Coning

This is something I wrote over a year ago as a medical student in Calgary and I was reminded of it being in the pediatric emergency here. I haven't edited anything, reading it now the emotions and descriptions seem so crisp and fresh and I wonder how my perspective has changed.

The Children’s Hospital emergency department. As a medical student you rotate through for a week and you either love it . . . or you really don’t. I had just finished seeing two really cute kids from Newfoundland here on holiday, one of them had fairly severe asthma and the other had, uh, a cough. I was sitting at the desk listening to one of the emergency docs ranting about people using the health system when they didn’t need to when an ambulance pulled up. The staff was pretty lackadaisical, apparently there hadn’t been a patch to let them know the ambulance was arriving which normally happens so they can be prepared. They were unsure what to expect, but didn’t seem too worried.

“3 year old boy, seizing for about 45 minutes before he got to a Medicentre clinic, given valium while 911 was called. Briefly stopped on the way here but now showing decerebrate posturing and his right pupil is blown.” The history reeled off by the paramedic. It was like an electrical shock passed through the nurses and docs who were in the area, all heads turned, and rushed with the stretcher into the trauma room. The tension was palpable, superimposed with a forced calmness. His mom following the whole procession, hand over her mouth, crying silent tears. Seemingly forgotten in the intensity of the moment. The family had moved from Vietnam 3 years previously, she spoke in faltering English, searching for words when she was asked what had happened. Flustered and crying. The doctor, put her hand on her arm, a gesture of sympathy but it seemed cold and calculated in her attempt to get any information she could out of the mom. “Page ICU, neuro, respiratory, and social work stat. Let CT know that we’ll be there in 5 minutes.” More and more bodies appeared out of nowhere. I had been told during orientation to watch the trauma rooms and get in there whenever I could so I had followed with the rest and tried to stay out of everyone’s way. It was clockwork, everyone had a role. Recording, drawing up meds, preparing to intubate, it all happened at once. I counted 17 people, all around the stretcher which laid the small body of this 3 year old little guy, Daniel. Writhing back and forth, to the untrained eye it could even look like he was just having a bad dream. To the medical professionals in the room, it mean he was ‘coning’, there was something increasing the pressure in his head and part of his brain was herniating. As if suddenly remembering something, one of the nurses turned to mom and asked if there was anyone she could call, any friends or family? No, no family in town, but the husband was on his way, he just had to pick up the 3 month old on the way.

I saw everyone buzzing around as if in a blur of activity, the only constants were Daniel on the stretcher and his mother, frozen in the same position, sobbing, hand over mouth. Clueless as to what was happening. The reality hit me, her world was ending right in front of her eyes, her pain and fear hit me in the gut. A nurse would stop once in a while put her hand on her shoulder and explain that they were going to try to stop the seizure, put a tube down his throat to help him breath, and take him to CT to get pictures of his brain. They were doing everything they could she said. The mom just shook, is shock. After what seemed like an hour but was actually a few minutes ‘social work’ arrived, apparently their job was to be with the mom. When she entered, she was the fifth person to ask if dad was on the way. Yes, yes, he’s coming. It was almost something people asked when they didn’t know what else to say and could offer no other consoling words.

In all of this I stood, an observer, a witness . . . was it possible I was invisible and had no part in what was happening? There to learn primarily, but I can never stop the feelings and thoughts that go with academia.

He was wheeled into CT, the respiratory therapist bagging him all the way. Mom sat outside CT with the social worker, a crowd of nurses and docs went in to watch the scan as it happened. There was a bleed in his right hemisphere, and yes, he was coning, uncal herniation, the bottom of his brain was squishing out below his skull. Was there trauma? Should we suspect abuse? Where’s the dad? Did he have a mass there previously? A near chorus of wild speculations. I’m with the emergency doctor and a resident, we stop on the way out as we pass her. “There’s some bleeding in your son’s brain, we’re going to take him to the ICU. Don’t worry, we’re doing all that we can for him right now. Alright? Is your husband on his way?” Yes, he coming.

The emerge doc goes to see the next patient, knowing that Daniel is now being taken care of by the intensive care physicians and the neurosurgeons. I’m full of questions and the first year emergency resident can’t hide her eagerness to use this as a teaching case. As she goes through the CT scan with me on the closest computer explaining the pathology in detail the dad walks in pushing the 3 month old daughter in a stroller in front of him. He asks where his wife and son are, the resident, immediately somber, takes him straight to his wife who is with the ICU doc. Things are explained, now in a bit more detail, the prognosis is not good. Tears well in his eyes. They assume he understands all that is happening. He too covers is face with his hands, cries out, crumpling to his knees. Sheer pain. “My son, my son . . .” his wife joins him, they cry together, sobbing uncontrollably, shaking as they embrace. My heart broke.

I was sent back to emergency to see more patients, my mind was nowhere near the child with croup, or the roller bladder who needed some stitches. The nurses stood in a group, “what could we have done differently? We didn’t get a patch from the ambulance. He really should have been intubated already by the time he got here. Why did they wait so long? They should have called EMS from their home. Is there anything else we could have done?” Constant questioning, reassuring themselves that they couldn’t have prevented this. And my role? I learn, at this point in my career I am a witness to both the functioning of the health care system and heart ache along the way. A family’s life is forever changed, we pause for but a second, and then the system keeps on clicking, like clockwork.