The Child

During my shift at surgical casualty, I heard the intern calling the consultant with a case. “Her pupils dilated and non-reactive to light.” Who? Who had such severe head injury? The nursing student told me that the patient was in the resuscitation room. I ran over to try and help out. When I got there, I realized the patient was only a child, looking no older than 4 or 5. And there was no doctor present. One sister was trying to get IV access, and another one was taking the patient’s blood pressure. Nobody was in any hurry, there was no flurry of activity – nothing that I was used to on the site of an active resuscitation. A man was standing next to the little girl, manually bagging her. She had no spontaneous respirations. I checked the girl’s eyes – they were indeed fixed and dilated. The sister was having some trouble getting the BP, so I volunteered to try – 138/92. At this point, a consultant walked into the room. “She’s hypertensive, doctor. I think she has raised ICP. And her pupils are fixed and dilated.” “Ok,” he replied calmly, and started writing notes on the chart.

I ran to my intern and told him the situation. “Shouldn’t we start mannitol? Raise the head of the bed? Maybe hyperventilate her? Send her for a head CT? Give neurosurgery a heads-up?” “Aren’t they doing all that?” the intern asked me. “Not as far as I can tell.” “Well, you go make sure all that is done.” So I ran back to the resuscitation room, and repeated myself. “Should we start mannitol? Raise the head of the bed? Maybe hyperventilate her? Send her for a head CT? Give neurosurgery a heads-up?” “Just make sure her BP is ok before giving her mannitol,” the consultant replied. I stared at him. We had already wasted so much time. Every precious moment we gain could be life-saving. The sister went to reconfirm the BP that I had just gotten, moments ago. “Yep, her BP is good.” She started the mannitol drip while I raised the head of the bed. Then she called the radiographer manning the CT and informed him that we were coming. Then, with the help of another health personnel, we wheeled the patient to the CT unit, bagging her the whole time.

The brain CT was not promising – diffuse axonal injury with severe edema; no intracranial bleeding. There was nothing for neurosurgery to do at this point. I turned to the sister. “Do you think she’ll survive?” “No chance,” came the reply. “Not without a ventilator, and we don’t have any available vents.”

I later found out that the girl had been hit by a car, along with another child. The man with the child, whom I had assumed was a male relative, was just a passer-by who had witnessed the accident. He put both injured children into his car, and drove them to the hospital. The other child had been DOA. This child was barely hanging in there. Her parents had been contacted. We were probably going to keep bagging her until her parents arrived to say their goodbyes.