ER – a place where every minute counts; more so in the pediatric ER, where sometimes the only thing standing in the way of a child getting better is an intravenous line. There are times when, as a resident physician, you feel very comfortable examining children regardless of their size or the severity of their illness. However, sometimes it affects you emotionally, in ways you don’t understand…and are too embarrassed to admit.
Time in the ER goes by fast. It was only fifteen minutes into my ER shift, and I was giving the third combination nebulization to this very ‘tight’ two-year-old boy, whose heaving chest made me nervous. I thought to myself, he would need admission. I glanced at his dad standing near the window, who clearly looked impatient and frustrated. His child had already received three treatments in the clinic before being sent here, but his respiratory distress persisted. Sometimes, talking to the parent is the toughest part, as they seem to want quick results. “Why hasn’t my child improved? “ he asked me for the fourth time. As if responding to my cues, he walked over to me and took the mask from my hand and sat down next to his child. Mustering courage, I explained that if there wasn’t improvement admission would be required. He didn’t look at me. He pursed his lips and continued to look at his child who was breathing in the white fumes of albuterol. I stood there for a few seconds and then taking the chart, went up to the station and scribbled orders for magnesium sulfate. The nurse came up to me and said that she would prepare a bed and get a monitor ready. I gave her a half smile. The nurse knew my thoughts already.
As I made my way to see a new patient, the overhead speaker screamed “pediatric trauma alert”. I saw my attending rush to the trauma station. I dropped the chart back into the rack and hurried towards the trauma area picking up some blue gloves on the way. I caught up with my attending, who told me that the trauma alert was for a fourteen-month-old baby who had been flung into the air. That’s all we knew. Well, when you hear such things, you imagine the worst, you anticipate the worst and you…pray! The patient hadn’t arrived yet and I went to the trauma cart and started preparing by picking up a tourniquet, intravenous catheters, alcohol pads, syringes and all the equipment I thought I would require. I placed them in my coat pocket and walked to the trauma nurse to get the full story. Apparently, there had been an altercation between the baby’s mother and her ex-boyfriend. The mother was holding the baby and her ex-boyfriend had grabbed the baby and thrown him four feet across the room. We didn’t know what injuries the baby had sustained. In a minute, we saw the EMS bring in a baby strapped to a stretcher wearing a cervical collar. There was a woman, possibly the mother, with some abrasions on her face, walking alongside the stretcher. The trauma team had already begun cutting the baby’s clothes. As they were clearing his spine, I took a quick glance over his entire body and heaved a sigh of relief. He was awake, looked alert, a little stunned perhaps, and had no obvious signs of external injuries. But I knew I couldn’t relax, as we didn’t know whether he had passed out when the incident had occurred. I quickly took his right arm, tied the tourniquet just above the elbow and rubbed some alcohol on his antecubital area. I couldn’t see a vein. I patted the area a few times. I still couldn’t see a vein. He was a chubby baby. I released the tourniquet and reapplied it to his wrist. As I rubbed the back of his hand, I felt immense stress building in me. I couldn’t see a vein there either. I could feel the ticking of the clock. I had to get the intravenous catheter in. I knew I had no time. I flexed his hand, removed the cap of the needle and slid it through the skin, blindly. No blood. I retracted the needle half-way and glided it in another direction. No blood. The baby started crying. I took a deep breath, retracted the needle again, changed its path just slightly and saw a line of red blood in the catheter. I slid the catheter completely in, retracted the needle and released the tourniquet. A few drops of blood stained the sheet as I stabilized the catheter with tape. But it wasn’t over yet. When I tried flushing with saline, I met resistance. I peeled the tape off, redirected the catheter and replaced the tape. This time the saline flushed easily and I screwed the tube of the intravenous fluid bag to the port of the catheter. I bandaged the baby’s arm to the arm board to prevent the catheter from kinking. As I removed my blue gloves, I noticed that the baby had stopped crying and was alert and vigorous. “Baby, you did good”, I thought to myself. The trauma team ruled out any injury and we continued to observe the baby in our ER. It seemed like forever, but only fifteen minutes had passed by.
I rushed back to see my previous patient. He was lying quietly on the bed with a monitor attached to his body. From a distance of six feet I tried to evaluate whether his breathing had improved. I couldn’t really tell; his chest was moving in the same way. I asked the nurse to give magnesium sulfate and walked over to his dad to tell him our next course of action. He looked defeated. I was hopeful that his son would turn a corner soon. I rotated the monitor so that it could face me, while I sat in the nurses’ station. I knew I had to look out for dropping blood pressure. I sat down and resumed writing orders for him. He would need another bolus of saline. The rack for new charts was empty. I was relieved, as there was enough on my mind already, rather than be concerned by another disease, another patient, another parent.
Another fifteen minutes passed by. The fourteen-month-old baby seemed very active and happy and was now drinking milk from his bottle. He was oblivious to what had just happened to him, something he will never ever remember and I was happy for him.
I saw the asthmatic boy talking to his dad. He was sitting up and pointing at the TV, saying something about SpongeBob. I smiled; he had turned a corner. I went over to him and listened to his lungs. I could hear good breath sounds. His chest was still heaving slightly but not as badly as before. I called the floor resident and proceeded with clearing him for admission.
The long hand of the clock struck twelve. That hour was over. There was a new chart in the rack. My next new patient.