PICU: Day Two, AJ's Story

In the middle of rounds in the PICU today, a 2 year old boy bleeding from the nose and mouth (possibly septic shock, even though he was afebrile) was brought into PICU from the ER. The boy, AJ (short for Armando Julian), had a history of ALL and had both neutropenia and thrombocytopenia. After rounds, I saw one of the attendings, Dr. S, inserting a central line into his femoral vein, so I asked if I could observe. He said it was fine and proceeded to pimp me about the layout of the femoral vessels and all the landmarks involved. The boy's eyes were open, but they were unblinking and unseeing, which scared me because there were no signs of life in those eyes. Eventually his eyes had to be taped shut before his parents came in to see him.

Grand Rounds was on an interesting topic today: Munchausen syndrome. When it was over, I arrived at PICU at the same time as AJ's dad, who looked very frantic. I soon found out why: AJ was hemorrhaging again (blood was oozing out of his nose into the ventilator) and the doctors were trying to stabilize the bleeding. They gave him a blood transfusion, a platelet infusion, epinephrine, and more. I remained hopeful that he would be okay until his mother ran out of his room screaming, "HE'S DEAD!" AJ had coded, and his nurse was giving him chest compressions. Dr. S saw me and Dingding (the 2nd year resident) standing on the sidelines and said, "Come on, time to get dirty" and motioned us into the room. I stood where I was, unable to believe that he wanted me, a lowly med student, to jump right in, but Dingding immediately gloved up and got in line to do compressions. All the while, AJ's parents held on tightly to each other, with his mother crying and praying to God to save her baby. It was heartwrenching, very hard to watch. Eventually, AJ's heart started beating on its own again, and Dr. S called his parents over to the conference room so he could talk to them. As they left, I heard one of AJ's relatives tell his mother, "He's a fighter."

Once the family was gone, I learned how dire the situation was from Dr. S. AJ's blood was not clotting and he was hemorrhaging into his lungs, so unless the bleeding could be stopped, death was imminent. Sure enough, about thirty minutes later, AJ's heart rate started falling again. Dr. S asked the nurses to administer a dose of epi while he contacted the family. A minute later, his mother runs in asking, "Is he going?" Dr. S explained that they were going to do chest compressions again, and his mother shook her head. "He wants to go. Let him go." Dr. S yelled, "Stop!" and all hands left the baby. I watched as AJ's heart rate dropped from 80 to 30, and then his time of death appeared in large numbers: 15:19. He was gone.

When the finality of death set in, AJ's mother started screaming, and curtains were drawn around the crib to give the parents some privacy with their child. The nurses removed all of AJ's tubes, wrapped him in a blanket, and laid him in his mother's arms while her husband stood beside her. Through the crack in the curtain, I watched his parents rocking him, stroking his hair, and I walked away to give them some space. But I could still hear them talking, and I heard AJ's mother telling him that he was so brave, so beautiful, and most of all, that she loved him and that she was sorry. I felt awkward just standing around, so I asked Dingding if I could leave and he said sure. Before I left, I had a talk with Dr. S about how he deals with all the death and dying in the PICU. His answer: One day at a time. When I left, I had to pass by many of AJ's relatives who were crying in the hallway, and that only made me sadder. This is the saddest day I've ever experienced on my peds rotation.