Wednesday, April 18, 2007

Parents and their responsibility

If you haven't guessed already, I am in Pediatrics these days. In the past few days three clinical experiences have happened that make me want to write this post.

1. Sunday night on call, a 2 year old was brought in with altered mental status (responsive only to painful stimuli), optic nerve atrophy in his left eye and priapism. Turns out that 4 months ago when he had presented with some vision loss in his left eye, an MRI had been done. It revealed a large craniopharygioma in the sellar/suprasellar region of his brain. This is a benign and in his case, cystic tumor. The prognosis was good with surgical resection and radiotherapy. The family, being Amish, told the neurosurgeon that they would think about it. They never came back. Instead, they decided to try a low-sugar diet and some nutritional supplements. Needless to say, this didn't work. The tumor had got larger and now was compressing the aquaduct of silvius in the brain and blocking the flow of CSF resulting in an obstructive hydrocephalus. This is why the toddler wouldn't wake up. That night, we had to intubate him, put a central line and arterial line in his left subclavian and left femoral respectively, put an NG tube and foley catheter in and the neurosurgeon did a bedside craniotomy to place an extraventricular drain. He is scheduled for emergent brain surgery in 4 days. His prognosis is not very good at this point.

His parents, no doubt, felt they were doing the right thing by trying to treat this tumor with diet management, although there is no evidence for this treatment and even the makers of the nutritional supplements they used do not recommend their product as a treatment for brain tumor. Now, their son lies in serious danger of either losing his life, or being permanently blind and/or neurologically impaired the rest of his life.

What do you think of their choice and the consequence to this toddler?

2. The night of call, I spent from about 10:30 pm to 5:45 am working on this single patient. I do not think I sat down for 5 minutes. It was non-stop, hair-raising, nerve-racking action. In the wee hours of the morning, one of our PICU nurses comes in with the story that one of our flight crew nurses who was going through a divorce had killed his children, ages 8 and 4 and then shot himself. Reportedly, he drugged the younger one (a boy) and shot the elder one (the girl) in the head. Apparently, he was going through a messy divorce and stood to lose his kids. We still do not know how he killed his kids. Did he shoot them, like he shot himself? Did he drug them? Did they suffer?

What do you think of this parent's decision?

3. Tuesday morning in clinic, our team's job was to evaluate a little 6 year old for autism. The concern was raised because the child had speech delay, some apparent anxiety and stereotypical behavior -- finger-flicking, head rocking and some repeated movements with her hands. She was a delightful little girl who was brought in by her father. During the interview, we discovered that Mom had been an alcoholic. She would leave this little toddler (at the time) in her rocker rather than let her walk around. Consequence: motor development delay. Mom would get loaded with alcohol and play loud music. She did not interact with the kids. Consequence: anxiety, fear, speech and language delay.

We do not think this little girl has autism. We think she may have re-attachment disorder and anxiety that manifest in the odd, stereotypically behavior, lack of desire to interact with her peers and her various delays.

Thanks, Mom?

In all fairness, most parents do a wonderful job of loving and raising children, making good choices to protect their health, well-being and safety. We can't help our heart-ache when we see the contrary as I did over these last few days.

Sunday, April 01, 2007


I am in pediatrics these months. However, as a Med/Peds resident I still do clinic one afternoon a week and this last week was Internal Medicine. I looked at my schedule at the date of birth on the sheet: 8/6/05. At first, that didn't seem odd. I had a lot of patients who were less than a year old. Wait! I am in Internal Medicine this afternoon. This can't be right! But it was. My patient was a 101 year old lady.

I went into the room. This was a pleasant lady sitting in a wheelchair (she wasn't disabled). She got around with a walker. When I asked her what health complaints she had, she surprised me by her reply.

"Doctor, I don't have the strength I used to. I fall asleep sitting down for a while."

In my mind, I thought that if that was all the problems I had at 101, I'd take it.

She came to see me because she had been living in a Retirement home and her money had run out. She was going to be on Medicaid and was being moved to a Nursing Home. I felt sad that she was going there. After all, this was a functional, fully cognizant female who was about to move into a home where most of the residents were demented and many dying. What could anyone do?

I finished the encounter and came home shaking my head. 101?

Damned if you do, damed if you don't...

In the last week, we had two codes in Pediatrics. Both involved kids less than 6 months of age.

The first one arrived in the ER pulseless and not breathing. We coded him for 25 minutes. He never came around. He was pronounced. There were tears of frustration, grief and shock in the eyes of everyone who walked away from the dead baby. We knew very little about this baby except the couple of sentences the EMT shouted out as we got busy to work on him.

I cannot describe to you how that feels... to do chest compressions on a 3-4 month baby, watching the monitor for signs of life, hearing the litany of a code be chanted behind you "1 more dose of epi now!" "stop compressions, check for pulse!" "continue compressions"

The second code was in the PICU. It was a patient on a ventilator. This was a premature, about 3 month-er that we knew. He stopped breathing (if you can do such a thing while on a breathing machine) when one of his lungs pulled away from the chest wall and collapsed. This led to his heart slowing down and then stopping. He went pulseless.

Peds residents and doctors ran from wherever they were to the PICU and became part of the crowd doing things. I did chest compressions, then needled his right chest wall to relieve the pneumothorax.

I have attended or participated in 4 peds codes so far in my training. This was the first time that the baby lived. Those statistics, dismal as they are, are about right. Not many infants survive codes. Kids do not have the reserve that adults do.

Coming away from this code was different. There was elation, nervous laughter, heady joy -- he lived!

I went back to the wards to resume my duties. I was taking care of a 2 year old admitted for increased secretions from his trach tube. Trach tube? This is a tube attached to the throat to help patients who cannot breathe effectively through their mouths and nostrils. This two-year old lay stiff in bed, with blind eyes open, a thickened pallette and flushed. At 10 months of age, his teenage sister turned away from him in the bath-tub for just a minute to see to another sibling who fell off his bike. In that minute, this little boy drowned. Since the family lived next to a fire station, the crew was over there in record time and he was successfully rescucitated. He lived! This was a code like the one I was just at, in that the patient lived.

Unfortunately, in that short period of time he was down, his brain suffered an irrecoverable injury from being without oxygen. He cannot talk, walk or see. He needs a breathing tube in his throat to breathe effectively. Should he have been saved? Of course! Who can predict what degree of injury and what subsequent recovery is possible? We have no a priori knowlege, so we must rescucitate.

Of course, as I care for him on the wards and wonder about the one we did not save and the one we did, I wonder about these things. What will the outcome be for the one we saved? Will he be like this 2 year old?

I am a christian. I do not swear. But in this case, the phrase "damed if you do, damned if you don't" seems to say it all.

Update on 4/2/2007:
My pager went off in the early hours of the morning. I was off-duty, but I had left my pager on. I looked at the read-out and saw the code message and the room message. Later that morning, the news was confirmed. The 3-monther we had successfuly rescucitated had coded again and this time, did not survive. He died of cardiopulmonary failure that morning.