25 February 2006

Well, that's just not fair

His parents brought him in, limp in their arms and unresponsive. He was seven and small for his age. Oddly, they didn't seem particularly concerned. I don't know what they were thinking, but the triage nurse took one look at him and brought him straight back and came and got me from my morning coffee. He was a funny-looking kid, pale with a large forehead, but cute in his way. But the way he lay on the gurney with his eyes closed and snoring respirations while the nurse put an IV in told me something was amiss, seriously so.

A quick interview yielded no clues -- he just collapsed while walking to the potty. No illness, no ingestion, no trauma, previously healthy kid. He had been talking when mom came to get him, though he couldn't walk on his right leg, but then got sleepier and sleepier on his way in. I thought perhaps he had had a seizure with a prolonged post-ictal state. But obviously, this kid was going to need a huge work-up -- CT scan, spinal tap, blood tests, toxicology tests, etc.

The Head CT obviated the need for the rest of the work-up:

The bright white stuff is blood, most likely from an aneurysm or vascular malformation, and there's a lot of it. You can see from the lines drawn that the left side of his brain is being pushed over to the right. Not good, not good at all.

As I mentioned, the parents were oddly clueless about the gravity of the situation. So when I sat down and explained the results of the scan, it hit them like a blow from a hammer. They crumpled before my eyes and it was all I could do to keep from going down with them. Somehow I preserved my professional mien, and managed to convey the essential information they needed to know. Then I left them to pick up the shattered pieces of their life while I went to work getting this kid to the care he was going to need. Helicopter to the regional neurosurgical center. Intubate him for airway protection. Mannitol (sure, why not?). Lots of sedation, probably unnecessary, as his GCS was probably 8 or less.

I broke off his two front teeth intubating him. They were baby teeth and getting ready to fall out on their own. A silly little thing, but somehow made me feel so much worse. Not that he will ever know. I don't know if he will live. He may, but even if he does, life as his family knew it is over, or at least fundamantally changed forever. It's just not fair.

I made sure to give both my kids an extra hug before bed tonight.


  1. Beth has had a very powerful interaction in the last few weeks. She has been taking care of a 16 year old with terminal metastatic bone sarcoma. He almost literally walked to Seattle from Guatemala, and came to the bone clinic when he was unable to work anymore. Since his treatment started it was clear that he was too far along in his disease to cure, but it was very important that he be able to see his father one more time. Another family who recently lost their child to cancer paid for the father to come to Seattle from his very remote village in Guatemala. Apparently the other villagers were concerned that he would get lost, or that the plane might not be able to make it all the way. When they were first reunited, the son kept reaching up to touch his father's face and asking "are you real?"
    We are privileged to take part in some of the most dramatic and difficult moments in people's lives. Now I'm going to go pick up my son and spend the rest of the day playing with him.

  2. During my PICU rotation recently I helped take care of a young patient whose CT scan was similarly dramatic (perhaps not as bad, but obviously Not Right to the radiological layperson), but with no symptoms save headaches and N&V. She was scheduled for exploratory neurosurgery the next morning, but it was my last day on PICU, so I never heard the outcome. I finally pestered my supervising MD enough that he pulled the chart ... to find she'd been discharged home with no deficits. Don't know much further other than it was blood, not a tumor, not from abuse. Your case reminded me of mine that I thought I'd share, to say that one turned out okay for once, if nothing else.


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