by Joe DeLucia
How do you care for a dieing child? How do you care for the child's killer?
|“Baby’s Mother’s Boyfriend”
Looking up from behind my computer screen, I saw one of my best emergency room nurses. She calmly walked past me carrying a limp baby in her arms. We made eye contact. I could see the fear on the nurse’s face. Her facial expression said, ‘you better come quick.’
With composure but hastily, I followed the two of them into the resuscitation room.
The nurse lay the baby down in the center of the bed, like a tiny doll on a grown-up bed. The baby’s ashen, gray skin, the color of the recently dead, was dark in comparison to the bright, white bed linen.
The color of the recently dead only lasts for a few short minutes. It is not the pink color of a healthy baby, nor is it the blue color of a dead baby whose blood has already pooled due to gravity. It is that in between color when the blood sits in the cells losing all its oxygen and going through enzymatic changes. It’s the color that is saying you have to save this baby’s life now before it turns to dead blue.
Within seconds, other nurses and a respiratory technician joined us. I have always been unsure how, that even in a busy, loud emergency room the message always gets silently sent; ‘we need help, a baby is about to die.’
The team gathered around the baby in the resuscitative room. Lifesaving machinery, ventilators, fluid infusers, medication pumps, extracorporal circulation assist devices, pharmacy carts and bright surgical lights are surrounding this baby still dressed in his blue onesie and diapers.
In my monotone, almost robotic voice, I start shouting orders, “We need a line, get set up to intubate, draw up epi. We need info; somebody get information from whoever brought this baby in”.
My mind is trained and well disciplined. I need to go down the list of what most likely injured this baby and what is most likely going to save the baby’s life. All comparative statistics based on age and circumstances, but mostly guesswork and experience. No time to think about the poor baby or how he resembles my toddler who is hopefully safe at home. No time to feel.
“Get the Breslow Tape:” The baby measures out to yellow, putting him in the small child range, weight approximately 12 to 14 kg. “I need a 4.5 uncuffed endotracheal tube and a number 2 straight Miller blade. Get a 20 French chest tube just in case.” List of medicines with appropriate weight dosages are listed on the tape.
One nurse automatically starts chest compressions, violently pushing on the baby’s sternum with her fist, hopefully circulating lifesaving blood and oxygen preventing the blue color of death.
His clothes are stripped from him. The baby lays naked, his penis and scrotum confirm he’s a male. Wet diapers, the urine is still warm. This is a good sign, both that he recently produced urine and that it is still warm. Small children due to high body volume to weight ratio lose body temperature rapidly once their heart stops beating. This proves that he is still one of the recently dead.
As the equipment is prepared, I examine the baby. Good equal, bilateral breath sounds while the respiratory tech is forcing air into the lungs with a bag valve mask. Head is normocephalic, no evidence of trauma. The abdomen is soft, no distention or masses. No surgical scars. Extremities and torso are without marks, evidence of trauma or rash. I can feel femoral pulses while chest compressions are being done.
Most importantly is the face. I examine the expressionless face. No grimace or response to any of the torture we are putting him through. Nares and mouth are clear. No evidence of pus or infection. I pry the eyelids open and look into blue eyes. There is no look back, just an empty stare. No evidence of hemorrhage. The pupils do not respond to light.
I take my left forefinger and thumb and pry the baby’s mouth wide open. In my right hand is the laryngoscope with the #2 Miller blade. I grind along the baby’s pearly white teeth with the blade, deeply inserting it into the throat until I can pull up on the epiglottis. With a clear view of the glottis, I insert the #4.5 uncuffed endotracheal tube until I can see the black mark on the tube entering the glottis. Like well oiled, precision work, I withdraw the laryngoscope, the respiratory tech grabs the end of the tube connecting it to the ventilator. We both tape and secure the tube.
I am good, and I know it. I am confident to the point of cockiness. I am proven by both experience and days of graded tests. Insecurity is not going to save this child.
I look up, and there still is no vascular access. “Damn it, where’s the IV?” The nurses tried heroically. The baby is covered with needle pricks, some still oozing blood. Without circulation, the vessels don’t fill. Empty vessels make it extremely difficult to place an IV.
“Let’s do a cut-down.” A nurse opens the sterile tray on the bed before I can even get my gloves on. Luckily there’s enough room on the bed for the equipment. I take a scalpel and mercilessly slice open the inner left thigh of the child. For a second, I notice how cute and plumb the leg is. At least the child was well fed. With my fingers, I tear apart at the fatty subcutaneous tissue. It becomes slippery, like grease and the odor enters my nostrils. I finally find the femoral vein, taking pointy scissors, I nick a tiny cut in the wall of the vein. Next, I slide a wire into the vein, over the wire a dilator. Removing the dilator, I insert a large 18 gauge IV over the wire and into the vein. I slide the wire out and even before I place my first stitch, a nurse rapidly attaches IV tubing and starts bolosing normal saline into the vein. Maybe the baby was dehydrated; maybe fluids will help him. No, I examined him, his mucous membranes were moist. He was not dehydrated.
We start giving all the medicines we have, all the medicines that could possibly save the child. “Give epinephrine!” “Give sodium bicarbonate!” “Give atropine!” “Give another 30 ml. per kg, normal saline bolus!”
I am good, no we are good. Before I can finish my words, the meds are given and being repeated at regular intervals. The team works as their souls depends on it. No one wants the mark of a baby’s death on their soul.
My mind races. I have to figure out what caused this baby to stop living. I have to cure it.
“Who’s got any info?” The clerk who’s been standing in the background shouts back, the baby’s, mother’s boyfriend brought the baby in. He was babysitting while the mother was working. His Mother works at McDonald's. The baby is almost two years old. The boyfriend states baby had a bad cold recently”.
That’s not the information I need. “Ask him if the baby has had all his shots or has any medical problems.”
We keep filling the baby with meds and fluids. We keep pumping the baby’s chest and blowing air into the lungs. We add antibiotics and steroids. Maybe the cold turned into meningitis. No, it can’t be. I examined the baby. This baby didn’t have any signs of infection.
By now the team is tiring and sweating. I can see some tears in their eyes. They do not stop.
The clerk returns and apologizes for taking so long. “I couldn’t find the boyfriend; he was outside smoking. He doesn’t know anything. We’re trying to call the mother.”
Outside smoking?!. Doesn’t know anything!?
Furiously, I stomp from the resuscitative room and find the boyfriend pacing nervously in the waiting room. He appears nervous but not concerned. Tall, handsome, wearing cowboy boots and hat, smelling of stale cigarette smoke, he almost sarcastically asks if there is anything he can do to help.
I ask about the recent illness. Was the baby running a fever or throwing up?
He answers in an unsure tone, “Oh, yeah, the baby was running a high fever. I gave him aspirin. That’s not good to do, right? I didn’t know. I’m sorry”.
Now, even angrier, I am more complexed. The baby didn’t feel feverish when I first examined him. Or did I just examine him later after the heart stopped beating than I thought and he already lost enough heat to feel normal? Aspirin for a toddler with flu? That could cause Reye’s syndrome. Reye’s normally doesn’t cause cardiac arrest especially this soon.
My perplexion causes more anger. I am better than this. I should know the answer. I have to figure out what’s wrong to save the baby. My time is running out.
I hear shouting from the resuscitative room. The nurses have continued to work feverishly in my absence.
With an element of glee and exhaustion, one of the nurses tells me they have a heartbeat. She is right. I can hear the lub dub of the baby’s beating heart through my stethoscope. Slowly the recently dead color vanishes as the cells are replenished with oxygen.
Slowly the baby gives us the answers. As the blood circulates, I can see the bruises taking form. The marks of four finger on both the baby’s lower flanks and back with thumb imprints on his belly, as if someone had grabbed the baby around the waist and squeezed. I again look into the baby’s blue eyes. There’s a little bit of a sheen, and the baby looks back. The baby wants us to know. I can see the retinal hemorrhages forming. Pathognomonic of the shaken baby syndrome. This baby was shaken to death.
I tell my team. We continue life support knowing it’s fruitless. We start the legal process, notifying the police and division of child services.
My team is exhausted both physically and mentally. Once relieved by the pediatric intensivists and intensive care nurses, we start seeing the other ER patients. No time to recoup or recover. No time to mourn, not only for the loss of the child but also for the mark on our souls. The baby is brain dead. He will be brought to ICU until the mother is notified and hopefully for organ harvest.
I wonder if I should have been such a good doctor. It was fruitless, no hope. Should I have known that? Should I have tortured that baby with all my expertise medical procedures? Should I have just held him, comforted him and let him know he was loved in his last few minutes of his life, trying to undo the abuse he endured?
With working 12 hours shifts, it barely feels like I left the ER. Once again, I am hiding behind my computer catching up on paperwork. Out of the corner of my eye, I catch the orange jumpsuit, centered by two blue suits walking. Another inmate from the local jail is being escorted to the secure examination room. From the back, I notice he is limping slightly.
For public relations purposes, the administration does not want the inmates to be in the ER very long. Out of courtesy to the police officers, I try to see the inmates right away. As I walk to the secure exam room, I am receiving cold, hateful, threatening stares from the nurses. One of them whispers, “you better not.” I have no idea what is going on but am sure they’ll let me know later.
I enter the room locking the door behind me as per protocol. Two police officers are leaning back in chairs on either side of the exam table. The orange suit is sitting on the exam table. First, I notice the smell of stale cigarette smoke; then I notice he is tall and handsome. It is the baby’s, mother’s boyfriend.
“Hey doc, how you doing,” he acts as if we’re old buddies.
I stare at his face in utter disbelief. How dare he come back to this ER after what he did to that baby. How dare he come back after what he put my staff and me through, misleading us about the prior day’s events.
“Doc, I was playing basketball and twisted my ankle. It really hurts.”
Less than 24 hours after killing a child, he’s playing basketball in jail. No remorse. Does he really think he deserves, medical treatment, pain relief or compassion?
The voices and instincts of my youth invade my thoughts. Growing up in a rough, poor New York neighborhood, my father taught me to protect those who could not protect themselves. I remember my father saying, ‘if someone was to attack you or try to rob you, extract revenge. You’re responsible for beating the attacker so bad that he would never be able to attack again. For if he could, next time it could be your sister or mother’.
I wanted to jump up on the exam table and strangle the orange suit even with his hands handcuffed behind his back. I wanted to squeeze the life out of him just as he did to the baby. I wanted to inflict pain and terror. I think I would have if not for the police officers.
The voices of my youth quieted down. The good doctor came back. I examined his ankle. There was mild generalized swelling, no point tenderness, the normal range of motion and he was able to ambulate. Per Ottawa’s ankle rules, no chance of fracture. I gently placed an ace bandage around his ankle. I gave him some aspirin (he liked aspirin) and his discharge papers. I knew better than to ask the nurses to do anything.
The baby’s, mother’s boyfriend got two and a half years suspended the sentence for involuntary manslaughter.
I spent the rest of my life regretting and questioning what I had done. Should I have squeezed the life out of him as my instincts and father demanded? Did I regret not harming him or did I regret breaking my physician’s oath even momentarily?
I still see the baby’s expressionless face in my dreams. Did I treat him correctly in the last moments of his life?