female extracted from a house fire with close to 90 percent body surface area burns. Intubated at the scene. She’s hypotensive on ten micrograms per kilo per minute of dopamine. Her oxygenation is in the toilet.”
I see a small naked child with blond hair matted to her head. Her face is free of burns but is covered with a thin layer of dark soot. The inside of the plastic endotracheal tube is nearly black due to the soot coming from her lungs. Her small arms and hands are beet red and swollen with charred areas of skin on her palms. Her tiny fingernails have chipped pink polish and dirt underneath them. Her entire chest wall is covered in what seem to be full and partial burns. The superficial layer of skin is gone with large patches of exposed beefy-red tissue. The areas that are not charred are tight and shiny. Her feet and face appear to be the only areas spared by the fire. In medical school I hated taking care of burns. The charred skin and painful dressing changes made me light-headed and squeamish. It takes a steely resolve to overcome your own discomfort and attend to the patient.
I pluck the stethoscope from around the resident’s neck, in order to fully assess her air movement. I place the diaphragm of the stethoscope on the child’s damaged chest. Silence. I ask the respiratory therapist to take her off the ventilator, and I start bagging her myself to see if her chest will move. Nausea rolls across my stomach. Her stiff chest won’t move no matter how hard I try to squeeze air from the bag to her lungs.
I determine that we have to perform an escharotomy of her chest. This is an emergency procedure meant to relieve the compression of the chest by separating the inelastic eschar area of burn from the tissue below, thus allowing the chest to move enough to provide adequate oxygen delivery. It’s the only chance to improve her oxygenation. It’s a procedure I have only observed. But thankfully a nurse with a burn center ID enters the room. She comes right to the table and introduces herself.
“I heard we have a bad burn. Can I help?” she asks.
“Yeah, she has circumferential burns around her chest and I can’t get good air movement.” I reply.
“Escharotomy?” she offers.
“That’s what I was thinking. Let’s do it,” I answer.
There is no need to sterilize the area since we are working on tissue that is already dead. She grabs a scalpel and makes an incision along the side of the child’s chest. She then hands the blade to me. I don’t have time to be nervous or to second-guess my decision. I mirror her motion, and the burned skin filets open, revealing healthy pink tissue below. With that her chest begins to rise and fall with the breaths from the oxygen bag, and for a moment I am hopeful. I look up to see the number of spectators in the trauma bay has multiplied. Medical students, residents, and paramedics have filled the room watching the scene unfold. There must be at least 30 people in here. Some are standing on stools, a few sit on the stainless steel counters. It’s like some surreal reality TV show,: the patient and I reluctant stars, my inexperience on display.
I hear a male voice with a New Jersey accent ask, “What’s the story?”
The voice belongs to a large, lumbering, bear-like man in a long white coat and scrubs. He has wire rim glasses and shaggy dark hair. His calm voice could be asking, “How’s the weather?” And he seems to be in no particular hurry.
The surgery resident gives him a brief synopsis. Without acknowledging the information, he approaches me and introduces himself as Dr. Wurtz, the trauma Attending. Behind him is a well-dressed younger man in a shirt and tie who looks like he’d be more comfortable in a country club. He introduces himself as the burn Attending, Dr. Edwards. He deliberately circles the trauma gurney with his arms crossed and lips pursed. When he makes his way to me he leans in as if he has a secret, and I catch a whiff of expensive cologne. “Maybe you should try some aerosolized heparin down the ET tube.”
I’ve never heard of that before, but I call for the drug, and a faceless voice calls out, “Got it.”
Feeling like an idiot, I nonetheless plow forward. I ask for the blood gas results and the surgery resident says they haven’t gotten any labs yet. We need this crucial data to guide our resuscitation efforts.
“What have you been doing?” Dr. Wertz asks the resident in an irritated voice. I empathize with the young resident. I remember trying to anticipate my Attending’s every preference. Always on display, always proving myself. I still feel that way.
“I have a good pulse here. I can get an arterial sample,” I say.
A nurse hands me a syringe, and I plunge the needle into the child’s femoral artery. Dark wine colored blood fills the syringe. Arterial blood should be bright red—I already know the results will be critical.
“Turn up the dopamine and give a fluid bolus, please,” I call out.
Again, the same voice responds, “Bolus going in, dopamine to fifteen.” Whoever that is, I like him. He is fast and efficient, and whenever I look up he is searching my eyes for the next order. Does he know how scared I am?
As expected, the results of the blood gas are dismal. She is going to die if we don’t turn this around. “Bicarb,” I say. Her blood gas is terribly acidotic, and this drug is meant to buffer the metabolic derangement. “An amp of Bicarb.”
While the burn nurse gives the drug, I open a central line kit and start to place it in the child’s groin. I hit the vessel, thread the wire and dilate it. I notice my hands begin to shake. Thankfully, my muscle memory kicks in, my hands quiet, and I finish placing the catheter.
“Strong work,” Wurtz says with a pat on my back and a dismissive glare to his resident. The line should have been done as soon as the child hit the door, and the poor resident didn’t do it. I turn my attention to her ventilation. I ask the respiratory therapist to let me squeeze the bag again. Her chest is still tight. I instill saline down the breathing tube and bag, again trying to coax the blood and soot out of her airway. I do this again and again.
“Let’s get another blood gas.”
The results tell me she’s dying. “Another amp of bicarb, please. And she needs blood.”Dr. Wurtz glares at the chief resident again and says, “She didn’t get blood yet?”
The resident hangs his head, raking his hand through a mop of thick black hair. It’s a rookie mistake. He mutters to another resident, “Damn I should have thought of that.”
Suddenly, somebody calls out, “Heart rate dropping!”
“Start chest compressions,” I order. Since I know no one’s name, I point at a nearby nurse to initiate CPR.
“I need a code dose of epi, calcium, and bicarb, please.” I administer the drugs through the line in her groin, and instruct the surgery resident to place an intraosseous line in her tibia because we need more vascular access to give continuous infusions of epi, and she will need blood.
“I can’t, she’s too burned,” he replies.
“You can do this. We need more access.” I instruct a nurse to hand him the I/O gun. As he drills the needle into her bone, I see he is sweating through his scrubs. He gets the line, and searches my eyes for approval. I give him a nod.
“Start an epi infusion in the central line, and give the blood in the I/O,” I instruct him. I turn to Dr. Wertz. “Can you take over? I need to talk to the family.”
“Sure, we’re goin’ nowhere fast. This isn’t turning around.”
I ask no one in particular what the child’s name is. A female voice answers, “Lauren.”
I find my way to the waiting room where I search for the little girl’s family. I recognize them immediately. A large group of young adults cluster in a corner. An older lady is hugging a 20-something year old woman who is sobbing in her arms. I steel myself to deliver the bad news. I approach them and ask if she is Lauren’s mother? She nods yes.
“I’m one of the doctors caring for your little girl and I need to tell you some bad news. “ I pause and wait for her to make eye contact with me. “She is extremely sick, and I don’t think she’s going to survive this. We are doing everything we can, but it’s not going well.”
She starts to sob, and buries her head in the older lady’s chest. Then I notice that she has a disposable Bic lighter in her hand. She keeps flicking it so that flames jump from the spark wheel. Her action gives me a weird feeling, and I begin to wonder what actually happened at that house. I notice that her hands are dirty. Not from the fire but because she hasn’t showered in several days. She has a slight head tremor and her skin is unnaturally tan, like leather. Her clothes are misshapen, stained, and reek of stale cigarette smoke. Her short crew-cut hairstyle frames her puffy, acne-dotted face. Crooked, rotting teeth age her. Children who are victims of burns are also often the victim of abuse and neglect. I hypothesize that this mom, too, is a victim of poverty and the cycle of abuse. She likely has a substance abuse problem of some sort, and this fire is either due to neglect, the manufacture of meth, or perhaps just living in substandard housing. Later, I will notify Child Protective Services as part of the routine work up of a pediatric burn. None of this changes the fact that this poor, young mother will lose her child today. It’s tragic on so many levels. My heart breaks for her, for her little girl. They are both victims.
“Can I go see her?”
“Not just yet.”
I repeat the facts of our failing resuscitation efforts and let the awful news sink in. She looks down at the ground and says nothing.
“Is there anyone I can get for you? Would you like a pastor or a priest?”
“She was never baptized. I think I’d like to baptize her.” She swats away the tears from her face and nods decisively to no one in particular.
“OK. We’ll call someone. Right now I’ve got to get back to your daughter. I’ll update you with any changes.”
In the trauma bay Lauren’s blood pressure remains dangerously low, and her oxygen saturations are now in the 60s. Her abdomen is distended, putting more pressure on her ailing lungs. In a last desperate attempt to save her, Dr. Wertz decides to open her belly to relieve the pressure. Within minutes he has her abdomen open. Fluid gushes onto the floor, and her swollen intestines are wrapped in gauze. Again, she codes. Chest compressions, code drugs, fluids, repeat. Finally, her heart rate returns, but it is slow and irregular. We have reached the point of medical futility.
I turn away from Lauren and face the room full of nurses and doctors.
“I think we should stop resuscitation. Is everyone in agreement? Does anyone have any other suggestions?”
The chaotic movements of the nurses and doctors cease, and the room quiets. The burn nurse looks me in the eyes, nodding.
“OK, if she codes again, no chest compressions. Let’s get her cleaned up. I’ll get her mother. Thank you, everyone.”
The nurses scramble to pick up the needles, plastic wrappers, and bloody gauze scattered on the floor. Lauren’s face is turning a pale blue and she has no color to her lips. A tearful young nurse grabs a clean sheet and covers her burned chest and open belly in an attempt to make the child presentable for her mother.
Lauren’s mother stands up when I enter the waiting room and greets me with hopeful, expectant eyes. But as soon as she sees my face, she knows. She shakes her head back and forth, mouthing the word no repeatedly.
“Mom, you need to come to the trauma bay and hold your little girl,” I say quietly. “There is nothing more we can do.” She pounds her fist against her thigh, and wails, “No!” The waiting room filled with unwilling witnesses grows silent as she falls to her knees and moans. “I left her for just a minute, it was just a minute… I only left her for a minute.” I kneel beside her, put my arm around her shoulders and smell whiskey and cigarettes. The blue Bic lighter is still in her hand.
“Lauren needs you now. Come on, come and hold your baby.”
I help her to her feet and guide her toward the trauma bay. We walk the gauntlet of the waiting room. Some stare, others avert their gaze. An older lady pats her on the shoulder and tells her she’ll pray for her. A priest greets us in the trauma bay, inquiring if she still wants a baptism. She nods stiffly. A nurse positions Lauren in her mother’s arms. While I try to bag oxygen into Lauren’s dying lungs, the priest begins the baptism rite. Lauren’s mother’s tears fall onto her dying child’s face. One tear hits a soot-filled patch. I watch it track down her cheek, leaving behind a trail of clean pale skin. The priest continues the ritual and when he finishes, I disconnect the oxygen bag. Her mother rhythmically rocks her little girl, sobbing, “I’m sorry, I’m so sorry.” Lauren’s heart rate slows to 30, then 10, then zero.
I listen one last time to her burned chest and hear nothing. She is pulseless, and her lips are blue. I look up at the large digital clock on the wall and call, “Time of death: Eleven-forty-two.” The room is empty of residents and medical students who have moved onto other responsibilities, other learning opportunities. The show is over. Although I know her death was inevitable, I feel like a fraud, a failure. I wander out of the trauma bay in a disoriented, deflated haze.
Dr. Wertz is waiting for me at the nurse’s station with the surgery resident by his side. He shakes my hand and thanks me for my efforts. As I turn to walk away he grabs my arm.
“Just a second,” he says. He grabs a tissue from the nurse’s station and wipes some soot from my face.
“Welcome to the team. Nice job.”
STORY IMAGE CREDIT: Flickr Creative Commons/KOMUnews