The EMS call alerted us to a young drowning victim en route. I dropped my chart and hurried to the resuscitation room. “Did they say how soon they’d be here?” I asked the head nurse, Cammie, who was hurriedly putting on gloves. “Did they say how old the kid is?”
“They said they were just getting off the highway…and they said toddler age,” she responded, as I cracked open the plastic tab securing the pediatric cart containing airway tubes and drugs for children. I noted my hands were shaking a little, and I consiously tried to calm them. It was my first night working as an attending physician. On my own finally; after seven years of schooling and residency. Now, I was the only doctor working in the community ER. Actually, I was the only doctor in the entire hospital.
As I was mentally calculating the size of tube we would need to intubate our patient, the ambulance lights shined through the ambulance bay. Deep breaths. The paramedics hurried through the automatic doors. What do we know so far?” I shouted from the head of the bed. One medic was at the head of the gurney, obscuring the tiny figure’s face with an oxygen mask, and the other was squeezing the bag to breathe for the little girl. Just outside the bay stood a young woman with tears streaming down her face, hands up to her mouth. With the mascara streaming down her face, she looked like a portrait that was washing away in the rain.
Quickly one medic responded: “Two year old drowning victim. Estimated 10-20 minutes in pool. Parents pulled her out and started chest compressions and spontaneous circulation has been present since we arrived. She’s been unresponsive since arrival. We’ve been bagging her since then–about 15-20 minutes–and she’s been 100% on 15L O2.” They lifted her off the EMS gurney and onto the ER bed. I finally saw her; she had medium brown hair just past her shoulders. Just like my two year old daughter.
“Let’s resume bagging,” I said aloud as I tried to push the last thought out of my mind. Then Cammie took over from the medic the bag-valve-mask device pumping oxygen into the little girl’s lungs and began giving it little squeezes every several seconds. “Do we have IV access?” I asked.
“Almost.” “Working on it,” said two of the other nurses out loud from each side of the patient. At this point, the masked girl was bathed in a too-bright light from overhead, one nurse at each arm, Cammie up top at the head bagging, and I was examining her pupils to determine her baseline neurologic activity.
“Pupils are dilated and minimally reactive,” I noted ominously out loud. “Do we have that line yet?” OK good, I breathed out. As I was mentally calculating the dose of sedative required to sedate her, it occurred to me that she probably wouldn’t need any sedative since she was not responding to any of our other painful interventions “Let’s stop bagging,” Then I grabbed the metal intubating device with my left hand and gently inserted it into her mouth in a sweeping fashion to move her tongue up and out of the way to visualize the vocal chords. “Tube,” I said, and grabbed the narrow flexible hose and inserted through her vocal chords and in the next motion inflated a balloon that would keep the tube in place.
“Good breath sounds bilaterally,” Cammie said.
I positioned a carbon dioxide detector strip to confirm that the tube was positioned and doing its job of ventilating the carbon dioxide the little patient was producing. “Good color change I confirmed. Let’s please get a stat portable chest x-ray to confirm placement.”
“Sats are 100%,” one of the other nurses remarked out loud,” and I simultaneously looked up at the monitor in relief.
“Let’s please hook her up to the vent,” I instructed the respiratory therapist. “I suppose some higher PEEP pressures to push the fluid out of her alveoli is needed,” I half said to myself and walked over to the young woman that was still not quite in the room. She was still cowering behind her hands, and managed to nod “yes” when I asked if she was the young girls’ mother.
“Is she going to be okay?” To which I responded that I don’t know. That she has a heart beat on her own. And that her immediate oxidation is improved, but that we’re breathing for her. I told her it was concerning that she was not waking up and not breathing fully on her own, and that her pupils were not fully reacting to light. I told her that this could be a sign of some damage to her brain; that it’s hard to know how much or how permanent the damage could be and what her recovery will be like.
I walked back to the doctor’s station still somewhat dazed. The beeping from the numerous other patient monitors became apparent. I asked the secretary to page the pediatric intensivist at the large children’s hospital in Dallas. The adrenalin was beginning to wear off, and I wearily sat down and opened up the little girls chart. So that was her name. Abigail.
–DrMedicineMan
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