The first call came from another emergency department, telling us that they were transferring a fifteen-year-old girl in critical condition to our hospital. The second call, coming just a few minutes after the first, informed us the girl had died. Then they called a third time to say that they would transport her after all; she was alive but in dire condition, with fixed and dilated pupils, no spontaneous respirations, and no gag. As we prepared to receive the patient, a fourth call heightened the anxiety we were already feeling about the arrival of a critically and probably hopelessly ill child. This caller told us the girl had been injured by throwing herself in front of a moving train. She was brought into the trauma section of our ED by a MedFlight crew. Their brief, straightforward report gave us the salient details: They found her next to train tracks, unresponsive, without purposeful movements. She had shallow, spontaneous respirations. Her heart rate was sixty beats per minute. There was a large laceration on the back of her posterior scalp. They intubated her, placed two peripheral intravenous lines, and brought her to the nearest hospital. As that facility was not a trauma center, its ED staff decided to transport her to our hospital. On our examination she had no spontaneous respirations, a weak pulse, and no blood pressure. The remainder of her exam was unchanged from the report we had just received. The MedFlight team was performing CPR, and at the head of the stretcher, in what had suddenly become a crowded space, a senior neurosurgeon was calmly guiding his resident through the basic neurological exam in the setting of trauma: evaluate the level of arousal and responsiveness, check the pupils carefully, test for corneal reflexes, look at the tympanic membranes for evidence of blood, check for a gag reflex, and look for symmetry in the remainder of the neurological exam. After the resident completed his examination, the senior surgeon remarked that the patient was nonviable. As the girl had only a thready pulse and no spontaneous respirations, we needed to make our first decision regarding the course of our intervention. Our options, based on the likely outcome of patients with such massive brain injury, were to stop CPR and all other support, to embark upon full resuscitative efforts, or to take a middle ground and try one round of medication to see if we could restore her pulse and blood pressure. Without much enthusiasm and with uncertainty causing us much discomfort, we seemed to gravitate toward this last option. We were not entirely pleased when the epinephrine in fact gave her a reasonable and adequately palpated pulse with a rate of seventy. Shortly after her heart rate returned, we were notified that her mother and sister had arrived and were waiting in the grief room. I entered the room and found the mother of the almost lifeless child and her thirteen-year-old daughter hanging on to each other for the girl's dear life. I told them that the injuries were critical and appeared to be beyond the girl's ability to survive, let alone survive with any meaningful function. I added that the girl was not in any pain. Then the mother talked briefly about her daughter and asked several wise questions: How could we tell so soon that her child's injuries were so severe? What tests had we performed and what tests were we planning to perform or could we perform to learn more information? How could we tell so much from our examination alone, and, finally, could she please see her daughter Sally. I answered her questions as best I could. Certainly, she could see her daughter, but give us a few minutes please, I said, not adding that the extra time was needed to clean her up and cover her exposed body. When I returned to the girl's bedside, her vital signs had deteriorated. Her pulse was thready and her blood pressure had dropped. This young sister and daughter, a struggling tenth grade student with many friends, appeared to be dying, with the likely end quite near. …
Read full abstract