What Would You Do?

I work as an emergency staff nurse in a 300-bed, suburban hospital in the Kansas City, Kansas, area. I am sharing this case scenario to ask the question, “What would you do?” I truly believe there is no right answer. Now reflecting on the situation, I wonder what could have been done better. Emergency nurses everywhere are routinely faced with ethical dilemmas. When is it appropriate to intervene and emergently treat critically ill patients, and when should you not?

In November 2007, I was asked to assist the ED staff with patient care in room 9. I agreed and headed to the room. I was immediately baffled by the numbers of people standing over what appeared to be an empty stretcher. I realized there was not just 1 patient but 2 tiny bodies on either end of the bed. EMS was giving report to our staff, saying, “It was a scoop-and-run transport.” I was instructed to assist with the little boy. The police informed us that the twin’s mother was found deceased in their home, estimated dead 5 to 7 days, and the babies had fallen down behind their bed. EMS had heard tiny “cat-like” cries alerting them of their existence. The premature twins were severely dehydrated and hypothermic from obvious lack of care. The baby boy was slightly bigger in size and showed a little more vigor. He was spontaneously breathing, but his breathing was shallow and labored. His skin looked and felt like leather. His oral mucosa was crusted dry, and his fontanels were visibly sunken. He was also very lethargic, with only occasional blinks after stimulation. His rectal temperature was 93.4°F, and his estimated weight was 2.5 kg. Blow-by oxygen was provided by respiratory therapy, and the monitor showed a central heart rate of 125 beats/min with a regular rhythm. It was difficult to assess the boy’s oxygen saturation because of his diminished perfusion. Another registered nurse and I feverishly assessed any available intravenous (IV) access. We found a visible external jugular vein that was successfully cannulated. An IV bolus of 25% dextrose was initially given. Surprisingly, the boy’s blood glucose level tested approximately 200 mg/dL. We then changed fluids to normal saline solution and administered multiple 20-mg/kg IV boluses.

Meanwhile, at the bottom of the stretcher, the other ED team was trying to assess and treat the baby girl. A second emergency physician was requested to assist with her care, and the local level 1 children’s hospital was notified of the emergent need to transfer the twins.

My focus remained on the little boy, but I was able to overhear the status of the baby girl. Unfortunately, the girl arrived in much more distress than her twin brother. Her weight was estimated at 2 kg, with intermittent spontaneous respirations. Her skin turgor was tented with delayed capillary refill. Her initial rectal temperature was 89.6°F, and her blood glucose level was approximately 250 mg/dL. The team attempted placement of 2 interosseous catheters before successful access was obtained and resuscitative fluids could be administered. Endotracheal intubation was delayed by the large quantity of crusted secretions in the oropharynx. In the interim, 100% oxygen was administered via a bag-valve-mask device. Laboratory samples were obtained, showing severe acidosis, dehydration, and electrolyte imbalance. At that point, the children’s transport team arrived and assisted in securing endotracheal tubes in both babies and administering additional warmed fluid boluses. The twins were then transferred for further intensive care.

My impression was that the little boy probably had a 50/50 chance of meaningful survival whereas the little girl’s prognosis seemed much more dismal. I left the hospital feeling both elated and sad at the same time. It had been a wonderful experience to be a part of a great medical team caring for such critically ill children. It was also very disturbing to imagine the possible long-term outcomes for these children. I could not decide what was better: living a life mother-less and with possible disabilities or dying. The other dilemma that haunted me was a comment made by a nurse who cared for the little girl. She remarked, “I just wanted to stop sticking her and wrap her up in a warm blanket and rock her until she passed.” That comment shocked me. My perspective had been very different. The little boy was stronger upon arrival and responded well to the treatments. I never thought about stopping resuscitative efforts. The little girl, on the other hand, was more distressed and it took much longer to successfully resuscitate her. The baby girl did die later that night, whereas amazingly, the little boy was discharged from the hospital to extended family just 2 weeks later.

This case shows the endless dilemma we all face with pediatric resuscitations. When should we aggressively treat, and when should we rock them to sleep?