THE rescue squad was pushing the stretcher down the hall at a near run. A firefighter rode on the side of the gurney, like a kid holding onto the side of a grocery cart. He leaned over the patient’s chest, and counted loudly, “One-one thousand, two-one thousand, three-one thousand,” each time he pumped on the patient’s rib cage. A paramedic scrambled at the head of the stretcher, her black boots dancing sideways, a quick crisscross, right-left-right. Her hands were busy, too—with her right hand she held a mask against the patient’s face, and with her left she squeezed a bag, forcing air into the lungs. Both gloves were smeared with blood.
A woman standing at the desk of the nurses’ station pulled her little boy to her. They both stared with their mouths open as the knot of people hurried past.
I leaned over to the unit secretary. “Page the trauma team.”
“Just did.”
I went to the room designated for trauma cases. Someone had turned on the suction line. Its hissing was barely audible above the bustle of people preparing to move the patient to our stretcher.
“There’s one more strap.” Barry, the chief paramedic, pointed to the end of the stretcher. “At her feet.”
A firefighter squeezed the black plastic clasp, and flicked the orange webbing free. “Okay.”
Barry grasped the yellow plastic backboard. Lisa, the ER nurse, leaned over our stretcher to help. She grabbed one of the handholds and in a swift arc they whisked the patient over to our stretcher. “Twelve-year-old, hit by a car,” Barry continued. “I tried to intubate her with a 6-0 tube but it wouldn’t go in. Vocal cords were too small.” He winced. “Tried again with a pediatric tube, but couldn’t see the cords the second time.” He handed an IV bag to Lisa. She stretched up on her toes to secure the bag to the hook suspended from the ceiling. Barry wiped his forehead on his shirtsleeve. “We were right around the corner, so we decided to scoop and run. She had a pulse at the scene. Lost it en route.”
The firefighter who’d been doing compressions on the girl’s chest glanced around the floor. “Is there a stool anywhere?” He stood on his toes and started doing compressions again. He needed to be higher, to be centered over her chest. Someone left, presumably to find a stool. The paramedic at the head fitted the face mask against the girl’s chin and nose, then began squeezing the green football-shaped bag again, pumping oxygen into her lungs.
I grabbed a pair of exam gloves and slipped through the people crowded around the stretcher.
The left side of the girl’s face had been torn to a ragged red pulp, and a small, bloody tag was all that remained of her left ear. A cervical collar kept her neck rigid, but her head jostled with every compression of her chest.
If someone comes in pulseless after blunt trauma, it’s unlikely you’ll be able to resuscitate them. But when it’s a kid, you want to work a code as long as you can. It’s human nature. And the first step, without which all others are futile, is to secure the airway. In every advanced life support class you learn “A” is for Airway; “B” is for Breathing; and “C” is for Circulation. Until you secure the airway, all other efforts are useless. All the fancy doctoring in the world can’t keep someone alive without an airway.
As I reached for the laryngoscope and a tube, Barry tapped me on the shoulder. “You better go with a 4-0 tube. I couldn’t get a 6-0 in.”
Barry had been a paramedic longer than I’d been a doctor. I hesitated. Just looking at the girl, a 6-0 looked more like the right size. But if he’d tried one, and it wouldn’t go…I looked at Barry. “You got a good look at the cords?”
“I was staring right at them. That’s what was so frustrating. The 6-0 was just too damn big.” He shook his head.
I clicked the lighted blade onto the laryngoscope handle and picked out a 4-0 tube. “It looks small.” I opened her mouth, and using the laryngoscope blade swept the tongue to the left. I advanced the laryngoscope to her epiglottis, the fleshy trap door that covers the vocal cords, and lifted it out of my way. The cords were big and white and inviting. I slipped the 4-0 tube in place.
The respiratory therapist took over. She taped the tube in place, hooked her bag to it, and squeezed.
“I’m barely ventilating her. The tube is too small.”
The girl’s chest hardly rose each time the bag was squeezed.
Ben Smith, a trauma surgeon, walked briskly into the room. “What do we have?”
“Kid, hit by a car,” I said. “Had a pulse at the scene.”
“Excuse me.” Ben slipped between nurses and paramedics to stand next to the patient. “Exam gloves?”
A nurse handed him a pair of gloves. He snapped them on, and felt for the femoral pulse. “I’m getting a good pulse with compressions.” He looked at the sweating firefighter doing the compressions. “Hold CPR.”
The firefighter straightened up. He stretched his arms over his head, leaned backwards to stretch his back.
“No pulse.” Ben looked at the paramedic. “Continue CPR.”
The firefighter resumed his rhythmic pumping on the girl’s chest.
Ben looked over to me and raised his eyebrows.
I shrugged.
“How old is she?” Ben glanced at her breasts and pubic hair.
“Bystanders said she was twelve.”
“Then let’s work this a little longer.” He looked at the IV bags. “We’ve got her fluids wide open, right?”
“I’ve got a second IV here.” Lisa looked up from the catheter sticking out of the girl’s forearm, slowly dripping dark blood. “Gimme a line.” Another nurse handed her an IV line.
“I may have to change the tube,” I said to Ben. “This one’s barely ventilating her.”
Ben nodded to me, and turned to Lisa. “Make sure the fluids are wide open.”
“They are.”
Ben looked to the paramedic. “How long she been down?”
Barry glanced at his watch. “About twenty minutes.”
The respiratory therapist squeezed the Ambu-bag, and frowned. “What size tube did you use?”
“A 4-0.” I listened to the girl’s chest with my stethoscope. First the right side, then the left. The girl’s breasts were small, with dark brown nipples. “We’re barely ventilating her.” I looked over to Lisa. “Does she look older than twelve to you?”
“I don’t know.” Lisa shrugged. “Yeah, maybe.”
Barry was standing behind Lisa. “The bystander said she was twelve.”
Any tube is better than none at all, and with the 4-0 in place, I had some time to think. I’d had no trouble seeing the cords, and a 6-0 would’ve fit easily. Of course, if I took out the 4-0, and for some reason couldn’t reintubate her, I was fucked. I held the tip of a 6-0 tube to her nostril. It would fit into her nostril, which is a good rule of thumb that it’ll fit through the cords. “You said a 6-0 wouldn’t fit?”
Barry nodded emphatically.
“The 4-0’s obviously too small. I’m going to pull it and try with this one.”
Barry raised his eyebrows and shook his head.
I pulled the 4-0 tube out and tossed it on the floor, clicked the blade into the laryngoscope, and peered down her throat. I could see the epiglottis, but not the cords. “Gimme some cricoid pressure.”
The respiratory therapist pushed down gently on the front of the girl’s neck, forcing her windpipe further into my field of vision.
“I still don’t see the cords.” I pulled up harder on my laryngoscope. “Can you give me more cricoid?”
“I’m pushing as hard as I can.”
I still couldn’t see the cords. I pulled the laryngoscope out. “Bag her up some, lemme change blades.”
The respiratory therapist scrambled to put the face mask back on the bag. “Can someone hold the mask against the face for me?”
Lisa gripped the girl’s jaw with her fingers, and pressed the mask against the bloody face with her thumbs.
“Thanks.” The respiratory therapist squeezed the bag, inflating the girl’s chest, which rose and fell steadily. We were ventilating her better with the mask than we had with the 4-0 tube.
I changed over to a curved blade, and checked the bulb. It worked. “Okay.” I gestured to the respiratory therapist, and she pulled the bloody mask out of my way.
I swept the tongue to the left, saw the epiglottis, but still couldn’t see the cords. “Damn.” I pulled up harder. “Gimme some cricoid.” The epiglottis stubbornly covered the cords. I should’ve left the 4-0 in place. Been satisfied with what I had. “Bag her up some more. I’m going back to the straight blade.” Why couldn’t I see the cords? The first time I tubed her, the cords were as big and wide as a door at the end of a hall.
“You can’t get the airway?” Ben moved toward the head of the stretcher.
“Yeah,” I said, “I’ll get it.” I clicked the straight blade back into the laryngoscope. Please, let me get it. Why did I pull the first tube out? I wiped the sweat from my forehead on the sleeve of my scrub tops. Just had to change the tube, didn’t I?
I looked again, but couldn’t see the cords. Time slowed down as in a nightmare. Where were the fucking cords? I straightened up. “Bag her up again.”
The respiratory therapist pumped air into the girl with the face mask.
“Gimme a scalpel,” Ben said. He wanted to cut a hole in her neck to stick in a tube.
The chatter in the room stopped, and everyone stared at me.
“Goddamn, Ben. I’ll get it.” I motioned the therapist to remove the mask. Please. I got the tongue to the side, and the cords popped into view like a huge billboard. “Gimme the tube.” The therapist placed the 6-0 tube in my hand. I eased it down between the cords with plenty of room. “It’s in.” I straightened, and took a deep breath. Thank you thank you thank you.
The respiratory therapist hooked the bag to the tube, and squeezed. The girl’s chest expanded briskly and fully. “That’s better.”
“How much fluid has she had?” With Airway and Breathing back where they should be, Ben had moved to Circulation again.
“This’ll be her third liter.”
“Pulseless after blunt trauma…” Ben didn’t finish his sentence. Everyone in the room knew this was a dead girl: we just hadn’t admitted it yet. I took a deep breath and let it out slowly. At least now she was a dead girl with the right-sized endotracheal tube: I’d done all I could do.
We stared at the girl as Barry pumped on her chest and the respiratory therapist pumped air into her lungs.
“Hold CPR.” Ben kept his fingers on the femoral pulse. “Nothing. Continue CPR.” He looked over at me. “Paul, unless you have any ideas…”
Studies have shown that people who are pulseless after blunt trauma are dead, no matter what you do. Still, it’s hard to give up on a kid. “Anyone else got any ideas?”
The nurses, respiratory therapists, paramedics, and X-ray techs looked at the floor, or shrugged.
I looked around the room. “I’m ready to call it, unless anyone wants to continue.”
“Time of death,” Lisa called out clearly, “14:53.”
I tried to smile. “Good job, team. It was a good effort. We just didn’t have enough to work with.”
As people drifted away from the stretcher, another paramedic walked in. “Is this the forty-year-old that was hit by a car?”
“Forty? They said she was twelve.” I looked at her body. The breasts sagged limply to the sides, the pubic hair was thick and profuse and wove all the way up to her umbilicus. The left side of her face was still a ragged red mess, but the right side no longer looked like a kid’s. “You sure you have the right dad with the right patient?”
“He showed up at the scene as we were leaving. Said he was her father.”
“Lemme go talk with him. Where is he, the Family Room?” I stripped off my protective gear.
“Yeah.”
“Do we have a name?”
“Patient’s name is Crystal.”
Barry, the chief paramedic, winced. “I don’t know why I couldn’t get the tube.”
“Don’t feel bad.” I patted his arm. “It was a tough tube.”
“Do you think she’s really forty?”
“When she first got here, she looked like a big kid. Now she looks like a small woman.” I washed my hands in the sink in the corner. “If the bystanders had said she was forty, she would’ve looked forty from the get-go.” I dried my hands and tossed the paper towel into the trash.
Lisa went with me to talk with the father.
An old man sat in a chair in the corner of the Family Room—a small, windowless room, with reproductions of impressionistic art on the wall. He had a scant fringe of white hair around a shiny bald scalp, and bristly white eyebrows. He leaned forward in his chair, his knobby hands resting on the top of an aluminum cane.
I sat down in the chair next to his. “You’re Crystal’s father?”
He bobbed his head. His face showed no emotion.
“She was hit by a car…” I said softly.
His head bobbed again. “I know.” He looked at his hands folded over the top of his cane. “I was there when they were leaving.”
I took a deep breath. “When she got here, her heart wasn’t beating.”
He nodded, as if the news wasn’t surprising.
“The rescue squad, nurses, and doctors did all we could.”
“I know you did.” He stared at his knuckles.
“And I’m sorry, but in spite of all we did, we couldn’t get her heart started again.” I spoke slowly, softly, clearly. “She died.”
He was motionless. “She was the baby in the family,” he whispered.
“I’m sorry.”
He swung his large, dark brown eyes to mine. “All growed up, but still my baby girl.”
We sat.
Lisa cleared her throat. “Some people want to see their loved ones, others don’t.”
The old man looked at Lisa.
“Would you like to see her?”
He slowly stood. “Yes, ma’am, I would.”
I walked beside the old man, consciously making myself go slowly. Patients continued to flow into the ER, and if I didn’t pull their charts from the rack and go see them, the place would grind to a traffic jam that wouldn’t clear till tomorrow morning. I took a deep breath. The old man deserved at least a few more minutes. We walked past patients on stretchers in the hallway. I kept my eyes on the floor to avoid making eye contact.
In the resuscitation room, a fresh sheet was tucked in around Crystal’s shoulders, covering her body. Gauzes covered the raw left side of her face. Most of the blood on the floor had been hastily wiped up, but a thin smear of red remained next to the stretcher. The paper wrappers from IV catheters, gauze, endotracheal tubes had been swept up and thrown away.
The old man peered at the torn, dead face, then back to me. “I think it’s her.” He pulled her hand from under the sheet and stared at the long, shiny red nails. “Yeah, that’s my baby,” he said, as he gently laid her flaccid hand on the stretcher. He shook his head slightly, and leaned on his cane, staring at the shiny red nails against the crisp white sheet.
He reached out and touched the limp hand on the stretcher.
I stared at Crystal’s body, relieved that she was forty instead of twelve. When I’d gotten to work that day, like every day, I went to my locker. There, I slipped into my running shoes, draped a stethoscope around my neck, put a pen in the pocket of my scrub shirt and trauma shears in the back pocket of my scrub bottoms. As I walked out into the emergency department, I felt the “ER Doc Paul” come forward. Curmudgeon, detached clinician, sometime jokester. A game face to help me through the shift.
When Crystal came crashing in, she was a twelve-year-old kid. Kids have a way of darting past the ER persona and staring into your naked eyes. When a child dies in the ER, or comes in dead and stays dead, the department slows down. A child’s death affects all of us: nurses, doctors, ward clerks, nursing assistants. All of our masks come off. Even at forty, Crystal was too young to die. But as I stared at her dead, adult body, I felt my mask settle comfortingly back into place. I knew I could face the rest of my shift without feeling the urge to cry.
Joanne, the charge nurse, motioned to me from the hall.
I walked over.
“There’s a chest pain in room two,” she said. “Looks sick.”
“I’ll be there in a minute,” I said quietly. “EKG ordered?”
She nodded.
“Thanks,” I said. “Be there in a sec.” I walked back into Crystal’s room. “Sir, if you have any questions or concerns, call me here in the ER. They’ll know how to get in touch with me.”
He nodded, and limped slowly out of the room and down the hall, leaving his baby under the white sheet.