CASES (18): TODDLER DEATH

It was a Saturday morning. Darlin’ and I had already been in the building early to administer the anesthesia for a surgical case. It was an emergency C-section with Dr. Wambo, one of my favorite OBs. Dr. Kreider was the pediatrician who was there to care for the newborn when it was wrestled out of the patient’s uterus.

When we had delivered the patient to the recovery room and made sure she was stable, we went up to the med-surg ward to make rounds on my inpatients. While we were finishing up rounds, I got a page from the answering service. They connected me to Dr. Paul Kreider who had been called to the emergency room. He said he had a case that he needed help with.

Darlin’ and I wasted no time walking down the steps to the ER on the ground floor. When we walked in through the big swinging doors, the ER was quiet. Dr. Kreider was standing in one of the bays with one of the RNs and a young man and woman with two little boys. As we approached, I saw that there was a smaller boy lying on the gurney in front of them. He was still.

Dr. Kreider briefly introduced me to the parents, and excused us as we walked to the nurses station. He gave me a quick history of what was happening to the child on the gurney.

He said, “These people live out in the country down around Liberty. This boy is three years old. They say he came down with diarrhea about three days ago. They thought it was just a common viral illness. But over the three days, he didn’t get better and started to get lethargic. He wouldn’t eat or drink. The diarrhea persisted. When they tried to wake him this morning, he wouldn’t wake up, and they got scared, jumped in their pickup truck and brought him up here. The boy is comatose. He is in shock. He is breathing but his blood pressure is low. I am going to admit him to the ICU. Can you help me manage him?”

We did not have hospitalists or intensivists at that time. We had to manage.

I told him, “Sure. Have you had time to check any labs?”

“No. We can draw some stat labs now and look at them when we get to the ICU.”

“OK. Why don’t you let me draw some blood gases and other labs at the same time. When we get upstairs, I’ll start and IV. We should put him on an O2 mask now.”

*******

In just a short while, the boy was admitted to the ICU. Dr. Kreider was there; he had asked the family to wait in the adjacent waiting room with other families who had people in the ICU. When I saw the results of the arterial blood gases, I told him that the boy needed to be on a ventilator and needed an arterial line. I asked the RN to help me, and she brought a respiratory care tech and the crash cart. The child was unresponsive when I started an IV, intubated him, and put him on a ventilator. Then I put in an arterial line to monitor his blood gases.

The labs indicated that he was in hypovolemic shock. With some IV fluids and oxygen, he seemed to stabilize, but remained comatose.

Dr. Kreider, like most community pediatricians, did mostly outpatient, office practice, with only a few hospital admissions. Neither he nor I were pediatric intensivists. He got on the phone and was busy trying to arrange and emergency transfer of the boy by ambulance to the University hospital where he could get specialized care.

After he had made that call, he went to the waiting room and spoke with the parents.

They were crying when he told them, “Your boy is very sick. He is in shock from losing so much fluid from his body. We have stabilized him for now, but he needs to be in the University Hospital where he can get specialized care.”

The mother, sobbing, asked, “But, is he going to be all right?”

“He is very sick. He is stable for the moment, but I’m sorry to say, you could lose him. That’s why the ambulance is on the way here right now to take him to the University Hospital.”

I went to the boy’s bedside and checked his vital signs one more time. Dr. Kreider thanked me for the help and Darlin’ and I left the ICU.

*******

The transfer went off as planned. The family followed the ambulance into the city to be with the boy in the University pediatric ICU.

I saw Dr. Kreider while making rounds the next day with Darlin’. He told me he had called and the boy was stable but still comatose and on the ventilator.

We saw Kreider again a couple days later. The boy had died during the night with his parents by his side.

There was an indescribable sadness about the case. When I told Darllin’, she cried.