16 May 2014

A Terrible Thing to Learn

It must have been very confusing for you; to be brought to the emergency department by your mother during your fifth week of life. When you overheard your mother on the phone with the nurse hotline before she brought you in, I'm sure the conversation made no sense: "fever," "newborn," "take her to the hospital now." After the nurse in triage took your temperature I'm sure things only got more confusing. You were bustled into an emergency room, you were stung with needles, first to take your blood, then to infuse medicines into your veins.

You were irradiated, and a urine sample taken, before you were bustled out again, this time to the pediatric ward in your mother's arms. You had a room, but you didn't even stop there before being brought to the procedure room. It was there that I slid the needle between your vertebrae and saw the turbid, yellow, sedimented, terrible cerebrospinal fluid drip and drab into a clear plastic tube.

Then it was back to your room, where you were poked again for yet another blood sample. Yet again, the news it bore was terrible. You needed more, different fluids now because you could not maintain your blood sugar. Through all of this your breathing was ragged, your heart rate maxed out, and you never stopped grunting. In every way you could, you told us you were sick.

***

This is one of the many terrible, but blessedly rare, things that we have to learn as modern pediatricians: how to deal with neonates who have fevers. As I near the end of my first year of pediatric residency I have seen a dozen or so infants with fevers. The necessary steps to work these infants up are second nature by now and dictated by a dealer’s choice of criteria laying out the necessary steps (oddly enough the various criteria are named after Northeastern cities: Rochester, Boston, and Philadelphia). Those under 28 days old get the full work up (a panoply of acronyms: CBC, blood culture, CMP, CXR, UA, urine culture, and CSF studies); those older than 28 days may get the whole package, or be spared the lumbar puncture to get cerebrospinal fluid.

Each time I have slid a needle between two vertebrae and collected the pristine CSF within, I have had to remind myself of the statistics regarding these infants. It is nearly impossible to tell—until it is too late—whether they are hiding an infection in the fluid around their brain. Yet, my inexperience lent me something that I did not realize until later: the feeling that discovery was enough, that the inevitable result of ferreting out those 7-9% of well-appearing febrile infants who were hiding serious infections was all it took. After that, it seemed to me, recovery was automatic.

Put another way, I did not understand the terror that my attendings carried with them through every encounter with a febrile newborn. In an era of aggressive prophylactic antibiotics combined with aggressive prenatal surveillance, I had never seen medicine's stark shortcomings. I had never seen how bad things can turn out, even when everything goes right. This is not an indictment. It is simply my realization that I had internalized the same cultural attitude towards medicine that much of society has: namely, that if we have a diagnosis, it is only a matter of time before a full and complete recovery is made.

***

I knew you were sick and I knew that you needed more care than the pediatric ward could provide, so we arranged to bustle you off yet again, to the pediatric intensive care unit. I signed you over to the PICU resident, I told him your story, I told him what we had done, the results of the labs that had been drawn thus far, and what we were waiting for. Then I loitered, for half an hour past when my real role in your care had ended and two hours past when I had been scheduled to leave. As another half an hour passed, I realized I was doing nothing useful and was burning the precious few hours set aside for me to sleep. Before I left, I checked the pending labs one last time. The protein in your CSF was 870, the glucose was less than 2 and there were "many bacteria (gram positive cocci)". As I left I stopped and relayed the new, startlingly bad numbers to your new doctor, and then continued on out of the hospital for the day.

***

The lab results I saw just before I left should have crushed me; however, they did not. They made me feel… thrilled and elated at how we had done everything right, how we now had a diagnosis and that our interventions had certainly saved your life. From here my mind took a shortcut, I saw the timeline of events that led you to my care: that your mother brought you in within an hour of noting your temperature; that you were triaged in the emergency department within five minutes; that you were seen by a doctor 10 minutes later; that you received antibiotics within an hour of checking into the emergency department; from all of that I assumed the rest was a foregone conclusion.

Later that night my initial elation ebbed and my emotions took a dip. From the highs of feeling that I had helped to make the diagnosis that would save your life I started to think about what those results meant. I knew that the presence of bacteria in your cerebrospinal fluid over an hour after you had received antibiotics was a terrible sign. I knew that the amount of protein and glucose in the fluid indicated an overwhelming infection in and around your brain.

On the first count, that we saved your life, I was right. I have no doubt that a short time longer without antibiotics and you would not have survived. Yet that success is tempered. You will survive, but your life will be unimaginably different. I slept fitfully during your first night in the hospital, every time I awoke in the middle of the night I texted the night resident to get an update on your condition. Every update bore bad news; first you needed to be intubated, you needed drugs to keep blood flowing to your organs, then you started having seizures so yet more medications were added to forestall them. The next day the imaging studies of your brain dredged up words I had not seen since medical school: cerebritis, leptomeningeal enhancement, subdural empyema.

The terrible, sad truth is that much of what has happened inside your tiny fragile body is irreparable. It’s impossible to know what your life will hold. It’s not even possible to predict when you’ll get out of the hospital. What I do know is that you have taught me a lesson that I could not have learned any other way, you have taught me to fear the limits of medicine.

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