“My baby stopped breathing!” the panicked voice echoed across the ward and cut through the hum of voices at the nursing station. “Help!” The beehive of activity at the desk halted; our breaths held as we turned to look at the far side of the pediatric ward.
I looked up from my papers as I started jogging. I was the resident on call for the pediatric ward that afternoon, and I had been standing at the nurses’ station talking to the day residents for sign out. We hadn’t talked about that room. I didn’t know this baby. Rushing into that room I was running into the unknown.
The dull weight of anxiety throbbed in my chest as I saw a mother standing in the doorway of a room with tears streaming down her face. She was holding up a small infant in both hands. The infant’s face was dusky, her mouth slack, and her extremities dangled uselessly as her mother held her. My voice projected across the ward to call a code blue.
I hadn’t run a code before. It terrified me, but I knew it would happen at some point. I had passed the necessary training to participate in a code, but critical events such as this one were rare in pediatrics. Would I remember all the steps? Would I be paralyzed by anxiety and doubt? I had carefully memorized the algorithms and practiced what I would do in just this situation, but would the scenarios I had memorized translate into competence?
I carried the infant into the room and laid her on her crib mattress. Jumbled thoughts fluttered about my mind, scraps of paper, disordered and useless. I half noticed that a crash cart was being wheeled into the room.
“Are you ok?” I asked the baby, rubbing her back and her sternum, trying to elicit a response. She didn’t cry, there was no movement or breath. Then I felt a heartbeat. Under my hand the impulse of her heart pressed up against my fingertips. She was in there; a small little life. That sensation overwhelmed my senses. I felt it tapping between the toothpick contours of her ribs. My mind cleared. My jumbled thoughts came together, and I knew what to do next. I took a deep breath and proceeded. Look at your watch and count the pulse. “Her heart rate is 100,” I said to the team. “She’s not breathing. We need to give breaths. Where is the mask?”
As I counted that tiny heartbeat, a dance unfolded around me. A nurse placed the baby on the monitor and another prepared her IV. I was handed bag and mask. I placed the mask over her nose and mouth and positioned her head. The mask fit easily, and I pressed the plastic bag, pushing air into those fragile lungs. The quiet of the room was broken only by the mechanic pulse on the heart rate monitor, but a silent roar of will surged through the air. It was a scream of hope emanating from each of us, begging her to breathe. Another push on the bag, and I sent a prayer riding on oxygen into her body, begging a response.
“Will she breathe again?” I asked myself. “Will her heart slow and stop?” The thought came unbidden. “Can I save her?” And then the questions every young doctor must ask, “Am I doing this right; have I forgotten anything? Am I going to fail this patient, this family?” The Hippocratic oath tells us to first do no harm. As physicians we cannot always heal, but we can provide solace, ease pain, and mitigate disease. Above all things we must strive to never, either by action or omission, make something worse. Every physician will ask themselves if they are causing harm instead of good, even with the best of intentions. At that moment, as a junior doctor, I struggled to find assurance that I was doing the right thing.
I delivered another breath as doubt coursed through my veins. “Please breathe,” I whispered. Did her fingers move? Another breath, “please breathe,” I whispered again. The silence of the room was oppressive. Another breath, and suddenly her face twisted into a grimace, her arms startled and raised in the air, and an ear-piercing wail cut through the blanket of anticipation that shrouded the room. The beep of the heart rate monitor sped up. I placed the mask to the side and took a deep breath myself, unaware that I had been holding it.
A tear wandered down my cheek, and the weight of a hand was placed on my shoulder. I looked up into the face of my attending physician. “Well done,” she said.
That night once the ward was quiet, I reflected on the events of the evening. What would have happened if I had frozen and not remembered the steps of resuscitation, or if I had proceeded with the code but done them incorrectly?
I was starting to learn that practicing medicine is a balance of risk and benefits; a constant decision-making process. Early in my career each choice plagued me with insecurity. I hoped someday I would overcome any uncertainty. The intervening years have taught me that will not happen, nor do I want it to. It is an integral component to the development and improvement of any physician. There are infinite variables that must be considered before each step is taken. It never becomes routine; each patient presents a different facet of health and disease. I carry the uncertainty that comes from such a complex system as a constant companion. It used to be foreign and terrifying, now it is a familiar adversary clenched in the tight muscles of my shoulders. Algorithms provide a structure to initiate care, but uncertainty is what pushes me to look beyond the algorithms and search for inspiration.
Alexandra Pinon, MD, FAAP is a board certified Pediatrician and Navy veteran working in California. She completed her residency at the Naval Medical Center San Diego.
This post has been edited for length and clarity from its original appearance in The Chronicles of Women In White Coats.
