Watching the triage nurse run to your resuscitation room with a lifeless baby in her arms has got to top the list of stomach-dropping, check-your-own-pulse moments at work.

This happened to me recently, during what had been up until that moment an otherwise ordinary day.

Quickly moving to the room, I looked down at the gurney and saw a little baby, gray and mottled, struggling to breath and foaming at the mouth.

“Suction and oxygen,” I said, as the nurses started the organized chaos thing they do during a code, with even more urgency than usual since here was a patient that had absolutely no business dying.

His mouth was suctioned and a bag valve mask was applied.  Within seconds he was pink again, and the monitor showed an acceptable inital heart rate in the 130’s.  The nurses started to work on an IV, and I noticed that he wasn’t fighting the needle sticks at all, just laying still and stiff with his hands flexed down.  Was he seizing?  I pulled his eyelids back and saw his eyes almost imperceptibly darting back and forth, over and over.

I reflexively ordered his glucose checked, and it came back normal.  So was his temperature.  Meanwhile, a veteran nurse managed to secure an IV — a fantasticly clutch performance considering how infrequently we run infant resuscitations — saving the patient an IO.  A milligram of ativan was given while I went to find out more about him from his mom.  He’s three months old.  Born on time and had been fine ever since.  Including today, until he threw up and started gagging on it.  She turned him over, then went to get a rag, and when she came back his legs were shaking and his color was bad.  She scooped him up and drove straight over.

“You came to the right place, we’re going to take good care of him,” I told her.  She really didn’t, of course, she should have called an ambulance and he should be at the Children’s ER being cared for by an entire pediatric team who specializes in this type of thing, but no matter: she was scared and crying and looked young enough to have a pediatrician herself.  Sometimes people just need reassurance, and facts don’t need to get in the way.

I checked back with the patient.  Is he still seizing?  I think he’s done, he’s lying floppy still instead of stiff still.  I told the respiratory therapist to stop bagging him and just watched him breathe for a little bit.  I estimated about 8-10 gasping breaths per minute, way slow for a 3 month old, and decided to intubate.

3.5 endotracheal tube and a Miller 1 please.  Boy, do those numbers sound weird.  I’m not intubating adults everyday or anything, but it happens on a semi-regular basis.  This will be my first infant intubation, however, in nearly two years.

The Miller 1 goes in and there’s the epiglottis and there’s the cords.  Back and forth they open and close with each breath, a novelty as I almost always chemically paralyze people prior to getting this far.  And now I put the tube in and it’s tiny but so’s the patient and my entire view is now obscured, but I keep heading to where the cords were but the tube meets resistance and what’s the deal are the cords closed or am I in the wrong place and the nurse beside me says 93%…91%…89%…

Meh.  The tube and blade comes out, since oxygen levels are dipping too low.  “Bag” I say, watching the sats drop down to the low 80’s before recovering.  Should I do something different?  Geez, I had such a good view, I give it another shot, but get the same result.  If this were mini-golf I’d be trying to knock my ball through the windmill only to have it keep clanging right back to me.

Ok so one more time and this time I paralyze him first with succynlcholine and give some atropine too for good measure.  And finally the tube slides where it’s supposed to and gets foggy and the chest rises and the CO2 detector changes color – all of it meaning the intubation is successful.

It’s somewhat demoralizing that it took three tries, but no time to dwell on this.  I saw some purposeful movement just before paralyzing, and now that the drug is wearing off I see it again.  I talk to the ER doc at the Children’s Hospital and give him my assessment: emesis, aspiration, hypoxia, seizure.  I offer to do a spinal tap but he’d prefer not to delay transfer and that’s fine by me as I still have lots of other patients to take care of.  The transport team comes to wisk him away by helicopter, but before he goes he starts seizing again, this time in a refreshingly obvious tonic-clonic fashion.  I give three more doses of ativan and start dilantin but he keeps seizing, and finally I decide to transport him anyway – he’s intubated and life flight will continue the ativan every five minutes while letting the rest of the dilantin run in.

I felt pretty good about my assessment until he reseized, and sure enough I learned that it was dead wrong.  He continued to seize at the Children’s Hospital until his bloodwork returned showing profound hyponatremia — his sodium was way too low.  They questioned his mother more closely and she confessed that money had been tight and to stretch out his formula she had been diluting it with water.  He was the first patient I’d ever managed with this, but it’s such a freaking classic board scenario (I even mentioned it here) that I couldn’t believe that I didn’t at least ask about this, especially after he started his more refractory second round of seizures.    

I nailed the practice board case but haven’t thought about it since.  Real life, I’m thinking, will prove more memorable.