Decompression Sickness

“There’s a pediatric drowning in Resus Bay 2,” the charge nurse said to the young Dr. Cranky, “they need you in there now.”  Your earnest host had been in his residency program for less than a month when he heard those words.  The memory and images are still fresh, forever seared in his brain.

The residency program where Dr. Cranky learned the sacred art of Emergency Medicine was located in the southeastern part of these great United States.  Given the blistering temperatures of the region, many homes and most apartment complexes possessed that potential pediatric death-trap known as a swimming pool.  Your host would learn over the next several years that, with lax safeguards, it was not unusual for small children to find themselves wandering into harm’s way.  Such was the case on that hot day in July, twenty-two years ago.

Still unsure of himself, your inexperienced author hurried toward the resuscitation area.  The curtain had been pulled, but he could see the frentic activity beneath its lower edge.  Dr. Cranky pulled the fabric back and saw his Chief Resident, F*cking Frank Flannigan at the head of the bed.  He had just finished inserting an endotracheal tube into a young girl’s trachea so we could breathe for her.  Your host looked up at the monitor.  “She’s in asystole,” Frank said, “I need for you to do a venous cutdown.”

A venous cutdown is a sacred ritual which no one does anymore.  It has since been supplanted by intraosseus access (IO), a technique which was originally developed and widely used in the 1940’s.  With the advent of silastic IV catheters it was forgotten about and fell into disuse until its resurgence in the early to mid-1990’s.  The main advantage of IO access is that it is much faster and easier to perform.

This is the IKEA version of what Frank wanted Dr. Cranky to do

It was then that your humble servant looked down at the patient and froze.  Before him was a young girl who was about the age of three.  She had blonde hair and freckles.  Her skin was dusky and cyanotic, a result of the deoxygenated hemoglobin which was no longer coursing through her veins.  The monitor showed asystole, her heart having stopped as a result of the acidosis from her hypoxemia.  And she looked just like the Cranky Daughter.

Your host’s mind started racing.  Was this young lass, to whom fate had been so cruel, really his own flesh and blood?    Dr.Cranky knew there was a pool just outside the apartment they lived in.  It was not unusual for the gate which surrounded it to be left open by the older children who lived nearby.  He could feel panic start to set in and didn’t know what to do next.

“Cranky, are you still with us?”  It was the Big C who broke your alarmed scribe’s trance.  He had come over to the resus bay and was now standing next to Frank.  “We need for you to do a cutdown,” he said with a calm and reassuring voice, “and we need for you to do it now.”   He showed no panic.  His speech was not pressured.   His face was calm. He simply declared a statement of fact.

“No problem, I’m on it,” your shaken host managed to mumble.  And with that Dr. Cranky regained his composure and accessed the young girl’s saphenous vein without difficulty.   Unfortunately, and despite our best efforts, we were not able to prevail and our young charge was pronounced dead shortly thereafter.

Immediately following this your dismayed correspondent went to the resident’s room to sit down and collect himself.  He really didn’t know what to think and felt ashamed for having choked at such a critical moment.  Everything had seemed so confusing and surreal.  It was just a few minutes later that the Big C found him.  Dr. Cranky told him about the young girl’s resemblance to his own daughter and how he felt he had let everyone down.

“Ah, now I understand,” the Big C said.  “No problem Cranky, don’t second-guess yourself.  It happens to all of us from time to time.  You’re just having a little decompression sickness is all.  Come back to the Department when you’re ready.”  And then he left.

That was the first and only time your humble servant has ever frozen in the twenty-two years he has been in practice.  He has witnessed many horrendous things in his career but this one event is probably the most potent.  He cannot think about it to this day without feeling a lump develop in his throat.  And although he would like to say he “pulled himself up by his bootstraps,” he knows it was his estimable mentor’s demeanor both during and after the traumatic events described above which allowed him to prevail.

Dr. Cranky raises a glass to you, Big C, wherever you are.

About Dr. Cranky

Dr. Cranky is a residency-trained, board-certified emergency physician who has been fighting in the trenches of American medicine for far too long. Each day he tries to stay one step ahead of burnout. Despite his best efforts, burnout seems to be closing in fast.
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