It was Easter Sunday morning, and instead of being home for my six-month-old daughter’s first Easter, I was, as a third-year pediatric resident, on call in the intensive care unit. Hoping to lift my spirits, I sneaked downstairs to the emergency room looking for candy. There I found my fellow residents nibbling on jelly beans and chocolate rabbits in between treating patients. Ours was a busy inner-city children’s hospital that served the locals as well as those referred in from the suburbs. That day we had no shortage of children bleeding and vomiting onto their holiday best.
I had just bitten into a chocolate-covered coconut egg when the fire rescue people radioed that they were bringing in an eight-month-old baby found unresponsive after a fall. I joined the team in the trauma bay, putting on gloves, preparing lines, and checking our intubation supplies. The radio call had given us no vital signs, so when the big, red dump truck (as we called the fire rescue vehicle) pulled up, we joked that this was probably all for nothing. This would be like so many other falls: a frightened parent; a screaming, healthy baby. We were wrong.
The paramedic rushed in carrying a limp, blue infant with curly brown hair and a blue face. Laying her on the stretcher, he told us she had fallen off a bed. A nurse cut off the child’s dirty, pastel green sleeper embroidered with Peter Rabbit. I listened for a heartbeat; there was nothing. A doctor gave the child oxygen while the nurse did chest compressions and another doctor grabbed for the laryngoscope. I worked to find an IV site on the baby’s chubby little hands and feet.
The endotracheal tube went in, followed by epinephrine. Someone went out to get the history from the family. I listened again to the chest. No heartbeat. We injected epinephrine two more times then started an IV with bicarbonate and fluid. I felt a pulse. As we taped lines and tubes and called the x-ray department, we all reasoned aloud. Why had this beautiful baby with dimpled cheeks and ringlet curls who had fallen perhaps two feet, come in without a heartbeat? Each of us had seen infants who had wriggled out of arms or carriers, fallen farther, and come in virtually unscathed. The doctor who had gone to talk to the family came back and gave us the following story: The mother said she had just fed Allison and then left her on the bed while she went to the bathroom. When she returned, she found the baby on the floor with formula around her mouth, not breathing. The mother said the baby hadn’t been sick previously and had no medical problems.
We examined Allison head to toe for clues. Had she rolled off the bed, bled into her brain, and gone into cardiac arrest? Had she vomited, aspirated formula into her lungs and arrested? The mother’s account didn’t match the baby’s injuries. There were no visible signs of trauma, but the baby’s pupils were fixed and dilated, and there were retinal hemorrhages in her right eye. No one had to say anything; we all knew the story didn’t make sense because Allison was most likely a shaken baby.
Not again, I protested silently. This was my third case of child abuse in as many months, and the experience wasn’t getting any easier. The first was Kendra, a toddler whose father went to jail for stepping on her back and paralyzing her. The second was two month old Thomas, who died after being thrown against a wall by his mother’s drunken boyfriend. For me, the random cruelty of leukemia and meningitis pales in comparison to abuse inflicted upon such children.
I sat down at the emergency room desk and called the ICU to tell them about our newest patient, while the attending physician called the police.
“We have an eight-month-old infant who was brought in without a heartbeat and required resuscitation,” he said. “The family’s story doesn’t fit the mechanism of the injury, and our working diagnosis is child abuse.”
I thought of my six-month-old daughter, who’d recently suffered weeks of colic. I knew the frustrations of working an 80-hour week and coming home to a crying baby night after night. Raising a child is more than cute clothes, toys, and smiles; nothing prepares you for the sleeplessness, the endless work. Throw in the stress of maintaining other relationships and making ends meet, and the likelihood of child abuse swells.
Depending on parents’ personal resources, emotional stability, and support network, they cope differently. That’s why one child spends Easter all dolled up hunting for colored eggs and another winds up in the hospital dead.
By now, Allison’s cheeks were almost pink, thanks to the fluids flowing into her and the mechanical help with her breathing. We prepared for the trip to radiology to take a computed tomography scan of the baby’s head. Checking her pupils, one of the nurses said, “She has beautiful brown eyes, but she must have picked a lousy time to cry.”
“It breaks my heart,” said another nurse and mother of four. “Better to let her howl alone in her crib that shut her up this way.”
Allison’s CT findings were not subtle. The scan showed brain swelling and signs of old and new bleeding. My throat tightened. The results clinched our diagnosis and also told us that this wasn’t the first time someone had hurt the baby. I paged the neurosurgeon to give him the findings and then lifted the motionless baby back onto the stretcher for the ride up to the operating room. There surgeons would make a hole in the baby’s skull to drain the hemorrhages, hoping to relieve the pressure on her brain.
Before leaving Allison with the anesthesiologist, I patted her hand and brushed a curl from her closed eyes. I found myself making a silent wish that she would not make it out of the operating room.
I wanted to spare her the pain, and I wanted to spare myself. Having seen the CT scan, I wasn’t happy with our resurrection in the emergency room. Allison would never sit up, would never smile and play peek-a-boo, would never walk or talk or play. She would probably never breathe on her own again. She would fall prey to every childhood virus and become desperately ill. She would become contorted and contracted. She would suffer.
In one corner of the waiting area, I spotted an unfamiliar couple huddled together and knew they must be Allison’s parents. Part of me wanted to scream, “Murderers!”
I knew it was not my place to make accusations. Yet chances were one or both of these parents had stepped over the line I worked hard to preserve, the line that protected children from illness and injury. Parents and doctors normally form an alliance against the threats to a child’s health. I couldn’t ally myself with these parents. As their daughter’s physician, I would keep them up to date on their daughter’s condition, but as Allison’s advocate, I was now on the side of the police.
The little girl made it out of surgery, and we settled her 18-pound body on the stretcher between the ventilator and the intracerebral pressure monitor. To fight her hypothermia, we stripped her down to a diaper trimmed with ducks and bunnies, and turned on the heating lamps. When the unit secretary escorted the parents in, they stood beside the stretcher and didn’t touch their child.
“These intravenous fluids are helping keep Allison’s blood pressure up enough to take oxygen to her swollen brain,” I explained to them. “This,” I said, pointing to the clear tubing filled with blood-tinged cerebral spinal fluid, “drains the bleeding around the brain which may relieve some of the pressure.
“When the brain is this swollen, it often dies from lack of oxygen. We will be doing tests to look at Allison’s brain waves to see if her brain is still working.”
I looked at the mother, now gripping the railing, and at the father. No matter who had done what, their daughter’s death would be a painful loss. I continued, more softly, “It’s okay to hold Allison’s hand and talk to her. If you like, we can send for the chaplain.” Allison’s father said they had been putting off her baptism, and he asked for a priest.
The unit secretary told me I had a call. “This is Sergeant Harris,” a voice said. “I’m calling about Allison Meyers. Can you update me on her condition?”
“She’s critical after surgery to decompress her brain,” I said. “I just called the technician to do the first study for our brain death criteria protocol. If there’s no brain activity in two studies 24 hours apart, we’ll discontinue her life support.”
“My lieutenant spoke with the parents while the baby was in the operating room,” said the sergeant. “I wanted to know if, in your professional opinion, these injuries could have occurred the way the parents have said.”
I paused, feeling the full weight of commenting on such grave charges. “No,” I answered. “In my experience, injuries like these usually come from shaking a baby.” The policeman thanked me for my time and said to call him if the child’s condition changed.
I hung up, knowing I was in for a tense wait. The 24 hours after an electroencephalogram showing no brain activity is a desperate time to be a doctor. The patient is dead, yet the medical staff does everything to maintain the body’s tenuous hold on life until the next EEG.
After the priest had baptized Allison, the technician arrived and started securing the jungle of EEG leads among the baby’s curls. I called home to see how my family was doing. My husband filled me in on our daughter’s day. She had taken two good naps and polished off an entire jar of peaches and banana at lunch. She babbled in the background while he gave me the bird count from the backyard feeder.
By this time everything was ready for the EEG. As the pens dropped onto the paper, I held my breath. The lines traced the straight course of brain death, and I let out a sad sigh. Relief suffuse my tired body.
The neurologist and I sat down with the parents to tell them that their daughter was brain dead. I explained that we would do another EEG in the morning, and if it was the same as this one, we would shut off the medicines that maintained her blood pressure and turn off the ventilator that breathed for her. The father seemed stunned, and the mother looked down.
“What happened to our baby?” he asked, first looking at me and then his wife. “Allison was fine last night, and we were with her the whole morning.”
“I don’t know what caused all the damage to her brain,” I explained to them. “But the swelling has blocked off enough blood flow that her brain isn’t working anymore.”
I called the police to update the detectives. Based on their questioning, they told me they planned to arrest the mother.
All night long Allison’s blood pressure continued to drop. We had tried all the possible drugs to keep it stable. Her pressure hovered around 50 over 30.
At four in the morning I lay down to get some rest. Before sunrise my beeper went off. I stumbled over to the ICU to pick up the blinking line. “Hello, I’m Allison’s aunt. I was wondering if you could tell me how she is.”
“She’s in critical condition,” I said. “I can’t give out any other information. You’ll need to talk to her parents.”
The woman was silent, and then I heard a sob, “My sister said this is all because of Allison’s baby shots. Is that really true?”
Anger yanked me from my sleepiness. “I’m sorry,” I said, struggling with their lie. “You’ll have to talk to her parents.”
When I went in to check on Allison, I found a stuffed lamb tucked under her cold hand. As I checked her pupils and listened to her heart and lungs, I talked to her. She didn’t move. When the second EEG was done, it was no different from the first.
We set up screens for privacy and brought two rocking chairs to the bedside. Allison’s mother tearfully asked if she could hold her. A wave of pity softened my feelings toward these parents. “Of course,” I said. They stood holding hands while we capped the intravenous lines and disconnected the ventilator. The nurse wrapped Allison in a receiving blanket and handed her to her mother. The child took a few uncoordinated breaths and then was still. I listened, and once again there was no heartbeat. After I pronounced Allison dead, her mother quietly cried and rocked her. Her father held his head in his hands.
I went to the work room, chewed off a piece of now day-old Easter bread, filled out the death certificate, and called the police. On the drive home I thought about all the new parents like my husband and me that I would see during my career. I vowed to acknowledge their fatigue and exasperation, and to talk about healthy responses and resources. And I grieved for Allison.