I’ll never forget

It was an orange summer evening; a warm breeze was blowing outside. I was inside, working, and the little girl I was called to see was barely clinging to life.

Her head was swollen, her body bruised all over. Her pupils were so big that her irises were the barest ring of brown around the empty black. I swallowed hard as I reviewed the CT scan. Her brain was a uniform grey, interrupted only by flecks of bright white in the depths of the brainstem. Duret haemorrhages.

Only hours earlier, the family of five were traveling out of town on a holiday. An oncoming vehicle swerved onto the wrong side of the road. Four members of the family sustained minor cuts and bruises. Cruelly, the brunt of the impact was borne by the 6-year-old girl.

There was nothing we could do.

The distraught mother had refused to leave the girl’s bedside. She already knew. “Always listen to the mother” I was taught in my paediatric rotations. The father and the two siblings came into the meeting room with us. It was time to tell the family. Their eyes showed no sign of the fear I was certain they must be feeling at that moment. I breathed a sigh of relief mixed with shame when the ED physician volunteered to do the talking.

Over a decade later and I remember most how they faced the fact of their daughter’s imminent death with a calm dignity. Their gentle acceptance humbled me then. It humbles me still.

My colleagues got up to leave. I had somehow held back the tears for over an hour now. A few glanced as I lurched towards the sink. I was not sure if I was going to vomit or cry.

I was alone, my vision blurred by tears. I’m not sure how much time passed, but eventually I washed and dried my face and left the room.

Back to work. There were more patients to be seen.

I don’t remember, but I’ll never forget

I don’t remember the call.

I know there must have been one. There must have been a paediatric cardiac arrest call put out, otherwise I wouldn’t have attended the ED. I don’t remember it though. I was the ICU registrar on call, and I was in the ED waiting to receive you.

I don’t remember checking my equipment. I must have done, as I had it all to hand.

My first memory of you is your limp little body being hurriedly lifted onto the resuscitation trolley by your dad’s strong, determined, speedy arms.

You were covered in a rash. A viral exanthem, I thought.

You weren’t breathing. You had no pulse. We started CPR. I intubated you with one swift movement. We started ventilating you, and your chest rose, and CO2 was detected. Sigh of relief. Good.

Children have respiratory arrests most of the time right? Restoring ventilation should make you live again.

Your pulse didn’t come back. The ECG was a flat line.

Oh God.

Oh God.

Multiple thoughts now. Causes of asystole in a young child. Hs and Ts. Running through; no signs. Adrenaline boluses. No response. External pacing. No response.

Oh God. Please, God, no.

ECMO. Please can we put you on ECMO?

The nearest centre is an hour away. 30 miles as the crow flies.

No.

No no no no no.

If you lived 30 miles south of here you might have–might have had–a chance at living.

The pain that shoots through my heart in that one moment is excruciating. Anger. Fear. A horrendous sense of a giant universal wrong.

I don’t talk to anyone about ECMO. I can’t. The team leader isn’t thinking it. No one else is. I just…. I can’t do it. It hurts too much.

I hope someone else would bring it up. I would go with you in the ambulance. A mad dash to try to make you live.

But no one does.

We carry on CPR for 40 minutes. I carry on ventilating you; a shell of a man, watching myself holding back tears of frustration at the inevitable situation that is to come.

You’ve been down for an hour. The team leader, a consultant paediatrician says “stop”.

Your father utters a painful, weak “No, no”…
Your parents crumple around your little, rash-covered body.

I excuse myself from Resus. I tell myself I’m giving the parents a chance to grieve. But it is I, it is I who needs to grieve.

I collapse. Shaking. The tears flow, stinging my cheeks as they fall. I weep for you, for your parents, for the sun you will no longer see, the warmth you will no longer feel.

You had a beautiful 18 months on this earth that were cut tragically short.

I am so sorry.

I learn ECMO now. You sit on my shoulders as I study. Your little hands widen as I understand what it can–and what it can’t do.

I will never forget you.

‘Could I see your soul?’ by Nitin Arora

 

‘Your eyes are windows to the soul,’ I was thinking as I shone a light into your green eyes. They looked wide & innocent. The bruising around them, almost blasphemous.

I looked at you – 7 years old, coming back with mum after visiting grandparents. There was a car crash. Mum was fine but you – normally cheerful & bubbly – were crying, and then had a seizure, followed by a respiratory arrest.

Your eyes did not react to light, or to touching with a piece of gauze. No response to cold water in the ears, or to disconnecting from a ventilator.

‘The first set of tests show Joshua is brain stem dead. We will do a confirmatory second set shortly,’ I told your mum. She cried.

We contacted the organ donation team, and spoke to your mum who said she would like to think someone’s life had been saved using your organs.

I took you to theatre – your mum walked to the door with me. I promised her I’d look after you and stay with you all the time – I lied.

I connected you to the anaesthetic machine & theatre monitoring. Your skin was still pink and warm. But the operating theatre was a hub of activity. There were 3 surgical teams, organ donation coordinators, big bags of equipment, transfer bags, phones, paperwork. I felt lonely in the middle for you. The most important person in the room – you – were almost being ignored.

The surgery started. We alternated between the thoracic and the liver teams to dissect around your organs (your little body wasn’t big enough for both teams to fit around you.) The kidney team would work on you after the heart, lungs and liver had been taken.

I lied to your mum. Just before the surgeon cut into your skin – and warm blood flowed – I had blurred vision and had to step out of theatre for a second. I couldn’t talk, and I’d obviously got some grit in my eyes.

But I knew I needed to return and look after you – I’d promised.

Each step felt like a desecration of the human body – cutting through skin, bone, clamping blood vessels, and finally stopping ventilation… suddenly, everyone was gone and in theatre, there was the anaesthetic assistant, me and the scrub nurse. We talked about you for a minute and then started cleaning you up.

I went to talk to your mum… she was very strong.

We found later that you’d helped many children – the heart and lungs went to someone with CF, the liver was shared between two children, and the kidneys helped two come off dialysis.

Your eyes gave the gift of sight to someone… and (even though I know the cornea is colourless) anytime I see someone with green eyes, I think ‘I know those eyes- I shone a light in them’