Portal de Periódicos da CAPES

Heavy Air

2011; Wiley; Volume: 18; Issue: 2 Linguagem: Inglês

10.1111/j.1553-2712.2010.00999.x

1553-2712

Donna Seger,

Poisoning and overdose treatments

Being an emergency physician (EP) is like being a marine. Once an EP, always an EP—never “former.” Although I practiced emergency medicine (EM) for 30 years, I am currently a full-time toxicologist. Great lateral move in your 50s, as the nights become killers (although I used to think EPs who made lateral moves were wimps). But I still take care of many acutely ill patients, especially the most interesting ones: the toxicology patients. And I still teach as EM residents rotate with us. But it had been a long time since I had experienced the heavy air in the emergency department (ED). A toxicology consult was requested by the pediatric ED to see a 3-year-old with a brown recluse spider bite. These critters are endemic in Tennessee, so this is a common ED consult. The child had a nasty cutaneous lesion on her chest but also had a fever and tea-colored urine. Systemic Loxsoscelism with hemolysis. I told the residents to be aggressive and keep the Hct greater than 31 (an arbitrary number of mine), as toxin-induced hemolysis can occur so quickly. She was a beautiful little girl. Very brave when the IV line was being started. You could tell she liked to play barefoot outside as the soles of her feet were brown and thick. I spoke with the parents and took a look at her spider bite. As I was leaving, she said to me, “Could you let them know I am ready to go home now?” We all had a chuckle over the earnestness with which she spoke. An IV was started and blood was ordered as the Hct was 28. A couple of hours later I was in my office and received a call from the EM resident rotating on toxicology telling me our patient was in arrest. What patient? We only had one—the five-minute walk from my office to the ED is a two-minute run. The resuscitation was in full mode. Ventricular fibrillation. Amiodarone. Wait. Wait. Wait. This is an arrest due to hemolysis. She needs blood. And blood she did receive. Bags and bags of blood. Everything was done right, intubation, compressions, lines, blood, trauma blood, platelets, fresh-frozen plasma, and more blood. But she continued to hemolyze faster and faster. I kept thinking she is young and healthy. If we can get ahead of the hemolysis, she will still be neurologically intact. But we could not get ahead of the hemolysis. The code was finally called. Compressions continued as the parents, who had watched from outside the room, were brought into the room. When a child dies in the ED, the air becomes so heavy. Word about the death travels on the heavy air. Those coming in to start their shifts are respectfully silent and give those who were involved in the code lots of room to walk and try to breath in the heavy air. Try to maintain or regain composure. Most of the health care providers either openly or subtly wiped away tears. I felt I should say something to them as I was the most senior (I prefer “senior” or “experienced” to “oldest”). The ED attendings had managed the code with leadership, professionalism, and compassion. And that is what I said to them. But the other thing I said is that one of the hardest lessons to learn is that we do not control outcome, even when everything has been done right. And that lesson is hardest to learn when it is taught to you by a little girl who had just said, “Could you let them know that I am ready to go home now?”