Restless

There are some things which take a long time to digest. 

This blog post, written many months back, was nothing less than an out-pouring of the soul. It has gathered dust for some time in my draft box as I decided to write about happier things, and also realized that it needed drastic editing. Many details of the story have been changed for reasons which will become self-evident, but the essence I present to you here.

It is 5:30 a.m. and I am still awake because I am restless. My heart is beating quickly despite having done nothing but nervously browse the internet and play computer games since midnight. Even facebook has ceased to hold entertainment value: the news feed updates slowed to a trickle, and friends whose thoughts I actually would like to know have long gone to bed like decent folk.

If I still kept a journal, today would be marked in red pen and bold letters as the first day I saw a code called on a child. By "code," I mean that the ICU team initiated cardiopulmonary resuscitation (CPR), keeping alive someone who, by all the laws of nature, ought to be dead and stay dead. CPR is popular in movies and on TV. Even Bella Swan gets CPR on the wide screen. (It was terrible CPR, by the way). And always in the movies, CPR is the silver bullet. A few sexy mouth breaths (they never pinch the nose shut, of course) and a couple of tearful chest thumps, and then --POOF! He lives! He breathes! He is kissing his rescuer!

I have been avoiding this inevitable moment all evening. I have plied myself with pizza, Mystery Science Theater, Diet Coke, Starcraft, Pinterest, facebook, fashion blogs, guitar-playing, and singing (quietly) ... But now it is too late, or to early, to sleep and to forget, and the thing which I have tried to forget, which I cannot seem to resolve, has absolutely insisted that I sit down with cup of tea and a blanket and write it out. I am struggling to come up with a tidy solution or a handy answer, and what is left in me is an uneasy weight on my chest and a buzzing in my head that feels like my skin has shifted just to the left and up a bit and no longer fits quite right. I should stop and just tell the story now.

Today, before rounds in the pediatric intensive care unit (PICU), I had heard through one of the other providers that a child was coming to the ICU, just for observation. She looked sick, sure, but she should be fine, was the report. She had been hospitalized for another minor issue, croup or RSV bronchiolitis or some such bread-and-butter pediatrics. The caveat was that she had been born with a congenital heart defect (hypoplastic left heart syndrome) that required intense surgical repair (she was a Glenn, or in the second stage of repair). She was on the wait-list for a heart transplant. They were just being cautious. Don't scare the mother.

I was standing in rounds when the bed rolled in with the little girl. Cute as a button, bright eyes and long lashes, curly blonde hair. My daughter's size, a little smaller than her but pretty close. She was about three years old--also my daughter's age-- and she was crying weakly. Her mother and father fluttered at the bedside around two nurses and an intern attending to the patient. One of the nurses was holding an oxygen mask. There were piles of unopened toys and presents at the foot of her bed. Between two comically oversized GET WELL balloons, the oxygen monitors read 87%

Since this patient was ours, I left rounds as well, mostly out of curiosity, to listen to the intern from the other floor give check out to my ICU resident.

"Yeah, so she's a three year old, status-post Glenn," the intern was saying. "I got paged a few times on her because I guess she was crying all night long, but she always cries. We just gave her another dose of Lasix because we thought she might be wet. I guess she might look tired, but I don't know, I think she's fine..."

The intern shrugged, casting doubtful glances at the pale child, who was sitting upright in bed, continuing her mew-like cries and panting quickly. The oxygen monitors slowly began dipping further down. Low 80's, 70s. The intern left soon after, and our team filtered into the room.

At this point I noticed that there were more people than I would have expected. The attending, the resident, the fellow, the nurses, the nurse practitioners--more and more bodies began slowly trickling into the room. Not running, not rushing. Just appearing. There was a sense of purpose. When people walked across the room, their eyes remained trained on the continuous monitor that was reporting blood pressures, cardiac electrical rhythm, oxygen saturations.

When the child was finally situated in bed, and our team began examining her, something changed. Good doctors know a sick child when they see one, and what the brand-new resident couldn't see when he checked out to our ICU with a carefree, "Yeah, she's crying, but he always cries when you go in... I guess she looks tired but..."... my attending, who just happened to stroll in at that moment, instantly knew there was something brewing. The parents were in the room, so I was one of the few close enough to see him turn to one of the nurses and mouth/whisper:

"Get ready to intubate. And get the crash cart."

The "crash cart" is a rolling cart holding all the necessary items to begin resuscitation in the event of a life-threatening situation. It is not a good thing to see in a patient's room.

I had felt an uncomfortable chill settle into the room and had literally backed into a far corner, folding my arms across my chest and leaning against the two walls, observing. Medical students who have made it through third year know when they should probably disappear, and I was getting that feeling. People were coming into the room a little quicker now. Several people were keeping their hands on the patient at all times, feeling pulses, listening to heart rates. The patient was not opening her eyes.

"Hey sweetheart, wake up," the attending said. His voice was kind, but commanding and urgent.

"Honey, my love, open your eyes for the doctor," her mother had said. She had on a brave face although her eyes were misty. She sounded very motherly.

The girl's weak cries had died down, and she looked like she was asleep, although still breathing quickly. The attending's brow drew down even deeper, as he became more insistent.

"Sweetie, I need you to wake up. Wake up."

"Honey wake up, my love," the mother said, mimicking the doctor's commanding voice.

"Wake up sweetie. Nurse, get some epi."

Just as epinephrine and albumin were administered, something happened, like a switch being thrown. The patient suddenly groaned and arched her body. She threw her head back. I thought for a moment that the interventions had worked, that she was waking up because of the cold sting of the bolus. She opened her mouth very wide and made a deep, shuddering noise, somewhere between a breath and a grunt, and her eyes flew open but saw nothing.

A sudden alarm went off, and the monitors flat-lined.

The attending, who had been standing near her with his arms crossed, suddenly jumped on the bed and straddled the girl, pumping at her chest. The room exploded with nurses as my attending shouted orders. There was someone drawing up meds, someone administering them, nurses putting in lines, a nurse for each pulse, a nurse charting on paper, another on a computer, and several
 fetching items and refilling syringes that were flying out of the drawers almost faster than they could replace. Paper, plastic caps, wrappers exploded in every direction and where everywhere underfoot. Someone placed a board under the girl's back so that the CPR was more effective. A team of people were huddled at her head, gripping her chin and lower jaw and forcing a tube down her throat while the rest of her body jerked up and down in a rhythmic dance.

I made myself as small as possible, and it was so crowded that I couldn't move from my corner for fear of getting stuck by a needle or elbowed by a whirling nurse. I couldn't have left the room if I had wanted, for I was trapped between the crash cart and a supply cart and two nurses.

Honestly, though, I've seen this all before. Not only have we run "practice" code situations, but I have seen plenty of dramatic scenes in trauma surgery or on the OB-GYN service. Even more dramatic, I could say, involving lots of blood and tissue, and my boots would leave bright bloody footprints when I left the scene. Those scenarios, however, did not involve parents.

When all hell broke loose, there was one voice louder than the entire group of over twenty people combined. I have never heard any scream as blood-curdling, as chilling, as gut-wrenching or raw than the scream of a mother realizing that she is losing her child.

She screamed and she screamed and she screamed, holding absolutely nothing back, not an iota of volume. She screamed with her face, with her neck, with her chest, her entire body practically bent over at the waist, her head flexed up and her hands clenched by her face, and every now and then she would step forward and stamp, and point at the monitors, an accusatory finger that I felt was pointed at God.

"Oh my God, Oh my God. Oh my God oh my God oh my God."

She was screaming at the physicians, screaming at her child to "wake up," screaming at God to show himself, screaming at Jesus to intervene.

"God, where are you?" she screamed. "God, show yourself. Jesus, don't make me a fool. Jesus, don't make me a fool. Don't make me a fool, Jesus."

She was so hysterical that the staff couldn't hear each other's requests. When her husband tried to wrap his arms around her, she threw him off with a wild struggle, her elbows out and ready to fight. Another nurse instantly stepped in, and the two hung on to her as she raged and cried, fighting and grieving as though her energy could somehow impart life to her child. They dragged her out of the room, arms wrapped around her waist, and she fighting them the whole way. Her screams could be heard echoing down the halls of the entire ICU, but they had now lost any resemblance to speech and were nothing but bursts of animalistic screeches. The parents of the patient next door, a baby with newly diagnosed heart failure, gently slid their door shut.

Meanwhile, the resuscitation efforts proceeded. People administering CPR switched out, tired and sweaty. My resident stepped off to the side, patches of dark showing through his green scrubs, a sheen across his brow that he mopped away with a blue towel off a cart. The little girl's body and small limbs jerked up and down like a sad, beaten doll. Meanwhile all eyes remained trained on the monitors.

And finally, after twenty minutes, an axillary pulse was found. A heart rate was established. The room paused, waiting with tense breaths, until several minutes of sinus rhythm had gone by. Ten minutes later, there were a few less people in the room. Fifteen minutes, others slowly began picking up trash and cleaning trays. Twenty minutes, the room had all but emptied of the necessary care team, and they began setting up a sterile field to establish good arterial access in the groin. There was no announcement, formal speech, or dramatic gestures of high-fiving, back stretching and pats on the back. People just trickled out one at a time, heading back to their various tasks of keeping other patients alive.

Both the parents at the bedside were now quiet, subdued, weepy, relieved, trying to smile. The mother was disheveled, as if she had just woken up.

From my little corner, however, I noticed no relief on the faces of the staff. No smiles, no happy sighs, no congratulations or hand shakes.  "Let's see what the labs say," I heard. "That was a long time."

And this is the sad truth about the heroic efforts that I witnessed: CPR may save a life, but often it doesn't, and when it does there is no guarantee of what kind of life it has left behind. When death comes, it doesn't take kindly to being turned away, and the havoc that lack of circulation wreaks on the body can produce very bad things.  And should the child survive, she may have lost her kidneys, or intestines, or her brain. If any of these things had happened, which they easily could have, then she would have been resuscitated only to be handed a different death sentence: that is to say, she may not emerge a candidate for heart transplant anymore.

But how is a team going to tell all of these things to the parents, who are standing at the bedside, so grateful, so happy, so upbeat that the monitor shows a heart rhythm?

The child before them looks nothing like the child that first came into the room. A huge, swollen belly, cold, dark limbs, bruises all up and down her bare chest, a breathing tube coming out of her mouth and taped down, swollen purple lips, swollen eye lids and glassy eyes peeking through. But for the moment, the parents can say, yes she is still alive and with us, because the 2x2 screen above her bed tells us this is so.

I left that day feeling a profound sense of defeat, and so it was that when I returned the following Monday, one of the first things I did was ask after the patient.

"The little girl in Room 1? She passed on."

I stopped in the middle of taking a sip of my coffee. I felt a pricking behind my eyes and blinked it away.

"When?"

"A few hours later, same day," said the nurse very matter-of-factly. "She coded twice more and her echo looked so bad, and then the parents asked us if we thought she'd make it, and we told them the truth."

"So what happened?"

The nurse made a few notes into her computer entry system, then looked up from her laptop.

"We unhooked her. We let Mom hold her. She died in their arms."

When I went home that day, I stopped by the apartment to change before picking up my daughter. I went into the living room and looked at all her toys. Her favorite little bear plushie, the little Lego girls that she loves to pull apart, the puzzles she loves to assemble. I walked into her bedroom and put my hands on her toddler bed and imagined what the parents of that patient (I don't even know her name) did when they got home. What where the girl's favorite toys? Did she like to scribble with crayons, and did they hang up her artwork? When they opened their medicine cabinet, would all the prescription bottles bearing her name stare silently back at them? What about her shoes, lined up next theirs? The miniature socks and the tiny little underpants mixed in with their laundry, how long would those keep appearing when they pull out a load or move the dryer or when they look under the couch for the remote?

Where there other children waiting at home, old enough to grieve or too little to understand? Would the parents gather their brood in their arms and given them stronger hugs, tell them we miss your sister but we are here for you, too, and even think to themselves that now she has passed they will actually have time for the others, time for more than surgeries and appointments and prolonged hospitalizations?

Or do they come back to an empty home and an empty extra bedroom with no purpose now, with a house full of reminders of what they have lost, and do they wonder if they will ever want another child?

***

In my miscarriage some time ago, I experienced deep grief over the loss of the mere promise of a child. I cannot reach farther than that to understand the grief of losing a child that I have already borne into the world and held against my heart. Even so, when the mother screamed, I felt my soul scream with her, and I still cry every time I think of that day.