Accepted Manuscript The Rocking Chair Ruth E. Bristol PII:
S1878-8750(14)00545-2
DOI:
10.1016/j.wneu.2014.06.002
Reference:
WNEU 2392
To appear in:
World Neurosurgery
Received Date: 29 May 2014 Accepted Date: 3 June 2014
Please cite this article as: Bristol RE, The Rocking Chair, World Neurosurgery (2014), doi: 10.1016/ j.wneu.2014.06.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Rocking Chair By Ruth E. Bristol
RI PT
Pediatric Neurological Surgery Barrow Neurological Institute at Phoenix Children’s Hospital Phoenix, Arizona
SC
Correspondence: Ruth E. Bristol Phoenix Children's Hospital
M AN U
Outpatient Building, 4th floor 1919 E. Thomas Rd Phoenix, AZ 85016
AC C
EP
TE D
602-561-6185
1
ACCEPTED MANUSCRIPT
“I have a baby with a huge subdural, maybe epidural,” said my junior resident. My pulse quickened, my stomach churned. Not words you want to hear at any time, day or night. It was my first year as a pediatric neurosurgeon in a prestigious group, and I was still
RI PT
trying to figure out who I was.
The story got more complicated from there: a 12-day-old full-term baby had presented several days earlier with respiratory distress from respiratory syncitial virus. He had rapidly
SC
decompensated to the point of needing extracorporeal membrane oxygenation (ECMO); a point from which many children never return. And now, the anticoagulation required for the ECMO
M AN U
had resulted in an intracranial hemorrhage that occupied nearly a quarter of the skull. I discussed it thoroughly with our ultrasound expert and we still couldn’t tell if the hemorrhage was within the dura or without.
What should I do? Was it time to throw in the towel? Should we be as aggressive as
TE D
possible? Should we go straight to the OR? Should we try for a CT scan? He was too unstable for either.
From the social history, I learned that the baby was born to teenage parents, still in high
EP
school. Should that information factor into our decision making? Clearly they had chosen to keep the baby. What would it mean for the course of their lives if the baby survived, or didn’t?
AC C
Earlier that year our hospital had purchased a portable CT scanner, but it was only for use with adults. I called CT and luckily reached a tech with whom I had worked for the 7 years of my residency, a person I trusted, and one who trusted me. Could we do a baby on ECMO in the PICU? He said he would find out. Twenty-five minutes later the CT machine, three techs, an anesthesiologist, two ECMO nurses, a respiratory therapist, a pediatric intensivist, three ICU nurses, two residents, and a 2
ACCEPTED MANUSCRIPT
cardiothoracic surgeon filled ICU the room. Bodies rushed every which way, bells on the monitor dinged, voices called out medication dosages and double checked the patient ID at every intervention. The parents stood off to the side, shell shocked.
RI PT
The child was not yet ready to come off ECMO, and the CT scanner wouldn’t fit around his isolette. The team created a makeshift CT table from a patient’s bedside tray. Coordinating our movements every step of the way, we transferred him onto the table and advanced him into
SC
the CT scanner. The ECMO techs would have to wear lead to shield themselves from the radiation.
M AN U
Thirty-five minutes after my phone call, CT images of the brain appeared on the screen. It was a subdural, and it was huge. The brain was massively shifted. While we evaluated the images, the cardiothoracic surgeon decannulated the carotid artery, returning the baby’s circulation to his lungs. The heparin had been stopped, and ECMO could not continue. His
TE D
oxygen saturation was around 50%, at best.
Again, we deliberated. Was his intracranial pressure causing cardiovascular and respiratory compromise? Was there any chance evacuation of the clot would turn the tide in our
EP
favor? The teenagers responsible for this baby were stunned. They wished to press on. They agreed to step out for a few minutes.
AC C
We set up a makeshift OR in his ICU room and replaced the ECMO team with two scrub nurses, a circulator, and my chief resident. It was now after 5 p.m. and the chief was free for the day, but she was going into peds as well, and she wanted to help. We made a burr hole in the temporal region and began evacuating clot. Despite removing what seemed like several hundred milliliters of clot, the baby’s cardiovascular status failed to improve. The anesthesiologist began chest compressions. Oxygen saturation had dropped into the 30s. We closed quickly. 3
ACCEPTED MANUSCRIPT
The chest compressions continued as we removed the drapes and the OR equipment. The surgical staff left. The anesthesiologist, pediatric intensivist, and two nurses remained. The alarms on the bedside monitor had been silenced because we knew nothing was in normal range.
RI PT
The only sound was the soft hiss of the ventilator and the dull rub of the chest compressions. The intensivist and I exchanged one last, knowing look, and he called it.
One nurse went to get the parents, and the other appeared, as if out of nowhere, with a
SC
rocking chair. My breath seized in my throat and tears stung my eyes. I knew what the rocking chair was for. As a mother myself, it was more than I could take. Thankfully, there was a back
M AN U
stairwell nearby and I was able to make it into the quiet, gray, solitude before losing it. An hour later, I drove home with mixed emotions. My heart ached for the young parents. I could not imagine what they had already been through or what they were about to face. I was disappointed in myself that we were unable to save him. At the same time, I was tremendously
TE D
proud of my hospital and my colleagues. Every person involved in that 3-hour effort had given 110% with a “can do” attitude. We had performed the first portable CT scan on an infant in the state, and on ECMO as well, in less than 45 minutes. We had evacuated a subdural at the
EP
bedside. It gave me solace to realize that this kind of teamwork does save lives when the odds
AC C
are a little more in our favor.
4
ACCEPTED MANUSCRIPT
The Rocking Chair
Abbreviations:
AC C
EP
TE D
M AN U
SC
RI PT
ECMO – extracorporeal membrane oxygenation OR – Operating room CT – Computed tomography PICU – Pediatric intensive care unit ICU – Intensive care unit ID – Identification
S1878-8750(14)00545-2
DOI:
10.1016/j.wneu.2014.06.002
Reference:
WNEU 2392
To appear in:
World Neurosurgery
Received Date: 29 May 2014 Accepted Date: 3 June 2014
Please cite this article as: Bristol RE, The Rocking Chair, World Neurosurgery (2014), doi: 10.1016/ j.wneu.2014.06.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Rocking Chair By Ruth E. Bristol
RI PT
Pediatric Neurological Surgery Barrow Neurological Institute at Phoenix Children’s Hospital Phoenix, Arizona
SC
Correspondence: Ruth E. Bristol Phoenix Children's Hospital
M AN U
Outpatient Building, 4th floor 1919 E. Thomas Rd Phoenix, AZ 85016
AC C
EP
TE D
602-561-6185
1
ACCEPTED MANUSCRIPT
“I have a baby with a huge subdural, maybe epidural,” said my junior resident. My pulse quickened, my stomach churned. Not words you want to hear at any time, day or night. It was my first year as a pediatric neurosurgeon in a prestigious group, and I was still
RI PT
trying to figure out who I was.
The story got more complicated from there: a 12-day-old full-term baby had presented several days earlier with respiratory distress from respiratory syncitial virus. He had rapidly
SC
decompensated to the point of needing extracorporeal membrane oxygenation (ECMO); a point from which many children never return. And now, the anticoagulation required for the ECMO
M AN U
had resulted in an intracranial hemorrhage that occupied nearly a quarter of the skull. I discussed it thoroughly with our ultrasound expert and we still couldn’t tell if the hemorrhage was within the dura or without.
What should I do? Was it time to throw in the towel? Should we be as aggressive as
TE D
possible? Should we go straight to the OR? Should we try for a CT scan? He was too unstable for either.
From the social history, I learned that the baby was born to teenage parents, still in high
EP
school. Should that information factor into our decision making? Clearly they had chosen to keep the baby. What would it mean for the course of their lives if the baby survived, or didn’t?
AC C
Earlier that year our hospital had purchased a portable CT scanner, but it was only for use with adults. I called CT and luckily reached a tech with whom I had worked for the 7 years of my residency, a person I trusted, and one who trusted me. Could we do a baby on ECMO in the PICU? He said he would find out. Twenty-five minutes later the CT machine, three techs, an anesthesiologist, two ECMO nurses, a respiratory therapist, a pediatric intensivist, three ICU nurses, two residents, and a 2
ACCEPTED MANUSCRIPT
cardiothoracic surgeon filled ICU the room. Bodies rushed every which way, bells on the monitor dinged, voices called out medication dosages and double checked the patient ID at every intervention. The parents stood off to the side, shell shocked.
RI PT
The child was not yet ready to come off ECMO, and the CT scanner wouldn’t fit around his isolette. The team created a makeshift CT table from a patient’s bedside tray. Coordinating our movements every step of the way, we transferred him onto the table and advanced him into
SC
the CT scanner. The ECMO techs would have to wear lead to shield themselves from the radiation.
M AN U
Thirty-five minutes after my phone call, CT images of the brain appeared on the screen. It was a subdural, and it was huge. The brain was massively shifted. While we evaluated the images, the cardiothoracic surgeon decannulated the carotid artery, returning the baby’s circulation to his lungs. The heparin had been stopped, and ECMO could not continue. His
TE D
oxygen saturation was around 50%, at best.
Again, we deliberated. Was his intracranial pressure causing cardiovascular and respiratory compromise? Was there any chance evacuation of the clot would turn the tide in our
EP
favor? The teenagers responsible for this baby were stunned. They wished to press on. They agreed to step out for a few minutes.
AC C
We set up a makeshift OR in his ICU room and replaced the ECMO team with two scrub nurses, a circulator, and my chief resident. It was now after 5 p.m. and the chief was free for the day, but she was going into peds as well, and she wanted to help. We made a burr hole in the temporal region and began evacuating clot. Despite removing what seemed like several hundred milliliters of clot, the baby’s cardiovascular status failed to improve. The anesthesiologist began chest compressions. Oxygen saturation had dropped into the 30s. We closed quickly. 3
ACCEPTED MANUSCRIPT
The chest compressions continued as we removed the drapes and the OR equipment. The surgical staff left. The anesthesiologist, pediatric intensivist, and two nurses remained. The alarms on the bedside monitor had been silenced because we knew nothing was in normal range.
RI PT
The only sound was the soft hiss of the ventilator and the dull rub of the chest compressions. The intensivist and I exchanged one last, knowing look, and he called it.
One nurse went to get the parents, and the other appeared, as if out of nowhere, with a
SC
rocking chair. My breath seized in my throat and tears stung my eyes. I knew what the rocking chair was for. As a mother myself, it was more than I could take. Thankfully, there was a back
M AN U
stairwell nearby and I was able to make it into the quiet, gray, solitude before losing it. An hour later, I drove home with mixed emotions. My heart ached for the young parents. I could not imagine what they had already been through or what they were about to face. I was disappointed in myself that we were unable to save him. At the same time, I was tremendously
TE D
proud of my hospital and my colleagues. Every person involved in that 3-hour effort had given 110% with a “can do” attitude. We had performed the first portable CT scan on an infant in the state, and on ECMO as well, in less than 45 minutes. We had evacuated a subdural at the
EP
bedside. It gave me solace to realize that this kind of teamwork does save lives when the odds
AC C
are a little more in our favor.
4
ACCEPTED MANUSCRIPT
The Rocking Chair
Abbreviations:
AC C
EP
TE D
M AN U
SC
RI PT
ECMO – extracorporeal membrane oxygenation OR – Operating room CT – Computed tomography PICU – Pediatric intensive care unit ICU – Intensive care unit ID – Identification
