It Isnt The Dead Child Who Haunts Me

When I was a third-year resident there was one incident that still wakes me up at night. Not always, just once in a while. I can go for months without thinking about the incident, and then it surfaces, very much like a long submerged body that finally floats to the top of some still, dark lake.

It was spring, and toward the end of my last residency year. I was on the 12 am to 7 am shift in the ER.

Don't Say 'Quiet'

I was on with a second-year resident, a first-year intern, and an attending. I was manning the acute side, where the trauma, acute asthma, GI bleeds, overdoses, and other more serious conditions were sent. But there was none of it that night.

The ER was quiet, but obeying the ER superstition, none of us would ever say the "quiet" word out loud.

The intern and second-year were triaging the patients, with only a couple of reasonable complaints in the box: ear pain, fever, and cough. I was sitting in the workroom with the attending, Theo.

No Breath, No Heartbeat

It was about 2 a.m. and Theo and I were trading stories in the workroom, drinking coffee from the little all-night take-away across the street.

Then, predictably, "Aaahhhh! No! My baby!! Ahhhh!" We heard the screaming from down the hallway; the wailing grew louder and a woman clutching a toddler-aged child ran past us, then stopped, turned, and ran into the room.

The child she was holding wore a white onesie and was a well-developed child with dark hair. I noted two things: the child's limbs were flopping as the woman ran, and the child's skin was pallid.

Theo took the child from her and ran, with me following one step behind, into the code room. I watched as Theo put his ear to the child's chest.

No breath, no heartbeat. By now the intern, second year, and a couple of nurses were in the room. The code cart was pulled over; an endotracheal tube and laryngoscope were placed in my hand. I intubated the child without hesitation; less than 3 minutes had passed.

I attached the Ambu bag and gave the child quick breaths of 100% oxygen, watching his chest rise. The intern started doing chest compressions. Every second was precious if this child was to emerge alive. The mother was still wailing on.

She pushed into the room and stood by the stretcher as we worked.

The second-year resident got in an intraosseous line for emergency fluid administration -- a terrible thing to behold to the uninitiated. The crunch of the needle as it pierces the bone, mid-shin, makes me cringe even today.

I saw the brutality of what we do through her eyes. Chest compressions. Fluid was pushed. Epinephrine, bicarbonate, calcium. The blood gas was dire, with a pH of 6.98, well below the normal 7.4 pH. Theo met my eyes and his head shook just a little.

"What's your name?" Theo said, looking at the intern, who had changed out doing CPR with one of the nurses and was standing nearby.

"James," he replied.

"Jim, get a history," Theo said.

The intern pulled a chair over for the mother and spoke into her ear. Short sentences. Direct questions.

"How old is your son?" the intern asked. The woman responded that her son would be turning two next month.

The intern asked if the child had any other health problems. His mother said that he wheezes when he gets a cold, but not recently. She asked again, desperately, what was happening to her child.

Jim explained slowly, describing the meaning of each tube, each needle, fluid, medicine, syringe, and each number on the monitor above her bed.

What he didn't tell her, what he couldn't tell her, was that her baby's blood oxygen was so low it wasn't even registering, and his heart rate was absent. The CPR, the chest compressions, were keeping her baby's blood circulating.

"How long was he sick? Tell me what happened," he said. The intern spoke to her calmly, but his voice was shaking.

As the mother finished the intern looked up at Theo.

"Let's get some blood cultures and give a dose of ceftriaxone," Theo said.

At the head of the bed, I watched as Theo examined the child. There, under the onesie, on the child's torso, just on his left side above his hip, was a plum-shaped cluster of purplish lesions.

Smaller, fainter specks spread to his back and over his belly, where another purpuric lesion was taking shape.

"Meningococcemia," Theo said.

I shook my head. The perfect child was dying.

Theo looked around at us, at the child, at the mother. "That's enough," he said quietly. "He's gone. Time of death." He looked at the clock, "3:08 am."

Slowly the resuscitation efforts disassembled. The chest compressions and Ambu bag ventilation were stopped. The IV fluid was stopped. The nurse removed the intraosseous line and placed a dressing over the site, catching the slow, dark drip of blood. Another removed the endotracheal tube.

"Wait! What's happening?" said the mother.

Theo walked over to her and put a hand on her shoulder. "I'm sorry," he said. "Your son is gone."

She looked at her baby, but her eyes weren't aggrieved; they were vacant, unrecognizing.

"He's gone," she said.

She walked out or tried to. She was stopped by the social worker at the door. I overheard the usual, the social worker explaining the process of retrieving the body. The mother kept trying to end the conversation and leave.

"Do what you have to do! Please just let me go! You can call me tomorrow. Please." The mother pushed past, without a look behind her, and ran from the ER.

By this time, the child was covered with a sheet.

"I'll call the coroner and get the body released to us for autopsy," Theo said. "Take the first year, Jim, and bring the body to the morgue. Don't forget your flashlight."

"Oh, great. Thanks, Theo," I said, and looked over at the intern. "You wanna go for a walk?"

I grabbed a flashlight from the drawer and a fresh set of gloves, and we each took an end of the stretcher and wheeled it through the hall, past the now empty waiting room, to the back elevator. I pressed the down button.

The space was cramped, with two people and a stretcher. I pressed S2, the second and deepest level tunnels.

"How'd you escape almost your whole internship year without a trip through the tunnels?" I asked.

"Don't know. Lucky." The intern looked pale in the dim light. He was one of the more fastidious interns, wearing white pants, white shirt, and white jacket all the time.

The elevator descended; I can still hear it in my head. It moved with a slow, deliberate rattle interrupted every few seconds by a low, metallic moan.

"We've never worked together before. It's Jim, right?"

"James," he said, but he made it sound like a question.

"Look, don't be nervous. I won't leave you."

He smiled, thinly.

The elevator stopped, and the door opened to blackness and I heard James inhale, sharply. The dim elevator light absorbed into the dark space before it. The tunnels were always dark, the lights were on a timer and had to be turned on. I reached my hand out to the right wall outside the elevator, felt for the knob and turned it, full on, to 1 hour.

Dead Bodies Can Moan?

We pushed the stretcher down the hall and every 25 yards or so there'd be another reassuring sign pointing the way to the morgue. Every so often a dark passageway would split off from the main hall and occasionally there were rustling sounds in the blackness.

We finally arrived at the grey, windowed double doors of the morgue. I turned another knob on the wall and the lights went on inside. I could see James was sweating, though the air was cool. It smelled like a damp basement, with a trace of formalin. I hated it down here and remembered my first time, just as he'll remember his.

"Let's go in." I said, pushing one of the doors open with my leg and pulling the stretcher through. James fumbled to help push from the other end.

"Now what?" said James, his voice shaking.

"We have to put the body in an empty cube," I said.

There were several, and we picked the nearest one. I turned the long metal handle and opened the door, then slid out the metal slab.

Together we lifted the under sheet and with it the body, covered by a top sheet, and placed it gently on the slab.

At the moment we sat it down, the body, still covered with the white top sheet, sat up and moaned.

It stayed upright for a long count of five, then fell backward.

James screamed.

"Stop!" I said, as authoritatively as I could manage, and I pulled back the sheet and looked at the boy. His eyes were open, but they were glazed over and vacant. He was dead. There was no doubt that he was dead. I closed his eyes and pulled the sheet back over him.

"What...what was that?" James was talking too loud and his voice was shaking remarkably.

"Air in the lungs, or stomach, must've pushed out through the vocal cords when we set it down." I spoke as quietly and calmly as I could, given what just happened. With someone else this may have been one of those "No f---ing way!" moments that erupted into nervous laughter. But not with James.

"Are we finished here?" He yelled, nervously. "I want to go!"

"In a minute, James. In a minute. Just calm down." I spoke calmly, like I was giving instructions to an unruly child. "We have to register the body."

I wrote my name, then checked that the details were properly recorded, took the death certificate, autopsy consent, and other papers and placed them on the clipboard hanging from the front of the cube that the child was in.

"Okay. We can go."

"Wait," he said.

"Yes?" I asked.

"Shouldn't we, shouldn't we check on him? To make sure?"

"That he's dead? He's dead. Really."

He stared at me, disbelieving. "Look, I've never, I've never been down here, because I've never had anyone, any kid die." His voice trailed off, sounding strangled. "...in front of me!" He gulped and sobbed. "We can't be sure! We have to look!"

He was so scared and so fragile. I was just two years ahead of him and had sadly been exposed to enough awful incidents to be pragmatic about death. Looking at him, I remembered how I felt the first time.

"You'll never be the same again." I said. "And you'll never forget."

"That's what I'm afraid of!" James said, too loudly. Involuntarily, it seemed, his hands raised and covered his mouth. He shook his head.

I had no idea what to do with this guy. He was too scared to reason with.

I started pushing the stretcher back out the door. "James, give me a hand so we can leave?"

He nodded, slowly, and unclamped his hands from his mouth and helped me guide the stretcher out the door, down the sloping walkway, then up again toward the elevators.

We arrived at the elevator with 10 minutes to spare on the timer. I pushed the "Up" button and listened for the reassuring clunk of the ancient gears lowering the elevator. I looked at James, who watched fearfully up and down the hallway. I thought I should say something mature and try to get him to focus.

"So, what did you learn tonight?"

"That I never want to come down here again." He continued to survey the hallway, and his voice still shook. "And that dead bodies can sit up and moan."

Then he looked straight at me and started laughing, a wild, high-pitched, and uncontrollable laugh. It echoed off the endless tile halls, sounding fragile, insane, and frightened. I could feel my skin prickling into goosebumps.

"Well," I laughed, a fake, okay-I'll-laugh-too kind of laugh. "Maybe you'll never have to come here again. I hear you're lucky."

Please Don't Tell Anyone About This

The elevator arrived, we got on, pressed "G" for ground and rode silently up. Our walk back to the ER was silent, until we got just outside the doors.

"Wait." James said, stopping us. "Please don't tell anyone about...about this."

I wanted to ask him, but I didn't say anything. I just nodded.

Back in the bright lights of the ER, Theo gave us a 10-minute talk on meningococcemia, then told us both to take a nap while he stayed up to see the few stragglers that would come through before our shift ended at 7. When I awoke, I headed to the small work room.

James looked uncomfortable as he packed his few items into his backpack. He wouldn't meet my eyes, so I couldn't read what was going on in his head. I walked over and put a hand on his shoulder, causing him to startle noticeably.

"You did a good job last night," I told him.

"Thanks," he muttered. "Uh, you, too." Still no eye contact. "Gotta go. See ya."

"Yeah. Sure. See you, too."

But I didn't, not really. I saw him occasionally on the wards, but we never worked together after that night. He always looked so scared. I wanted to say to him, "Listen, it's hard for all of us. In our own ways, we struggle. Don't let your own internal monologue of fear stop you from doing your job and learning what you need to learn. Don't be so scared."

I wanted to tell him something that would inspire him or reassure him, but I didn't.

This Is What Haunts Me

He dropped out the following year. I heard that he placed into a psychiatry program, but no one could tell me where. No one knew much about him and he didn't develop any close ties with any of the other interns or residents.

I later heard that he had told the story of the dead child to a couple of his co-interns one night as they waited for admissions on the floor. I heard this much later, when I was in cardiology fellowship, from one of the interns that was by then a senior resident. She told me that James told the story and was laughing so hard he could barely get the words out. Laughter is a contagion. She said everyone was laughing, too. Not so much because of the tragically funny story, but because of James' delivery.

"Is it true?" she asked me. She said she could believe James made it up, just to have a moment of being able to be noticed and, well, liked.

"You never know." I smiled. "It's awfully creepy down there in the tunnels at 3 am."

Like I said, I can go for months without thinking about the incident, and then it just surfaces. And James? I like to think he's probably in some suburban office in Indiana, jotting down a grocery list in the margin of his pad when he's supposed to be taking notes on his depressed patients.

But who knows? If you haven't guessed, he's the one that keeps me up at night, not the moaning baby. I can't help but wonder what happened to him and if I could have helped him more, somehow. But I didn't.

I've tried to find him, but he's dropped off the grid; that's hard to do today, with every form of social media vying for our participation. And about that thought that haunts me every few months, that body floating face down in the dark, silent lake? I think it's him.

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You can listen to the audio version on MedPage Today's Anamnesis Podcast.