“That doesn’t happen often,” I quietly but excitedly say to myself while discussing our consult from the PICU. My attending hesitates, pondering the precarious balance between encouraging my medical curiosity and protecting me from the horrors of child abuse and mistreatment that still haunt her to this day. That day, I was a first-hand witness to the necessary but horrible clinical task of a brain death exam. This task is a rite of passage for those in the medical field. I appeared eager and enthusiastic, so my attending agreed I could observe. Coordinating with the patients’ other providers, I promptly set up the exam without a second thought. Later that evening, after lifting my head from the tear-stained pillow, I realized I should have taken the attending’s hesitation as a sign.
During my Child Abuse clerkship, we evaluated children who were spanked, hit, tossed, thrown, slapped, shook, cut, stabbed, strangled, kicked, beaten, burned, violated, sexually abused, raped and murdered. This was not the typical elective choice for a naïve optimist like me. I, however, wanted to witness the worst of my future specialty. I wanted to convince myself I could provide great and compassionate medical care when face-to-face with the worst society and nature has to offer.
A collection of certain symptoms or findings in the history, physical exam, imaging and/or labs, in the absence of accidental trauma or a known pathophysiological mechanism connecting them, is indicative of abuse. When we were consulted, with heavy hearts, we would cross off every potential medical diagnosis that could have caused those injuries. Like anchors in the sea, our fingers sank into the keyboard keys, cementing nonaccidental trauma (NAT) in our assessments.
At this point, I had a week of training under my belt. I had researched the protocols. I knew the nomenclature. I understood the pathophysiology. I felt ready. As a former team sport enthusiast, I internally screamed, “PUT ME IN COACH!” As fourth-year medical students, we became comfortable with the standard day-to-day cases in our preferred specialty. I did not want to see another upper respiratory infection, rash or asthma case. I longed for the zebras. I wanted to learn something new. I wanted a challenge. But in reality, I should have sat on the bench for a little longer.
This infant, who could not even crawl, had brain bleeding leading to significant intracranial pressure, which resulted in irreversible brain herniation despite proper neuroprotective measures. It was time to start a meticulous assessment for brain death. We all knew the outcome without the testing. The team, however, completed the checklists and confirmed the patient was in optimal condition for the standard neurological reflex evaluation. The lead physicians used an experienced, calm and procedural tone of voice to mitigate the worries, fears and deep silent sadness in the room. Was it for the medical staff or for the family? I will never know.
We entered what first felt like a completely silent room, and I immediately knew I did not like this form of quiet. Like hiking in the woods, one does not realize they are experiencing true quiet until noise breaks the trance. In today’s world, medical professionals rarely experience true quiet. Too many machines. Endless pages. Constant messages. But in this room, the alarms were silenced and there was not a cell phone to be heard. We are taught a full physical exam should take no more than 10 to 15 minutes, a focused exam less than five. A proper exam takes 25 minutes minimum. Have you ever heard a family silently sob for 25 minutes while you tried to focus? It is almost unbearable. The PICU fellow, surprisingly calm and confident, called out each exam maneuver with utter clarity in their voice, only occasionally sinking their head as they pulled away from the patient before speaking: “No reflex.” Sob. “No reflex.” Sob. “No reflex.” Twenty-five minutes later, finally, a new noise arose. Whoosh. The apnea test. The sound of rushing air escaped the endotracheal tube, similar to how a toddler haphazardly blows out a birthday candle. I realized this child never tasted cake.
“Oh, why was I here? How I long to be in the woods right now,” I thought. With our heads hung low, the PICU attending stated, as they have done too many times before, there were no signs of higher brain reflexes. The sobbing never ceased, only increased in intensity and pitch with every word. I then realized the room was never silent while we were there. I was just fixated on the patient. I had tuned the family out. You do not miss an infant’s crying until it is gone. While the family used the lungs that their child no longer had, I prayed and wished the sobbing and crying would come from the bed instead. I subtly sunk into the darkness, resigning to the fact I would hear this “silence” more often than I cared for in my future practice as a pediatrician.
Our attending explained to the family in an unwavering tone: “to truly diagnose brain death, a second brain death exam is required after 12 hours has passed.” Through gritted teeth and teary eyes, a family member said, “No.” Years of training, thousands of practice questions, hundreds of lectures, dozens of exams and endless small group discussions led me to this moment, but those were not enough to prepare me for the internal sensation that overwhelmed me. That one word shook me to my core. I kept my head down and clenched my teeth as hard as I could beneath my mask. I mentally screamed “HOW DARE YOU. One of you caused this. One of you should be in jail for the rest of your life. You took away so much potential. You have utterly tainted my belief in society!” I took a deep breath, reminded myself that it is not my job to investigate or blame the potential abusers, and only compassionately advocate for the medical necessities of the child.
I slowly picked up my head and left the room with the PICU attending in stride. With careful hesitations, I expressed my gratitude to my superior. “Thank you for allowing me to observe. It is an unfortunate outcome but at least now they can be sure.” The PICU attending smiled ever so slightly. They sensed I would be okay after this experience. The optimistic but naïve curiosity they saw in me before entering that room had not withered. I did not break. I did not falter. The secondary trauma had not yet corrupted me. The attending knows a future physician will one day take their place and they will no longer have to be the one to give this terrible news on a regular basis. Will it be me? I don’t know if I will ever be strong enough. But one thought became clear that day. Even though I prefer the silence of the woods, I will forever replay that family’s sobs and that child’s silence in my head. Until I no longer have a voice, I will advocate for every child I come across, until one of them takes my place and I retire to the silence of the woods.
Image Credit: “Think Outside Photo Contest – York River” (CC BY 2.0) by vastateparksstaff
Contributing Writer
INOVA Children's Hospital
Dr. Kenneth Lopez is a 1st-year Pediatric Resident at INOVA Children's Hospital in Fairfax who is experienced in multiple fields, including medicine, chemistry, biology, public health, sociology and mathematics. He has trained in multiple industry-standard lab techniques in immunology and microbiology, as well as clinical and epidemiological translational research within multiple disciplines. His diverse experiences, leadership skills and consistent compassionate and curious approach towards tasks, allow him to contribute dynamic ideas to organizations and produce high-quality work within multiple stages of project development and implementation.