Broken Promises

My first few weeks working as a medic in the emergency department (ED) of a children’s hospital were intense. The hospital was a regional medical center attached to a major university, and this was my first indoor paramedic gig. In the field, at most about 10% of EMS calls are pediatric — and of those 10%, at most, have something serious going on. So my 15 years in EMS at the time hadn’t provided me with a whole lot of pediatric experience. And if you’ve ever worked with healthcare providers dedicated to kids, you know they’re a slightly different breed — noticeably more involved and more committed. And these guys were at the top of their game — many of the docs were double boarded in pediatrics and emergency medicine, and were responsible for training a cadre of pediatric emergency medicine fellows, one of the newest specialties in the field.

There was so much to learn, both about in-hospital emergency medicine and about kids. Thankfully, we medics were embraced by the staff. Probably because the nurses were themselves highly skilled, knowledgeable and experienced, they perceived us not as a threat but as a blessing. They were overworked and needed help. Some of them even spoke of the social balance that the paramedics, most of whom were male, brought to the previously all-female nursing staff.

I was bombarded with new things to learn: how to insert 24-gauge angiocaths into teeny tiny veins covered with half an inch of baby fat; how to avoid blundering into a sterile field; how to place nearly invisible catheters into minute, occult orifices; how to take rectal temperatures while avoiding fecal explosions; how to immobilize a newborn/infant/toddler/child/teenager for a lumbar puncture; how to draw a blood culture; how to calm children; and, most useful of all, how to comfort parents. And I loved it.

When most folks learned I was working in a pediatric ED they would ask, “How can you do it? How can you see kids suffering every day?” But I found it a much happier and far more hopeful occupation than treating adults. Kids haven’t had the opportunity to abuse their bodies yet. They aren’t responsible for any ailment they may have. And, better yet, we can actually fix the majority of those who come through the door. Hit his head on the coffee table? Sew him up! Broke her wrist falling off her tricycle? Splint her up! Nausea and vomiting? Tank her up! True, the really bad stuff is emotionally tough, but it’s balanced by lots of satisfaction from helping the kids, and helping the families. So all in all I was excited, upbeat and getting a little cocky. Until Jeremy.

Jeremy was the cutest little baby. He was about 16-months old with sweet eyes and a tuft of soft curly hair on the top of his head. He had had a fever and wheezing for a couple of days, so his parents brought him to the pediatrician that afternoon. His pediatrician thought he was getting pretty sick, so he sent Jeremy to us.

Sometimes rooms were assigned to a nurse/paramedic team, sometimes the nurses were assigned rooms and the medics floated around filling in and doing procedures (a tough stick on a little kid can sometimes involve three or four people). I was assigned to Jeremy’s room. He was wheezing and retracting, distress but had good skin color, cap refill and Sa02. We gave him a couple of nebulizer treatments and started an IV. The doc ordered X-rays, fluids, antibiotics and tests. Jeremy’s parents were great, and I did the best I could to reassure them. After all, they had gotten him here, to a Level One pediatric trauma center. He appeared stable; we had the best pediatric emergency medicine specialists in the country, etc. etc. Of course he was going to be alright. He just had an infection. He was getting strong antibiotics, and who in America dies of a simple infection anymore? I guaranteed them Jeremy was going to be just fine. “He’s here now. He’s with us. He’s safe,” I said.

I went to lunch, and when I came back Jeremy was gone. “They took him up to the ICU,” my partner told me.

“Good,” I thought, they’ve admitted him. On my next break I went up to the second floor (why is ICU always on the second floor?) to check on him and his family.

When I got up to the ICU and could see one of the rooms was packed — attendings, residents, nurses, RTs — and Jeremy’s parents were huddled together in the hall. I asked, “What’s happening?”

“They say he’s not doing so well; they’re trying to stabilize him,” the parents said.

“They’re the best,” I said, “It’ll take a bit for the antibiotics to kick in. He’ll be fine.”

Of course Jeremy wasn’t fine. I came in for my shift the next day and went up to see them in the ICU. The room was empty, the bed made. Jeremy didn’t make it.

Even after 15 years in EMS I was still naà¯ve — probably due to the paucity of critical pediatric calls, probably due to the fact that there was no good outcome feedback mechanism in any of the services I had worked for. The fact of the matter is, unless you work in a really small town, you rarely find out what happens to your patients. This may leave you with a false sense of optimism. You may be greeted occasionally on the street by a patient who survived; you may never know about the ones who don’t.

And, of course, people do die of “simple infections” all the time. Not only old folks, but young ones — babies, kids, teenagers — even after they have gotten to the best pediatric hospital in the southeast, even when they get the strongest antibiotics science can produce. Over the next four years I watched far too many children die of pneumonia despite the most excellent and aggressive care possible, including a couple who ended up on ECMO (extracorporeal membrane oxygenation). Despite all our knowledge, technology and powerful medicines, there are tenacious toxins out there that we cannot defeat.

For the first time in my career, I visited the parents. I attended the funeral. And I learned a lesson about making promises; promises I had no right to make, and promises I had no way to keep.

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