Bringing back the dead

A 3-year-old girl is submerged under water for five minutes. When you're the doctor trying to resuscitate her, how do you know when to stop?


J.B. Orenstein
July 12, 2000 11:00PM (UTC)

"Line 1, Jul."

I had just stepped into the E.R. when the secretary diverted my attention to the phone. It showed a single column of three red dots, two blinking.

I stabbed at the bottom dot and heard the voice of Tina, a nurse from the ambulance and helicopter communications center. "Three-year-old girl, drowning victim," she said with a hesitant, sucked-in breath. "CPR in progress."

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A shared nightmare was about to unfold. "Shit. OK. ETA?"

"Five."

"OK." I hung up.

Coming in five minutes was a torrent of pain and grief whose name, for this story, would be Rebecca Rose. The summertime heat, between noon and 9 p.m., routinely invites a horror to emerge from the blue. An unattended child will go into a pool and drown. Once the rescue starts, the hard part of my job is not a matter of knowing what to do. I know what to do. The hard part is knowing when to stop.

The events run together seamlessly. A sunny-faced, moppet-haired toddler slips silently under the water and the dreamy summer day mutates into tragedy with the first, slightly raised calling of the child's name: Re-becca?? Re- BEC-CA?!! A scuffling scramble ensues. The missing child's name is called louder and louder until, with a wail, the facedown body is discovered in the pool. And then screams, sirens, the grunts of medics.

The Emergency Medical Services rescuers arrived at Rebecca's side in roughly five minutes, but they were helpless. Two or three attempts to place a breathing tube and IVs failed. They abandoned their efforts and rushed the skinny, blue, inert girl, in full arrest, to the doors of Trauma One, aggressively applying CPR for the three or four minutes it took to reach us.

About 8,000 drownings or near-drownings occur in the United States each year, mostly of kids and adolescents, half in private pools. Seven or eight out of 10 survive, but the rest die immediately or end up in a permanently vegetative state, almost better off dead. Nothing -- not cars, not guns -- kills more children under age 5. Most drownings take place between Memorial Day and Labor Day between late morning and dinnertime. During peak hours, a ghastly rate emerges of about 20 submersions every hour nationwide, and three or four deaths. Before you pack away the Weber grill or toss out the last empty tube of sunblock, you'll hear of a case on the late local news or read it in the Metro section of your hometown paper. Most of these drownings happen in pools, not at ocean beaches, lakes or rivers, according to Dr. Linda Quan, a pediatric emergency physician at Harborview Medical Center in Seattle. Quan surmises that more children drown at pools than beaches because fewer adults are present at homes than at public beaches to watch wandering children.

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Aside from variations in setting and players, once a child goes into the drink, the same drama begins. It plays out in only two ways. In one script, the missing child is found within four or five minutes and is revived by CPR -- by the bystander or paramedic -- in less than five to 10 minutes. A splutter of water and a frantic thrashing accompany the child's revival, followed by a hasty trip into the E.R. for an X-ray or maybe no X-ray, a CAT scan or maybe no CAT scan. It doesn't matter: No harm is done. The parents or caretaker are another matter. When the horrified sobbing and hyperventilating stop they'll depart for home with their healthy, uninjured child. Tremblingly grateful and scared still half out of their wits, some are secretly wracked by self-recriminations.

Some of these drowning cases take place under the supervision of a drunk or intoxicated "care" giver. "I've not seen any hard data," said Dr. Quan, "but it plays a role."

For Rebecca and the Roses, the story unfolded differently. Once they were inside the trauma bay, events started to go ominously "right." The interval from putting down the phone to taking up my position in the code room is a clouded gap. This was the time to rehearse my terrible job, to imagine the face, the body, the bright cheerful bathing suit that would materialize and later, the ashen, shattered parents. There was no chattering with the nurses or techs, just a few muttered preparatory questions and responses. Then, without warning, a phalanx of white-shirted paramedics snapped the door open, marched in with tiny Rebecca, one bulky torso of an EMT rising and falling in the rhythm of CPR.

I remember seeing a small, blue, sweetly oval face and dark, wet hair matted this way and that. I remember every other damn thing, too: Both the intravenous and endotracheal tubes, impossible to insert out by the pool, went in right away. The clear plastic barrel of the breathing tube slid carefully, effortlessly into her trachea. The nurse's crisp bark: "Line in. MEDS?" The way was paved for big resuscitation guns: "epi" or epinephrine, atropine, lidocaine, bretylium, cardioversion. In a hushed voice, I called for epi. Rescue drug No. 1.

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The first epinephrine dose is a "low" dose: Sometimes just a whiff is needed to kick-start the heart. The second dose, a high dose, is a rocket blast. If that doesn't work, the rescue is all but over. There are a few other drugs and a few other maneuvers, but basically, after the one-two epi punch, the rest is a foregone conclusion. Rebecca Rose, her pretty features partly distorted now by tape and tubes, did not respond to the low dose. I called for hi-dose epi, and again Rebecca resisted.

I waited a minute, absorbing the full impact. A little girl picking out her favorite outfit for the day perhaps only 40 minutes earlier -- a pink one-piece suit with bright yellow smiley faces -- now awaited my call for rounds of epi to fight for her life. I calculated the impact of our next moves. Another epi, hi-dose. Lidocaine. Shocks.

Ten to 15 years ago, there was uncertainty as to whether drowning in salt water was any different from fresh water, or if "wet" drowning differed from "dry." Dr. James Orlowski, a pediatric intensive care unit specialist, demonstrated that four out of five cases are "wet." Salt water, fresh water or no water, he and others have shown, makes not an iota of difference. The damage is done to the brain and to the brain only. After four minutes of lack of oxygen, called anoxia, irreversible damage occurs. Only unpredictable and scattered functions may survive after that. If the primitive, sub-limbic controls to maintain breathing and circulatory functions are spared, the cruel fate that awaits can last for weeks, months, years.

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The heart tolerates much longer deprivation. It's made of muscle, not nerve, which is far more resilient. The heart of just about any baby or child can be resuscitated after even 20 minutes of anoxia, sometimes more. Into this deadly zone of mixed destiny, from five minutes to perhaps 30, when the heart can be revived but the brain cannot, the cruelest outcomes emerge. Rebecca Rose came to me at precisely this treacherous interval: at a down time long enough to kill her brain, but short enough to spare her heart.

This is the conundrum peculiar to pediatric emergency medicine. At 20, 30, 40 minutes of resuscitation, I can call an end to it, heavy-hearted. But at the 10-minute mark I'm aware, emotionally, that all true hope is lost. Intellectually, I still owe the girl with a blue face and damp, tangled hair and the parents I haven't yet met one last round, perhaps two of resuscitative countermeasures.

I may pray it won't do the trick. I cannot justify putting everyone through this final, terrifying ordeal, because at that point the only possible outcome, with vanishingly rare exceptions, is of a terribly damaged baby returning. Regardless, I press on. The awareness that only the hollowest of victories may result is no deterrence to CPR heroics. How could I, how could any doctor, look the parents in the eye knowing I'd held something back? How do I decide if a mommy would rather mourn her lost child or cling to a diminished, damaged one? I don't, so the child must decide. I keep the resuscitative efforts going for at least half an hour, until all hope is truly extinguished. The heart may be more tenacious than the brain, but I've got the opposite problem. My brain is the more stubborn organ. When we can, we offer life; there are no guidelines for when to abandon hope.

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One question ought to help resolve this dilemma: Would you offer the same treatment to your own child? Would I rather face my own child's sudden, unexpected death or a bleak future of biomedical equipment, nurses and mournful half-life? I don't know, and I hope I never know. Would my wife make the same choice as me? She can't know, just as I cannot know. If the mom and dad find themselves on opposite sides of this unforgiving divide, their relationship may be destroyed. And yet, no couple can ever know this about themselves until they are placed in this terrible situation.

Hanging malevolently at the end of any CPR effort lasting more than a minute or two is the near certainty of either a declaration of death or the dreaded "ROSC" -- the return of spontaneous circulation. That is when I leave to report to the family of the grave circumstances of the extinction of their hopes and dreams. Judge and executioner, long-faced, I slam the gavel, no appeal. Dead or inhumanly damaged. Sentence already carried out.

After I ordered a second hi-dose epi at the 15-plus minute range, Rebecca did the unforgivable: She came back. Then she did the unbearable: She stayed back. A beat appeared on a monitor, then another. ROSC. I waved off the medic still pumping up and down on her chest and felt for pulses. Strong. Her color: pinker and pinker. My heart sank, I broke out in a cold sweat.

Her parents, who were in the waiting room, looked exactly as I had pictured them: disheveled with anguish, fearing my arrival beyond any imaginable terror.

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"She's alive," I said, tongue dry, thick voiced. I did not spell out for them that her revival would sour into something worse than defeat; that would be the job of the intensive care doctors. "But her prognosis" -- a carefully chosen, scary word -- "isn't clear." The toxic effects of prolonged anoxia could cause the revived organs to deteriorate within a day or two. But absent a spontaneous, quick death, a rigorous brain-death protocol would be enacted. A brain wave study, an EEG, awaited. Upon demonstration that the cortex, the highest functioning brain center, had not survived, Rebecca would have been declared brain-dead. The ventilator and life-sustaining equipment would be withdrawn and death would ensue in minutes.

Tough little Rebecca Rose, strong enough to hold back death for 15 or 20 minutes, was also resilient enough to withstand the first days of complications. She eluded brain-death criteria and has languished long years since then, most in a pediatric nursing home. Her limbs have contracted, her eyes dance crazily around and she cries out when her feeding tube or tracheostomy tube tug in the wrong direction. She has become this person.

It was all too much for her mother. She spent the first few days by Rebecca's side, but seemed to vanish after the EEG's damning sentence: not gone enough. Within months, she vanished, in order, I imagine, to resume her own life. Dad stayed by Rebecca's side. He still saw his precious daughter bloom inside the twisted, damaged, vegetative creature that remained. Each cough, each utterance that emerged was filtered through the prism of who she was and what he thought he heard her say.

I understand the mom. She made a reasonable choice. I might argue in favor of her case every time. But I feel the heavy beating of the dad's heart. As I said, one question should clarify the choices: What would you want for your own child?

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Drowning is a quiet research front. The brain suffocates; prevention is easy in principle: Pool owners should put up a four-sided fence and master CPR. Don't drink if young children are around a pool. Watch your kid every goddamned second. Don't put me, us, your Rebecca Rose, through this again.


J.B. Orenstein

J.B. Orenstein is a physician practicing pediatric emergency medicine in Fairfax, Va. His writings have appeared in the Washington Post, Annals of Emergency Medicine and Pediatrics.

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