My first night shift in a stretch of 7 was almost over. It was 6:15am and I had to keep moving otherwise the minute I would stop, my eyelids would drop like two ton shades and I’d fall asleep. That never makes for a good drive home after a night shift.
“Got time to see one more?” asked Jenny the nurse.
“Do I have choice? The door-to-doctor time storm-troopers would have it no other way,” I grunted back, eye lids drifting closed.
“Febrile seizure,” it said.
Good, this should be quick and easy, I think to myself. We’ll give some Tylenol, reassess in 30 minutes and this baby will be happy, smiling and bouncing off the walls. That way I can get out of here at 7am and be home in bed with my eye blinders on drifting towards sweet REM sleep at 7:20am. My sanity depends on it. 15 feet away, I head towards the room. Looking into room 4, I expect to see the usual post-febrile seizure toddler, sitting up in bed, recovered, awake and well appearing. First I see the child’s mother, well put together, attractive, smiling and relaxed. I cross the threshold to the room, look down on the hospital stretcher and I see a child, about 1-year-old, still seizing. Still seizing? I think to myself. This isn’t right.
“Jenny, get in here! We’ve got a seizing baby,” I say. I look down at the child, who is pale, head turned to the right, with the left arm twitching violently. “Call respiratory! Jenny, you get the IV, I’m going to start bagging. Someone get the Broselow tape and some Ativan. Let’s stop this seizure. Get some Diastat, too. We may need it. As I bag the child, Jenny quickly gets an IV in. We give a dose of Ativan and the baby stops seizing quickly. The O2 sat is 97%, the baby is breathing spontaneously and I stop bagging. I put an O2 mask on the baby. I feel the brachial and femoral pulses. They are bounding.
Considering the baby has normal vitals, I turn to Mom hoping to get some history while hoping the baby will quickly awaken from the post-ictal slumber. “Mom, hi, I’m Doctor Bird, tell me what happened please.”
She looks at me and smiles. Her lips spread apart and reveal a soul-sucking brown smile. Why is she smiling? Her baby just got done seizing? Why isn’t she panicked? I look towards Jenny the nurse whose face is beet red and stressed like mine, after a 12 hour night. I shoot a glance at the clock and it’s well after shift change now. I’m fried. I haven’t slept in over 24 hours. I look back at Mom and I realize she’s the calmest one in the room. There’s something really, really wrong here. In the corner of the room is a man sitting on a chair that I hadn’t noticed before. He’s smiling. I look at him. “Hey doc! How’s it goin’? Havin’ a good night?” he asks with a smile and a laugh as he slaps his knee. Having a good night? I’m having a horrible night, I think to myself, and I’ve got a seizing baby on the stretcher in front of me. It doesn’t seem to be cramping his style too much, however. I feel the energy drain right out of my chest. At that moment I know exactly what the diagnosis is, and I feel like I might puke my guts out.
“Charge nurse? Please escort them to the family consult room. Thank you. Suzy, call the chopper, now. Jenny, let’s get this baby tubed. Tell CT to clear the table, we’ll need a scan in 2 minutes. Call PICU at —– —— Medical Center. We’re flying this one out! Call social services and the police, too.”
Once intubated, stabilized and after another dose of Ativan we shoot over to CT. I watch the image slices appear on the computer monitor one by one. My stomach turns over. I see just what I feared: massive bilateral subdural hematomas (bleeding around the brain). There are skull fractures. There is a brain that looks obliterated.
The helicopter crew arrives and prepares the toddler for transport. As they wheel out the door with our tiny toddler in tow, Jenny the nurse, the respiratory therapist, Suzy the unit clerk, Bob the charge nurse and I all just look at each other. Nobody says a word. What is there to say? We all know as much as we need to know. Off we go, out the ED doors headed home, exhausted as the sun comes up after a very long night shift.
A few days went by. We all tried to work through the next few shifts pretending like nothing big had happened. It’s “just a job,” right? A few muttered comments here or there but most everyone tried to work past it. In a case like this, despite knowing you did all you could do, it’s hard not to feel like somehow you failed, since at the end of it, a child remains brain-damaged or worse. I tried to forget about the case and move on, but I had to get some follow-up. In a rare slow moment, during a shift a few days later I asked, “Suzy, why don’t you call down to the PICU at —– —— Medical Center. Let’s see how the baby from the other night is doing. I’m sure we could all use some good news right now.” I was hoping that my worst suspicions would be proven wrong, and my cynicism would lose out to wishful thinking. I sat down to check the Internet for the weather while I waited. Already up on the screen, was the local news site. The headline said: “Shaken Baby Dies: Mom and Boyfriend Charged with Murder.”
“You know what Suzy? Hang up the phone. We don’t need to call. I’m sure everything turned out just fine. You all did a great job with that baby,” I said. I headed to see the next patient, chief complaint: “Itchy nose.”
“Hello, Mrs. Jones, I’m Dr. Bird, how can I help you today?”
“BirdStrike” is an emergency physician who blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly.
Image credit: Shutterstock.com