Where Teddy Bear Dare Not Trod

A child’s Teddy Bear should not witness sad and painful experiences. Yet they do. Here’s a story for you.

I was working that weekend in the hospital for more than 24 hours already, mainly in the ICU, but still had a whole day to contend with. Then came Sunday morning, I was called to the Emergency Department (ED) for a CPR-in-progress. It was a woman in her 40’s who had a cardiac arrest. I was told she was still talking when she was brought by the ambulance. However she became unresponsive and her heart stopped few minutes upon arrival.

When I arrived at the resuscitation room of the ED, a team was furiously doing CPR on the patient, with the ED doctor directing the care. A Lucas device (a robotic contraption) was strapped on the patient’s chest doing the mechanical cardiac compression, while other personnel were hovering around the patient assisting in any way they can.

After about 30 minutes of CPR, which is already an eternity of CPR time, we still could not establish a stable cardiac rhythm. We probed the chest with an ultrasound while the Lucas device was temporarily paused, and it showed that there was no heart motion at all. In simple terms, the patient was dead.

But before we completely pronounce the patient dead, one of the team members suggested that we get the patient’s husband to the room so he can be present. So the CPR continued until the husband can be at the bedside. It is now acceptable to have family members in the room when CPR is in progress.

One study from France that was published in New England Journal of Medicine (a leading medical circulation) in 2013 showed that family members who watched CPR on their loved one have far less post traumatic stress disorder three months later. Similar later studies support this as well, stating that family presence can help ameliorate the pain of the death through the feeling of having helped support the patient during the passage from life to death and of having participated in this important moment.

When the husband came in to the resuscitation room, he was tugging along their son, who was clutching a Teddy Bear. The boy, I believe, was about 8-10 years old. The moment I saw the boy walked into the room, my heart sank. I felt that the boy should have been left outside and should have not witness this traumatic event. But it was too late.

Perhaps whoever spoke to them outside the room did not suggest that it was better for the boy to stay outside. Perhaps there was nobody who can stay with the boy outside the room. Perhaps it was the father’s decision to bring along the son to the room. Perhaps they have no idea of what they would witness. Or perhaps the father was not thinking clearly as he had more serious issues to grapple.

The boy was squirming while his father was holding him, and was shielding his eyes with his Teddy Bear. Finally he was able to escape from his dad’s grasp and he dashed out of the room with his bear. Was the scene too much for the boy or too much for the bear?

The father stayed in the room though until we finally stopped the CPR and pronounced the patient dead.

To lose a mother was already a tragedy. But to lose a mother at such a young age and witnessed it as she die was really heartbreaking.

Many of us feel that we should try to shield children from the painful facts of life. We believe that children should be all fun and play, sugar and spice, and everything nice. Yet for some kids, sooner or later, they have to deal with the ugly realities of this world.

I know Emergency Rooms are not for Teddy Bears. But I do not care about the bear. I care about the boy behind the bear. Besides the comfort from his cuddly companion, I pray that he finds lots of love and reassurance from the remaining family he has.

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(*photo from Pinterest)

Spinning Plates

When I was much younger, I had a fascination for juggling. I learned how to juggle on my own. I could juggle 3 tennis balls, or toy blocks, or even plastic bowling pins. Though I did not and would not try juggling chainsaws.

Juggling is an art. The more dangerous and challenging the feat, the more captivating it is.

Have you seen an act of spinning plates, where the juggler spins several plates on sticks? He goes from plate to plate to keep them spinning or else the plates drop to the floor and break.

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Three weeks ago I had one crazy weekend duty. I think it would fall as one of my busiest calls in the ICU in my recent memory. It was so busy that my Friday to Sunday, kind of blended to one very long day with only a few hours of sleep in between.

In one particular stretch of that call, hell broke loose.

I worked on a very sick young man in his 30’s, who was admitted to ICU room 5. I intubated him, placed him on ventilator, placed a large neck catheter for IV access, and started several medication drips on him, all in one rapid succession. I was in the midst of trying to stabilize him when another patient, a lady in room 18, went into cardiac arrest. “Code Blue”* was called.

I have to drop what I was doing on the first patient and ran to room 18. When I got there, the ICU resident was already running the code. After 10 or 15 minutes of CPR and fast paced intervention, we were able to resucitate her back. With her heart rhythm semi-stable, I ran back to room 5, and continued what I was doing.

Not too long after, the patient in room 18 went into cardiac arrest again. I ran back to that room once more. This time I beat my resident to the room and took charge of the Code Blue. My resident who eventually arrived told me that she got hung up in ICU room 16 who was also crashing. I saw another resident who responded to the the Code Blue, but I sent him to room 5, to continue on what I was working there.

After more than 10 minutes of CPR we got our patient in bed 18 going again. It was heartbreaking to see that while the CPR efforts were in progress, the family was just outside the room crying and wailing as we work furiously on their loved one.

After we got the patient’s heart beating again, I gathered her family to a nearby consultation room and discussed with them the dire situation. I told them that there was no guarantee that her heart would not stop again. But given of how sick she was, especially after successive cardiac arrest already, I knew her chances of walking out of the hospital was close to nil, and continuing to do the CPR would be an exercise of futility.

I was talking to the family, when I was called emergently to see room 16 who they were about to call Code Blue. This was the one my resident told me about earlier. We got the patient intubated and hooked to ventilator, started several IV medications and got him stabilized, at least for the time being.

After getting out of room 16, the family of room 18 approached me and told me that they have decided that if her heart stop again, to let her go peacefully.

Less than 30 minutes later, she died.

The patient in room 16 that we attended to also continued to circle down the drain. And despite our efforts, he also succumbed several hours later.

I finally was able to concentrate on room 5 when there was a lull in the chaos we were in. I decided to place him on extracorporeal life support, also known as ECLS** (see previous post about ECLS here), as he would not survive without it. The ECLS team was mobilized, and around 2 o’clock in the morning, the patient was off and running on ECLS.

I have not even mentioned the other 17 ICU patients under my care, but were not actively crashing during that time, nor the other 3 new ICU admissions that came during that span of 4 hours of absolute craziness. I even accepted another patient from an outlying hospital during that period, for whom I ordered our flight crew to fetch. Though the patient did not make it to our hospital, as he was so unstable and our helicopter crew was reluctant to fly him unless they stabilize him more for the flight. I heard he died shortly then.

Spinning plates? Seems like it, right? Sometimes I wonder if I could  keep up with this pace or would I like to continue doing this. Don’t get me wrong I do like my job. But I don’t like the awful stress and the awful reality that comes with it. For it is not just plates that are falling and breaking.

About the patient in room 5? He improved after we placed him on ECLS. He eventually was weaned off ECLS and ventilator after almost 2 weeks in the ICU. He went home from the hospital the other day, walking unassisted and off oxygen.

Success stories like him, though few and far between, keeps us going. After all, I believe it is still worth doing this.

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*Code Blue: an emergency situation announced in a hospital or institution in which a patient is in cardiopulmonary arrest, requiring a team of providers (sometimes called a ‘code team’) to rush to the specific location and begin immediate resuscitative efforts.

**ECLS: extracorporeal life support (ECLS) is an extracorporeal technique of providing both cardiac and respiratory support to persons whose heart and lungs are unable to provide an adequate amount of gas exchange to sustain life. It is done by siphoning blood out of the body and artificially removing the carbon dioxide and giving oxygen to the blood by running it through a special machine.