I was writing my notes at the end of a shift in the pediatric emergency room, when I saw the cop frantically run past me and a voice shouted. A rapid escalation of movement began, driven by an immediately palpable, frenetic energy. There was a rush of activity as the doctors and nursing staff abandoned what they were doing and poured themselves towards the trauma bay, where we saw the child. Hanging limp in the bloodied arms of the cop was a very young boy, blood running down his face.
There had been no warning. The emergency medical system that communicated the accidents and disasters from the ambulance to the hospital before they arrived had given no warning, because there had been no ambulance. On arrival the cop had sprinted straight by the front desk with the boy in his arms. Straight through the waiting room where patients were triaged and given a medical bed or sent back to wait depending on the severity of their problem. The cop had run directly to the trauma bay and placed himself in front of the open bed, and in his eyes I saw no sign of fatigue, only a frenzied desperation. As the nurses took the limp body from his arms and placed the child into the bed, my eyes traced the blood on the boys face back to a small, dark, round hole in the side of his right temple.
Several things happened very quickly. Diana, the soft-spoken, senior resident, began issuing clear, firm commands, directing the unbridled energy of the nurses to place intravenous lines into the boy’s veins to draw labs and give medications, and other nurses to place the child on a monitor to gain information on the boy’s vitals, his signs of life. The other resident, my tall, Icelandic roommate, was at the bedside, with eyes closed and his fingers pressed on the boy’s wrist. His blue eyes snapped open and his voice filled the room.
“No pulse, begin compressions”.
A nurse stepped forward, immediately pushing firmly and rapidly against the boy’s chest, working to restore blood flow from his heart to the rest of his body. Diana called for access, asking whether the intravenous lines had been placed. Two terse “No”s came from the nurses on both sides of the boy, hunched over as they explored the boy’s arms with their small needles. My Icelandic roommate shoved an I.O. kit into my arms, looked me in the eye and said, ““Put it in the proximal tibia”.
My heart racing, from the kit I took what was essentially a small plastic drill, with a thick needle attached, into my right hand. An intraosseous line was a way to gain access immediately, by drilling into the bone. As an intern, I was the least experienced of the team, and had never placed one before. I quickly cleaned the area below the boy’s knee with a sterile wipe, and held his leg steady, my left hand able to wrap completely around his thin calf. I pressed the needle against the boy’s shin, making sure to avoid the empty joint space at the knee. Pressing firmly, I pushed the button on the drill, felt a grinding sensation and then a pop. I removed the needle and connected the extension tubing, and pulled back blood into a small syringe. I felt a rush and enthusiastically shouted, “We have access”. Diane ordered for fluids to be pushed immediately into the I.O. and for the blood to be hung as soon as possible. Eager to help, I reached back to hand the needle to my Icelandic roommate. As I reached out to hand him the needle, his eyes went wide and he threw up his hands, “I don’t want that!” I realized I had spastically tried to hand him a sharp, bloody needle. I blushingly turned to find a sharps disposal bin, and outside the room saw a large, intent crowd of nurses and police officers watching the scene unfold in the trauma bay. As I turned back, I saw that in those few seconds the nurses had already begun to push syringes full of fluid into the I.O., trying to restore the boy’s blood pressure as the other nurses hung the blood at the bedside. There was a flow to the actions of the team as every member worked to save the child.
“Hold compressions, everyone stop.”
The Attending’s calm, clear voice came from the top of the bed. He was holding the boy’s head between his hands, and had turned the boy’s face to reveal a small, dark, round hole in the boy’s left temple, a mirror of the hole on the right. The Attending’s eyes were turned to the cardiac monitor, which showed a thin, flat line. Standing at the boy’s right side, Diana had placed an ultrasound probe under the boy’s rib cage, and the ultrasound screen showed the grey shades and shadows of a heart, completely motionless. The Attending addressed the room, “There is a gunshot wound to the head, pupils are fixed and dilated. The heart is asystolic with complete cardiac standstill by ultrasound, with no evidence of respirations. This child is dead.”
All of the energy left the room. Each minute since the boy had arrived had been willfully filled with a dozen tasks by the team, and suddenly everything moved slowly. Throughout the quiet room, shoulders relaxed, then slouched forward. Nurses began to slowly put away their tools and walk away from the room. I heard muffled conversation as the crowd outside dispersed. I didn’t know what to do. I couldn’t stop looking at the small, thin body of the boy lying on the bed in the cold room. I moved to grab a blanket from the back corner of the trauma bay. As I began to open the blanket, Diana’s soft voice asked me to help her taken the dirty sheets out from underneath the child. So, I reached my arms under the child’s body and lifted. He weighed almost nothing. As Diana pulled out the bloody blankets littered with gauze and the packaging of the needles, the boy’s small, sagging head and arms spilled down toward the floor. I laid him gently back on the bed, and Diana gently spread the blanket out over the boy.
“I think I’m going to be sick.”…
To be Continued
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.