When the Music Died

Illustration / Photo-credit: Saniya Kamal

Imagine yourself as an ER nurse or physician. Then imagine a parent bringing to you their dead child, with the expectation that you will bring her back to life. What do you do?

This happened to me, yet again. The overhead page for pediatric resuscitation was met with the routine ‘rapid response team’ deploying itself from the pediatric ward to the ER ‘resus’ room. There we met a distraught father who had brought in Sasha, his 2-year-old daughter. Once I took stock of the situation, I realized this was a no brainer: I was to follow the pulseless and apneic child (that is, neither heart nor lungs functioning) algorithm from the American Heart Association’s Pediatric Advanced Life Support guidelines. 

“Dead child -> go directly to Cardio-pulmonary resuscitation (CPR) -> do not pass Go, do not collect $200!” a professor from my residency years would remind us, specifically for that situation. 

I immediately instructed one of the team members to initiate chest compressions, the first intervention of CPR, while I gathered some more information. I found that Sasha was not a previously healthy child. She had been born with a complicated heart defect. A surgical attempt had been made at correcting the defect a few months back.

“Sasha had been quite normal this morning”, said Sasha’s father.

Although I didn’t think she was a normal child, given her heart defect, perhaps for her dad she was. What he meant was that morning she had been playful and feeding well, without overt indication of an interim illness approaching. She had choked while drinking milk; that was followed by copious secretions from her mouth and nose, and then she had gone limp. The parents had rushed her to a nearby ER. An ECG strip obtained there showed an ominous abnormal heart rhythm. That should have prompted immediate CPR in an attempt to revive Sasha. That ER, instead of providing immediate life saving measures through CPR, urged the parents to rush their child in their own car (versus calling for an ambulance) to our ER. During the transfer Sasha’s dad had been in constant contact with the cardiologist closely involved in her care. I guess at some point during the transfer Sasha breathed her last. By the time she was in our ER I speculated that she had likely been dead for over fifteen minutes.     

When you are in CPR mode the situation seems to have come to a standstill, although things are actually happening quite rapidly in real time. Even after 5 minutes of CPR and 1 round of adrenaline, latter in an attempt to jump start Sashas’s heart, the cardiac monitor continued to show a flat line. Sasha did not show any signs of returning to our land of the clinically alive. By then I had already discussed with Sasha’s father and her cardiologist the grim prognosis. There was no point in discussing hopelessness of the CPR with Sasha’s mother, as she was unable to comprehend and unwilling to listen. That, the mother had already demonstrated by repeatedly calling out Sasha’s name and shaking her shoulders, in an attempt to simply clutch her out of death’s tight grasp.

I called off the CPR. After a few seconds of realization sinking in, the anguished mother’s heart wrenching sobs were all we could hear above the beeping alarms and monitors in that area. As Sasha’s mother beseeched me to do something, I had to work extra hard not to ask my team to resume chest compressions and to give a second round of adrenaline. To make it easier for myself, I simply looked away...

No matter how many years I practice in the pediatric ER, dealing with the death of a child is not easy. Explaining to the parent the death of their child in a manner that they can comprehend is one of the hardest things to attempt. Especially when they look at you with the final vestiges of hope - their ‘do something’ appeal, repeatedly, at times. Even if they won’t say it, their eyes articulate it, “do something doctor…anything... to bring my child back”. 

As an ER physician, my first response and responsibility is to revive the child – to resuscitate him or her to the best of my abilities. However, when the child in question has been dead for some time, then should I be resuscitating that child at all becomes a major ethical and moral dilemma. When the parent tells you to ‘do everything’, and there’s no previous do not resuscitate (DNR) decree to guide you, I suppose you do everything within your means. At a minimum you go through the CPR routine. In Houston where I worked for a long time prior to moving back to Karachi, I would’ve continued resuscitating like an Olympian. Limitless ventilators and medical care in the absence of a DNR would have precluded discontinuation of CPR in a mere 5 minutes. I speculate that had Sasha been in the US, more aggressive resuscitative means would’ve been employed. And she would’ve been revived and promptly packed off to the ICU, irrespective of long term benefits. 

Having seen so many dead and dying kids already in Karachi (as patients in the ER), I have become acutely aware of my limitations: a lack of medical miracles to be performed as well as a lack of medical heroism to be demonstrated. When death must declare itself then what reason do I have to pull any child back to life? And even if I do what kind of a life am I bringing them back to? I am much more likely to ask these questions of myself in Karachi where I practice now. I have also become quite aware of the transience of 'clinical life'. Life can be taken away in moments. Moments can be hours, days, or months for some. And seconds for another. Perhaps that’s reflective of the unpredictability of our world. I don't know if any point is being made, but dealing with (or trying to) sick, injured, dying and dead kids (and their parents) is sobering, and provides valuable life lessons.

In Karachi I frequently call off CPR early after initiating it, with one caveat: only if I am able to gauge the futility of it, and that happens quite often. However, every time I have had to do so, and pronounce the child dead, a bit of me dies.

“Letting Sasha go was okay”, I tell myself. 

But still, a bit of me died that day….and so did the music...

Excerpt from ‘Sasha’ from the forthcoming ‘Journal of an Itinerant Observer’

[from Narrative Medicine]

CREDITS:

About the Author: Dr. Asad Mian is a pediatric ER physician, clinical researcher and Associate Professor at AKU.

About the Reviewer-Editors: Dr. Kanwal Nayani (AKU, MBBS class of 2015) is planning a career in pediatrics; Huma Baqir (AKU, MBBS class of 2017) is planning a career in psychiatry.

Illustration / Photo-credit: Saniya Kamal, AKU MBBS Class of 2018, hopes to become a neurologist, pursue art, popularize meta-fiction, conquer the world and stay happy.

Editorial Note: This is from a series collected as part of the Narrative Medicine Workshop at AKU on January 20^th, 2016. The editorial work was performed by the Writers’ Guild, an interest group at AKU, with the purpose to promote love of reflective reading and writing, within and outside of AKU.      

DISCLAIMER: Copyright belongs to the author. This blog cannot be held responsible for events bearing overt resemblance to any actual occurrences.