Opinion
ON MY MIND
Jennifer C. Kett, MD Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington.
Corresponding Author: Jennifer C. Kett, MD, Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, 1900 Ninth Ave, Seattle, WA 98101 (jennifer.kett @seattlechildrens.org).
Extracorporeal Membrane Oxygenation and an Angel “We have a baby who needs ECMO,” says a voice on the other end of the line. I recognize the sound of his adrenaline rush, just as my own occurs. We often take calls from other neonatal intensive care units requesting a transfer to our center. The calls for extracorporeal membrane oxygenation (ECMO) are usually the worst. As I take more information, my heart sinks. This infant has a diaphragmatic hernia, a congenital defect in the diaphragm that leads to severe abnormalities in the lungs. His blood gases have been extremely abnormal since birth—almost 18 hours ago. We have no way of knowing what that has done to his brain. His name is Angel. The other physician tells me that Angel’s parents understand how sick he is and that he is being referred for ECMO. They are not available to speak with me. I am certain that, despite this physician’s best efforts, they have no idea what awaits. The transport team scrambles the helicopter. I call my attending. I call in the ECMO team, even though I am not supposed to. I should wait until the baby arrives, to see if I can stabilize his condition. But there is no doubt in my mind that he needs ECMO. I doubt only whether we can get to him in time. The transport is difficult. Angel is unstable with low oxygen saturations and low blood pressure throughout the flight. Nothing helps him—not adjusting the ventilator, not the intravenous fluid, not vasoactives, not deep sedation. He arrives alive, but just barely. We move him from the transport isolette onto our warmer. He does not like that at all. The ECMO team is ready to go—the circuit is inside the room, filled with blood and churning away. We just need a surgeon to place the cannulae. The surgeons knew that Angel was coming. They know he’s here. They’re busy with a trauma patient in the emergency department. I call them again. I tell them that Angel’s not going to make it. I don’t like the sound of my voice. I am supposed to be calm. I am supposed to be in charge here. The situation is getting out of control. I see the surgeons at the end of the hall just as Angel goes into cardiac arrest. We start cardiopulmonary resuscitation as they prepare their instruments. The room, already tense, is a flurry of activity and voices. The surgeons put on their gowns and gloves—
Published Online: February 10, 2014. doi:10.1001/jamapediatrics.2013.4665.
spinning and twirling without taking their eyes off of the baby on the bed. We do compressions. We ventilate. We give drugs: epinephrine, saline solution, epinephrine, sodium bicarbonate, epinephrine, epinephrine, epinephrine. We can’t get in touch with the parents. They are on their way. They have no idea what has happened. Even if we could get in touch, what would I say? Should I tell them all this while they are driving? Minutes tick by. We are ready for the first incision. The surgeon looks at me over his mask, eyes weary, knife in hand. He asks, “Are we really going to do this?” Are we really going to do this? Are we really going to subject this infant to ECMO? Are we really going to cut his neck open and put plastic tubes inside? Do we seriously think he could survive? What has the lack of oxygen for the last 18 hours, for the last 8 minutes, done to his brain? Will he ever walk or talk or recognize his mother? If we save his life but he experiences no happiness, have we done something good, or the worst kind of wrong? His parents are on their way. Are we really going to do this? I turn to my attending for answers. He shrugs. I hear myself say “yes.” But I don’t really know why. We continue cardiopulmonary resuscitation, the surgeon places the cannulae, and Angel is connected to the circuit. His condition is stabilized. His family arrives. We explain what has happened. They thank us through their tears. Angel survives the night. The next morning, an ultrasonographic image shows extensive bleeding in his brain. We have no choice but to take him off of ECMO. Terminal decannulation is the formal term. It means stopping the machines and letting him die. His parents do not want to be present for his death. I hold the child as we stop the circuit. He doesn’t move. He never opens his eyes. He dies 12 minutes later. The cannulae are still sticking out of his neck. His parents come to see him. They are crying. They can barely speak. All they say, over and over, is “thank you.” I give them a weak smile and a firm hug. I am silently screaming, “Don’t thank me!” I wish we had known about Angel sooner. I wish we had gotten to him faster. I wish we had gone onto ECMO quicker, better, cleaner. I wish we had not gone on at all.
Conflict of Interest Disclosures: None reported.
jamapediatrics.com
Disclaimer: This account is fictional and is based on similar interactions that the author has had.
JAMA Pediatrics April 2014 Volume 168, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Auckland User on 05/17/2015
305
ON MY MIND
Jennifer C. Kett, MD Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, Seattle, Washington.
Corresponding Author: Jennifer C. Kett, MD, Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Hospital, 1900 Ninth Ave, Seattle, WA 98101 (jennifer.kett @seattlechildrens.org).
Extracorporeal Membrane Oxygenation and an Angel “We have a baby who needs ECMO,” says a voice on the other end of the line. I recognize the sound of his adrenaline rush, just as my own occurs. We often take calls from other neonatal intensive care units requesting a transfer to our center. The calls for extracorporeal membrane oxygenation (ECMO) are usually the worst. As I take more information, my heart sinks. This infant has a diaphragmatic hernia, a congenital defect in the diaphragm that leads to severe abnormalities in the lungs. His blood gases have been extremely abnormal since birth—almost 18 hours ago. We have no way of knowing what that has done to his brain. His name is Angel. The other physician tells me that Angel’s parents understand how sick he is and that he is being referred for ECMO. They are not available to speak with me. I am certain that, despite this physician’s best efforts, they have no idea what awaits. The transport team scrambles the helicopter. I call my attending. I call in the ECMO team, even though I am not supposed to. I should wait until the baby arrives, to see if I can stabilize his condition. But there is no doubt in my mind that he needs ECMO. I doubt only whether we can get to him in time. The transport is difficult. Angel is unstable with low oxygen saturations and low blood pressure throughout the flight. Nothing helps him—not adjusting the ventilator, not the intravenous fluid, not vasoactives, not deep sedation. He arrives alive, but just barely. We move him from the transport isolette onto our warmer. He does not like that at all. The ECMO team is ready to go—the circuit is inside the room, filled with blood and churning away. We just need a surgeon to place the cannulae. The surgeons knew that Angel was coming. They know he’s here. They’re busy with a trauma patient in the emergency department. I call them again. I tell them that Angel’s not going to make it. I don’t like the sound of my voice. I am supposed to be calm. I am supposed to be in charge here. The situation is getting out of control. I see the surgeons at the end of the hall just as Angel goes into cardiac arrest. We start cardiopulmonary resuscitation as they prepare their instruments. The room, already tense, is a flurry of activity and voices. The surgeons put on their gowns and gloves—
Published Online: February 10, 2014. doi:10.1001/jamapediatrics.2013.4665.
spinning and twirling without taking their eyes off of the baby on the bed. We do compressions. We ventilate. We give drugs: epinephrine, saline solution, epinephrine, sodium bicarbonate, epinephrine, epinephrine, epinephrine. We can’t get in touch with the parents. They are on their way. They have no idea what has happened. Even if we could get in touch, what would I say? Should I tell them all this while they are driving? Minutes tick by. We are ready for the first incision. The surgeon looks at me over his mask, eyes weary, knife in hand. He asks, “Are we really going to do this?” Are we really going to do this? Are we really going to subject this infant to ECMO? Are we really going to cut his neck open and put plastic tubes inside? Do we seriously think he could survive? What has the lack of oxygen for the last 18 hours, for the last 8 minutes, done to his brain? Will he ever walk or talk or recognize his mother? If we save his life but he experiences no happiness, have we done something good, or the worst kind of wrong? His parents are on their way. Are we really going to do this? I turn to my attending for answers. He shrugs. I hear myself say “yes.” But I don’t really know why. We continue cardiopulmonary resuscitation, the surgeon places the cannulae, and Angel is connected to the circuit. His condition is stabilized. His family arrives. We explain what has happened. They thank us through their tears. Angel survives the night. The next morning, an ultrasonographic image shows extensive bleeding in his brain. We have no choice but to take him off of ECMO. Terminal decannulation is the formal term. It means stopping the machines and letting him die. His parents do not want to be present for his death. I hold the child as we stop the circuit. He doesn’t move. He never opens his eyes. He dies 12 minutes later. The cannulae are still sticking out of his neck. His parents come to see him. They are crying. They can barely speak. All they say, over and over, is “thank you.” I give them a weak smile and a firm hug. I am silently screaming, “Don’t thank me!” I wish we had known about Angel sooner. I wish we had gotten to him faster. I wish we had gone onto ECMO quicker, better, cleaner. I wish we had not gone on at all.
Conflict of Interest Disclosures: None reported.
jamapediatrics.com
Disclaimer: This account is fictional and is based on similar interactions that the author has had.
JAMA Pediatrics April 2014 Volume 168, Number 4
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpedi.jamanetwork.com/ by a University of Auckland User on 05/17/2015
305
