Sensing a purpose

Abstract

The baby was dead, they all knew it. The cardiopulmonary resuscitation wasn't helping, nor was the frenzied presentation by the medics who had rushed her into the emergency department (ED). A 2-month-old, previously healthy, was found apneic and pulseless in her crib. Probably another case of sudden infant death syndrome. “Should we stop?” someone asked. The senior resident brought his face close to the infant's. Her lips were like marble, her dark skin mauve. Behind slightly parted eyelids, her eyes seemed plastic. “No,” he said. “Full code.” No one debated the decision, not the nurses, not the intern and junior resident, and not the attending pediatrician standing quietly at the foot of the bed. The baby was intubated, a femoral catheter was inserted, and chest compressions were continued until 2 doses of epinephrine had restarted her heart. The cardiac tracing, at first, was slow. After a push of sodium bicarbonate and an infusion of dopamine, the heart rate barely topped 100 beats per minute. The senior resident made arrangements for the baby's transfer to the hospital's intensive care unit (ICU). “I'm sorry,” he told the resident working in the ICU. “I think I saved a tragedy.” He watched the ICU team roll the gurney holding the baby through the ED's double doors and the parents, trying to touch their limp child through a network of wires, tubes, and professional hands. Swallowing a wave of nausea, he wished that someone had challenged him when he announced the decision to continue to resuscitate. Why hadn't he let her be? he thought. There were more patients to examine, 10 more hours of a weekend shift to complete. The senior resident shuffled through the night and left the hospital the next morning, badly in need of sleep and a sense of purpose. It was Sunday. The sky was overcast. He was cited on his trip home for driving the wrong way down a 1-way street. Sunday hung eternal. He felt hollow, was unable to rest, to go out, or to do anything except picture a 2-month-old baby lying lifeless on a starched white sheet. In the past, he had privately scorned physicians who flogged dead patients with technology rather than permitting them peace. Was he no different? He considered what he knew: rigor and dependent lividity were 2 reliable signs of death. Had the baby's body been stiff? He wasn't sure. Had there been dependent blood pooling? He had not checked. To his horror, he couldn't remember touching the baby before deciding to resuscitate; he had simply bent himself close, thought he saw something move behind her eyes' milky fog, and said go instead of stop. He had felt for her pulse, yes, but only as an afterthought, only as a matter of medical routine. Objectivity had not influenced his order to resuscitate. He had acted instead on instinct. Monday morning, and senior resident rounds came upon him heavily. He had not called the ICU and, by the time all the senior residents sat together for case review, had not asked for an update on the baby's status. Weekend admissions were presented and discussed; he sat quietly, feigning distraction by the new ward service he had assumed 3 hours earlier. Everyone around him seemed confident and competent. The resident who had been working in the ICU on Saturday cleared his throat. “I have a case that's kind of interesting,” he smiled. The senior resident paled. He listened in horror while the baby's ED arrival and resuscitation were detailed, wondering how someone who was supposed to be a colleague could so easily humiliate him. The presenting resident looked at him and paused. “I can't understand why you resuscitated her.” The senior resident shook his head. He opened his palms with a gesture of resignation. No one spoke. “Well,” the other resident continued. “The parents are sure glad you did. The baby was extubated last night and is taking a bottle again this morning. She looks like a completely normal little girl.” After the room had emptied—after fellow residents had decided the baby must have had hypothermia and congratulated him for trusting something they called clinical judgment—the senior resident sat alone. Something other than judgment accounted for what happened when his face had been close to the baby's. He had sensed that a life had not ended. And he had responded. The sun warmed the table as he mindlessly fingered a packet of new patient summaries. The day, he noticed, was clear.