Tuesday, July 6, 2010


It has been a few years since I spent the entirety of a day and a night at the bedside of one patient.  I did have to admit a handful of other patients with trauma and other injuries, but the surgeons did the lion's share of that care, and as I wrote the physician orders and interviewed them in the ICU, I was just meters away, and even then, only intermittently, from Mahmoud (not his real name), my 17 month patient with burns from his face to his feet. 

This toddler was brought to the base gate in the arms of his sobbing father one week ago.  The boy reached for his meal cup on the edge of the counter in the kitchen, but this familiar thermos was filled with boiling water which his mother had just poured in while preparing his breakfast.  Why his cup with scalding water was within his reach is something I cannot understand, and a question his parents will probably never be able to answer. 

Mamhoud's mother, 9 months pregnant with the next child, has not seen Mahmoud since he came to the hospital where his burns, not unexpectedly, expanded, as he developed, also not unexpectedly, a severe infection, which leaves him now intubated, flirting with death.  I had to explain, through an interpreter, how Mamhoud is very ill and may die as a complication of his burns to his father and uncle; the mortality of this severe of a burn in the United States   "But this is why we brought him here," they say, incredulously.  Knowingly, they say, "He would die at the [Iraqi] hospital," and indeed, death was certain at the local Iraqi hospital where they have no capacity to offer this level of care.  That is the my solace - that this child would be dead without me - in practicing outside of the scope of my own practice; a specialized profession in the care of adults.  We are taught from very early in medical education, the ethical dilemnas and the hard and fast rules.  In the US, you practice in the scope of your care or you lose your license.  The lines are blurry, sometimes, but surgeons don't do psychiatry, obstetricians don't do cardiology, and adult medical subspecialists don't take care of children.  The exigent circumstances which leave this child dead without me, and the fact that providing critical medical care with the resources available is something a "reasonable person with my skill set would set forth to do" in this environment, make this ok.  This is what I tell myself, and what the lawyers say.

That doesn't mean that you when you perform outside of your arena you don't second guess all of you decisions.  In 24 hours, I wrote over 100 orders on this child, maximizing his physiology.  I watched his bell rise, the movements of his fingers, the eletrocardiographic tracings all the while titrating his ventilator settings, and massaging his hemodynamics.  And each decision I made, unmade and re-made in tragic inefficiency, to avoid errors I am so much more likely to make in him than I would in an adult. 

In this vigil, I watched this boy, equal in age to my youngest son, and the more I stared at him or listened to his breath sounds, or readjusted his dozens of invasive tubes and lines, the clearer the evolution of his pathophysiology became to me.  Like a hidden puzzle in the Sunday comics, the pathology revealed itself to the patient observer.  As Sir William Osler noted over a century ago, the bedside vigil embodies the essence of what it means to be a physician.

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