Besides my fourteen year-old head trauma there is only one other patient in the PICU. Because that one is stable and expected to transfer to the regular pediatric unit in the morning, staffing for our night shift dropped down to two nurses, Kathy, and myself.
The fourteen year old’s parents had been at the bedside since his return from the OR. Throughout the evening his siblings, grandparents, and extended family visited two at a time until visiting hours were over at nine o’clock. His parents, who really are very nice, took advantage of our empty waiting room across the hall, deciding to spend the night sleeping on the sofas. Kathy and I outfitted them with sheets, blankets, and a couple pillows. I promised to wake them if anything happened.
Around two am, Corey came up from the ER on his break. “Hey Niki, let’s have breakfast after our shifts in the morning, okay?”
“Sure Corey. That sounds great.”
Corey and I met at New Employee Orientation when we were hired. He’s married with two small kids. He’s become one of my best buddies at work. We regularly go out for breakfast after our shifts.
The shift nearly passed without mishap.
Around six am, I was taking vital signs on the fourteen year-old. Nothing changed all night. I charted the oxygen saturation and TCO2 monitor readings to check against the results of the arterial blood gas I’d just drawn with his morning labs. Suddenly the monitor alarmed loudly. Glancing at the screen, I see the ICP numbers are rising, and then out of the corner of my eye I see bright red blood pulsating inside the clear plastic ICP device in the kid’s head and backing up into the tubing it connects to. What the Hell?
Then I shout,
“I NEED HELP!”
Kathy runs in, sees the blood, and says, “Oh my God, what’s happening?”
“I don’t know! I’m not even sure what to do. Should his head go up or down?”
I pondered this while quickly verifying his peripheral pulses and blood pressure manually. I take him off of the vent and begin hand-bagging him, hoping to control the rising ICP. Then I hit the code button. Meanwhile, the boy starts seizing.
Immediately, Gerald, the respiratory therapist runs in. The blood pressure and pulse are high, not low, so we don’t begin chest compressions, but Gerald takes over the hand bagging. Dr. Polk runs in from the call room as the dayshift nurses begin to arrive.
Dr. Polk orders ativan and a loading dose of phosphyenatoin, which I run to retrieve from the automated drug dispenser.
Immediately, Kris is at the bedside:
“Keep his head up! Call CAT scan. Tell them we’re coming down NOW, this is an emergency. Draw a type and match too,” she commands.
Dr. Polk is entering orders for the scan, and phones the neurosurgeon.
“Should we clamp the ICP tubing?” Kathy asks.
“NO!” both Kris and Dr. Polk yell out.
Dr. Polk asks, “Niki, what happened?”
“Nothing. He was stable all night, then this.”
Meanwhile, the rest of day shift arrives, and a team of nurses flurry into action, transferring the boy’s monitor leads to a portable unit, drawing more labs, and gathering equipment. A green O2 tank is slid into a rack on the bed for the ambu bag. Gerald continues hand-bagging him for the trip downstairs. Another respiratory therapist appears to roll the ventilator down with us.
“Has anyone told the parents yet?”
I awaken them in the waiting room, and bring them back to the PICU. When we get there the team has already wheeled the boy in his bed out the door, with Kris at the helm. Trailing behind, I explain what’s happening. The three of us take a second elevator to CAT scan. Once the parents are seated in the anteroom, I help Kris and the radiology techs transfer the boy onto the narrow table that slides into the tube-like machine.
Behind me, Dr. Polk and the neurosurgeon view the black and white images with grave expressions. The neurosurgeon makes a phone call and instructs OR to prepare a suite.
The CAT scan reveals the cause of the bleeding is an ateriovenous malformation, an AVM, deep in the boy’s brain. Most likely, it’s lurked there undetected since birth. Though no one knows for sure, it’s assumed that when the boy hit his head against the wall, the AVM began leaking, causing the original small bleed, but wasn’t picked up on the original CT. Apparently the bleeding continued, the pressure building until the AVM blew like an old rubber inner tube.
The boy is rushed to OR. I return to the PICU, where I struggle to grasp the medical terms I need to document the incident in the nurse’s note. My adrenaline level is so high, I have difficulty concentrating and keeping the events in order.
Kris comes back up for report. “You did okay, Nik. It wasn’t anything you could control.”
“Thanks Kris. I appreciate that, and your help too. I really do.”