Wednesday, April 1, 2009

Realms of Control

Pediatric Advanced Life Support (PALS) is a two-day long course designed to teach front-line providers how to manage the very young when they become very sick. Like so much else in my training, the gritty specifics of the class are by now pretty hazy, but I do remember one thing: how to take one look at a kid and know if she is really sick.

This kid was really sick.

Even in the arms of her mother, her entire body heaved with the effort of breathing. She was profusely diaphoretic, pale, and cool in the extremities. Her lungs sounded rhonchorous, or maybe stridorous, or maybe wheezy. They definitely sounded bad. The shirt she was wearing was covered down the front with vomit from an interrupted meal, and it looked like more was on the way. Blood pressure was low. Oxygen saturation was low. Heart rate was high.

The specifics don't matter. This child was seriously ill with a condition that remained beyond my control. Despite all of my training, the giant red bag that I carry on my back, the uniform, the lights and the sirens, the definitive answer for right here, right now, was to scoop the kid up and run to the hospital.

It is a difficult thing to explain to a terrified family. I told them that I didn't know what was wrong with their child, but I was sure she was quite unwell. I explained that things are likely to get worse if we can't get her to the hospital quickly, and we need to get moving right away. Don't worry about finding her a jacket, don't worry about her shoes. Let's go.

The family looked at me, shocked. Can't I do something? I'm not sure exactly what it was they envisioned me doing in their living room, but certainly it was more than to tell them their child was sick. And even though we had fancy looking tools: the cardiac monitor, end tidal CO2 waveform capinography, intravenous fluids and oxygen bottles, the truth was out. All of our training and experience, tools and protocols were nothing but fluff. They were along for the ride, as we were, against an uncontrollable pathology and a random outcome that only the hospital on the hill could really make sense of.

So off we went, down the road above the speed limit with the lights and sirens doing their noisy work. I went though my routine as I was trained, knowing that the efforts would land without much effect. And though it upset me to remain unable to offer any definitive treatment, it helped all of us to know that something, anything, was being done. The hospital was only ten minutes away.

The doctors converged on the supine patient, a ring of white coats bending forward to look over the similarly colored child. They attached monitors and took assays of varying types through the cluster of work. They called resources in from across the hospital, pulled out the stops, and brought experience and reason to bear. It was more than forty minutes before one of them stepped out of the room to talk with the frightened parents.

"Ms. Reynolds," they said, "we're not quite sure exactly what the problem is yet, but we know your child is very ill."