A Tale of Two Lessons

It was my first rotation in the ICU during my second year of pediatric residency. We arrived at the bedside of an 8 year old girl, who looked like any other kid her age. N had long dark hair, green eyes, and freckles. I have always loved children with freckles; maybe they remind me of her. The resident who admitted her overnight said she had an “anterior mediastinal mass” diagnosed by chest x-ray and was being sent for radiation therapy to treat it. Basically to define this location it’s the area in the chest in front of the heart extending up to the lungs. When the resident got to the “plan for the day” part, the cardio-thoracic surgeon interrupted and said this was a “ticking time bomb.” I did not understand what he meant until later.

The plan if she began having difficulty breathing was to run a full code. Intubate her if necessary, do CPR, and if that was not working, cut open her chest to pull the mass up off her heart and lungs until he could arrive and do surgery. I remember hearing this plan and not knowing my role.

I was curious about N’s illness and took some time after rounds to review her chart. She had been coughing for 6 weeks and complained of shortness of breath when lying down. Her primary care physician had prescribed a few rounds of steroids and she had improved each time. This is not unusual in cases of asthma and croup, but also chest tumors. She would worsen again each time, and after six weeks, her physician ordered a chest x-ray which revealed the tumor.

When the ICU fellow and I went down for dinner that night, we checked on our patient. She looked fine, smiled at us even. As we both sat down to eat, our pagers went off for an emergency. We ran up three flights of stairs and arrived at her bedside in a minute or two. I was still breathing hard from the run. I will never forget the look of fear on her face. She took another breath, laid back, and was gone. She was not breathing and had no pulse. It was in an instant. I straddled her on the bed and began chest compressions. The respiratory therapist was managing her airway with a bag to provide oxygen. The fellow began to set up for intubation.

All of the sudden, a deep voice came from behind me and said “stop, stop doing that to my baby girl.” Huh? What was this guy talking about? We had made a plan that very morning and no one had objected. She was a full code. She was 8 years old. She was awake and talking to me within the last half hour. “I don’t want you to keep doing CPR. I hope you are hearing me? I am talking to you.” I was in disbelief. “Sir, I am hearing you but I cannot stop. I do not have that authority. The attending is the only person who can make that decision with you. He is on his way. I am sorry, but I must keep going.” He began to cry.

The team was trying to decide whether or not to operate. Her father said he would not consent to that. I continued CPR despite the flat line on the monitor. The attending arrived within 7 minutes of her collapse and authorized us to discontinue chest compressions and airway management after speaking with her father. I stopped. The flat line never faltered. She was dead.

I was devastated. I was sick to my stomach and could not believe what had just happened. How did he let her go? Doesn’t he realize we cut patients open and save lives? Didn’t he love his baby girl? Remember, I was not a parent yet, myself.

An autopsy was completed and it is here I learned the tremendous lesson not to be forgotten through all these years. The tumor was not just sitting on her heart like a bun on a burger. The tumor had attached itself to her heart. It had snaked its way into the main vessels that return blood to her heart. There was no way for the blood to flow back into her heart, get oxygen and be pumped out again. If we had cut open her chest, she would have died regardless.

I am certain he loved her more than anything in the world. Somehow, that father knew what was best for his child. That is lesson #1. I will never forget this little girl with the green eyes and freckles or her father.

About a month ago, I was seeing a 10 year old girl for a well child check-up and her father said “she has been coughing for a few weeks and complains of being short of breath when she lies down.” Lesson #2, I ordered a chest x-ray that day.


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