The past 2.5 weeks on PICU have been great, I've got to work with some amazing doctors and had some incredible experiences. Due to the nature of the unit I was very much hands off and although there were some seriously sick kids there were never any crash calls or arrests.
I did go to one 'code pink' where a child had been given too much morphine post-surgery and wasn't waking up. All it took was a quick dose of naloxone and he was awake....and crying. It was quite impressive to see such a rapid reversal in someone's condition.
The worst case up until now had been a young girl who had been involved in an RTC and had sustained quite extensive brain injuries. In all honesty it did cross my mind when I left the unit on Friday that she may pass away over the weekend. She has, however, proved us wrong by slowly improving. Obviously the doctors are very realistic in what they expect her long-term outcomes will be but comparing what she was like early in her admission with now I can easily see a positive difference.
We also had a child admitted with a prolonged accidental paracetamol overdose which when the dose was worked out made everyone go "shiiiiittttt." But she is holding steady and is on the right side of buggered.
So despite there being some shitty moments there were also a number of positive moments such as:
- Seeing several children being discharged back to the ward - including some very sick kids
- Getting on really well with the PICU team and being made to feel like a member of it (albeit a dumb, yawning, unable to help with anything practical beyond basic stuff team member)
- Learning about various medical conditions, both rare and common(ish) like:
- Rheumatic heart disease/RF, which is still extremely common in NZ
- Hurler's
- Paronychia Congenita, specifically affecting the vocal cords
- So much congenital heart disease
- Meeting the parents of the children, who are able to hold it all together despite the hell that they are undoubtedly going through - those men and women are truly inspiring in their emotional strength
And that brings us to today...
The day started with loads of promise. The reg wanted me to take a couple of the patients and present them at evening rounds after teaching. I chose a baby with coarctation of the aorta who was having surgery and a bronchopneumonia. The morning was going swimmingly - hell there was even a plan for me to observe the extubation of one of the patients so that I would understand how it's done.
But then, as I wrote in the title, the bubble burst.
PICU has been looking after a child for the best part of a month who has a multitude of problems including graft-vs-host following a bone marrow transplant. The parents had always tried to be realistic when it came to the prognosis of their daughter but it was obvious that they also held onto the hope that she would pull through despite the proverbial shitstorm that she was going through. The doctors have tried everything to help her including nitric oxide and using an oscillator to help with ventilation.
Today seemed to be going similar to every day up until that point. The X-ray was of debatable significance and things were slowly moving along. But today when the nurses went to turn her in bed something went wrong. She desaturated. She started having a bleed from the lung. Things were going bad in a big way. I stayed out of the room whilst two of the doctors and the nurses tried to help in any way that they could, after about 30 minutes I was sent to go and get the consultant. When I told him that she had desaturated and was bleeding from the lung he carefully repeated the last part of the sentence in a manner that was half questioning and half processing the information. For a moment the words seemed to hang there, and I began to process what I had said, my thoughts finally catching up with the events up to that point, and in my mind all I could think was "Fuck."
Eventually the consultant and fellow came out of the patient's room after much discussion with the parents and other specialists. I only caught part of the conversation but I remember hearing the words "the parents don't want anything else to be done." There was some intense discussion between the PICU doctors about what could still be done but regardless it would all be futile. It was agreed that the best course of action would be to keep the patient comfortable and allow the parents & family to spend time with her.
Whenever I saw the parents for the rest of the day I could see the anguish in their body language, their faces and in their eyes. The look of someone who is too tired to carry on, is defeated and just wants the nightmare to end. Someone who's eyes are raw with the tears that they have shed. And the pained look on their faces that screamed out that they knew they would likely never see their little girl as she had once been before all of this, as she had appeared in the picture stuck on the monitor over her bed, the look of a parent who knows they are almost guaranteed to outlive their own child. I think it's hard to imagine a worse hell than what they are going through at this minute.
I don't know if she will survive the night and I guess it's something I'll find out tomorrow when I go in.
And it's not over yet folks!
With this experience still ringing in everyone's ear we started the lunchtime ward round. This was summarily interrupted by a 'code pink' which rapidly became a "can the doctors please make their way to room 4?" The baby that was originally on the ward had been bought down in a peri-arrest state. From a medical point of view it was an amazing thing to watch the team work together so fluidly. Acess was secured via the IO route and a Hickman line, drugs and fluids were given to stabilise BP and the baby was tubed literally seconds away from arresting. I mean seriously bradycardic. As the patient stabilised, it was possible for the reg to do the art line and central line in a more relaxed fashion.
Whilst all this was going on what was I doing? Well, I was observing. I'm a medical student in a highly specialised environment in which I have very little knowledge. So I watched. I felt useless, an obstruction, christ I felt like an idiot. But then the mother arrived and stood silently next to me. And after a minute she asked me what the green tube was for, and I told her that it was giving her baby oxygen. Then she asked me what the lines on the monitor were for. And again I explained what they meant. And this cycle repeated itself for several other actions the team was carrying out.
And then I realised something - I may just be a medical student, I may know next to nothing about paediatric critical care, I know for sure I'm not anywhere near the smartest in my year group (my AMK scores show that), but I do know what each of the various components of the resus entail and I can explain to mum what is going on. And that's just what I did. I stayed by mum and talked to her about what the doctors and nurses were doing to her child. When the trace for the heart rate dropped to zero I heard the sharp intake of breath and the breaking, whisper of a voice speak out in fear above the noise of everything else in the room - I knew it was an artifact but mum didn't, and so I told her that the heart was still beating (oh god I hoped it was still beating, I could hear the comments about weak pulses) and felt the palpable sense of dread ease slightly. I realised that no matter how small an impact it will make in the overall care of her child, I was able to connect with her at that time and with that simple act of speaking with her she suddenly wasn't alone and isolated. It was all I could do, so it's what I did.
Today may have been one of the most fucking emotionally trying days since I started not only here but in all of my five years to date. The bubble may have well and truly burst and with it I have now seen the darker side of it all. But before today I felt like I was suffering from an empathy burn-out, like I could no longer react with shock to what I was seeing - I was stood in a PICU and I wasn't shaken by what I was seeing - and then today happened. I looked into the eyes of a mother who was losing her daughter and knew there was nothing she or anyone else could do to stop it; and I looked into the eyes of a mother caught up in the fear and confusion of a paediatric arrest, isolated amongst a sea of health care professionals, waiting dumbstruck whilst they tried to save her child.
I may look back on this when I'm at home with my family and it may all hit me, but it may not, I don't know. But it has happened and there is nothing that I can do to change it. Academics and doctors always talk about shielding medical students from the worst shit until an appropriate time, but I do wonder how you can decide when this magical arbitrary cut-off time should occur and in what way. I've seen death and dying in a medical student capacity before this but (this sounds terrible, but I can't think of a more eloquent way to say it) it has never felt as real as it did do today. It can never compare to how it feels to lose a loved one of your own, but it felt as though a gap between 'personal experience' and 'medical student experience' was bridged or at least is beginning to become connected.
And you know what, I'm glad the bubble burst suddenly. It showed me that I'm not turning into some hard-nosed, uncaring bastard and it reminded me of a big part of the reason I wanted to become a doctor.
Hopefully the next post will be shorter and much more positive!
Dan
P.S. Mum & Dad if you're reading this, I'm ok, I talked with the doctors on the unit and am in a good place. If I need to phone you I will, but as it stands I'm ok x
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