08 November 2007

9 NOV 2007 The little I can do

9 NOV 2007 The little I can do
He died. The little boy who fell from the roof hung in there until this afternoon. Our efforts were well intentioned, but we started too far behind the eight ball. Sepsis is a term that indicates that an infection has spread throughout a body. The word basically means contamination, which is an accurate description of what happens when bacteria overwhelm a body’s defenses and travel throughout the circulation. There are newer terms, like “SIRS” which stands for systemic inflammatory response syndrome, but using a more complicated term doesn’t change the frustrating nature of the danger posed by the bacteria running rampant throughout the body. When the boy’s intestine started leaking, the bacteria in his intestinal juices hijacked the bloodstream and traveled to all ends of his circulation. The bacteria release a poison called endotoxin that damages cells and shuts down the body’s vital processes. As the bacteria enjoy free reign of the bloodstream, they continue to multiply and further poison the body. Perhaps if we had chosen different antibiotics or different fluids things might have been different. Who knows? It is likely that we just got into the game too late to have ever won.  I gave it my best effort, but effort didn’t matter because it didn’t bring success. He died.

Through the night, I watched the boy struggle to stay alive in the intensive care unit. One by one his organs were failing. His heart could barely mount enough force to circulate his blood. We were pumping powerful stimulants into his bloodstream to keep his heart pumping. His kidneys had stopped making urine. His immune system was weakening and his blood was nearly depleted of the white blood cells that fight infection. We were increasing the force with which the breathing machine was a forcing air in and out of his lungs. We had opened his belly to allow more room for his swollen intestine to bulge out so that his lungs had more room to breathe. None of it was working. He made a brief rally in the morning, and then continued a steady decline. Later in the day, there was a sudden drop in his oxygen levels. We had already agreed with his father that we would not push on his chest to restart his heart if it stopped. We made a desperate attempt to stave off the inevitable with a volley of drugs and a replacement of his breathing tube. It was all for naught. His heart weakened, slowed, and then stopped for good.

His father was close to us the entire time. Interpreter J. sat with him while we worked. I came to him to tell him we had failed to bring his son back. It struck him the way it would have struck any of us who are parents. It didn’t matter that I had been warning him about how poorly his son had been doing. Nothing can prepare a man for that. He wailed. He ran to his son’s bedside. He collapsed over the bedrail. He covered his little boy’s swollen face in kisses as he sobbed his name. I stood beside him and rested a hand on his shoulder. He looked over to me and motioned with his hand at his boy’s belly where his intestines bulged out under the sterile dressings. His eyes implored me as he spoke and I didn’t need J.’s interpretation to know that he was asking me to close his son’s belly.

I gathered some instruments from the operating room. A young technician helped me as I worked to close the incision on his belly. He told me that this was the first time that a patient he was caring for had died. I was sorry that it had to be a child. I told him that he just had to look ahead to the next patient and to hope for a victory that would bring us back from this loss. He helped me well. The intensive care unit nurse cleaned his body. As I closed the boy’s muscle and skin, I tried hard not to inadvertently hurt his intestines. I had to remind myself that it was too late for that to do any good. I hadn’t been able to give this boy what he needed, but I gave him the little that I could. I squinted to focus and my eyes burned.

I sat numbly in the locker room. I had been on call for emergency operations the night before, and I didn’t have any further duties. My other patients were safely tucked away. Tomorrow will be better. I have admitted to the hospital a boy who was injured several months ago. He was blown up by an IED. My friends who were the previous surgeons at this hospital kept him alive after his injuries. He needed a colostomy. Enough time has passed and he is ready to lose the colostomy and have his intestines reconnected. It is time for him to graduate. He is a skinny little boy, all smiles, like so many other children who have come through here. This operation to reconnect his intestines is so much smaller and less urgent than what he has been through already. In fact, he could live his whole life with his colostomy, and for Iraqis who cannot get to a surgeon, that is what happens. I am happy that I will get to take care of him tomorrow. It’s not much, but it is the little I can do.

LTC Christopher P. Coppola, USAF
APO AE 09315-9997


DSN 318-443-2925


cathy said...

Reconnecting that boys intestines may not be much (surgery wise) but to that boy, I bet it means the world.

im very sorry the other little boy didn't make it. I'm sure you did everything to keep him alive. it sounds like he was very very ill.

I am keeping you in my thoughts and i read every post you write. Thank you for what you are doing!

hamster said...

Would you mind if I kept you in prayer? That's the only thing I can do from Singapore.

rlbates said...

So sorry for all involved. What "little you could do" is often more than we think.

ChefSara said...

I'm so sorry to hear that...I'm not sure if it helps, but take satisfaction in knowing that you at least gave this boy a chance he NEVER would have had otherwise. And that chance is important. And remember how great it felt to see the burned boy recover and walk on his own. I know time is always needed to mourn these losses, but don't let them overshadow your triumphs!

Anonymous said...

Giving that little boy's father the knowledge that everything was done to try to save his son, and treating them both with dignity and respect in life and in death makes a horrible loss slightly less horrible. Sometimes that's the best we can do and even though it will never be enough, I hope that it helps you rest a bit. As a PICU attending that's what I hold on to when I have to do the profoundly difficult work of telling a parent their child has died despite our best efforts. You are doing good work, hang in there.

NICUTransportismylife said...

Like anonymous said above, sometimes I feel that perhaps the last significant thing we can do for families is to care for and respect their precious children (even if the end result is that they die). As wrong as it may feel, it is a priviledge to help a family through the death of their child and somehow make the experience slightly less horrible. I feel you had to have made a difference in that one, too. Lots of years in PICU and NICU have taught me this. Hang in there, and thanks for all you do.

Chris said...

Dear Cathy, Hamster, rlbates, Sara, Anon, and NICUtransport,

Thanks so much for commenting. It is very important to me that I get to have this dialogue.

I have done this long enough that I know that there is nothing to do but move on to the next one and do it better this time. The difference here is that I don't get to have a hug from M. to get me back on my feet like I do at home. I admire you who work in NICU and PICU because you are choosing to serve the most critically ill children. In my business of pediatric surgery, the vast majority of my patients fly right through their treatments.

Please do pray for me and and for my patients too.

Be well,