Editorial

Ricky

Copyright © 2010 Society of Hospital Medicine

After another round of epinephrine, I started chest compressionsagain. Warm sweat seeped down my neck and back. In just 10 minutes, the 24‐bed pediatric intensive care unit (PICU) had become much smaller and more confined. Everyone funneled into this one room, this one bed. Beyond it was a blur of color and sound. I forced my strength onto Ricky, my 17‐year‐old patient with muscular dystrophy and end‐stage heart failure. He was admitted 1 week ago with respiratory distress, and he had only gotten worse since then.

Ricky's body, now cool and pale, was a blob of relaxed skin and loose bone beneath me. I straightened my arms, jutted the heel of my left hand over my right and pushed onto his chest. I pushed hard and fast, like I was taught; a dumb robotic motion again and again, trying to keep good position and form. I stared up at the monitor between every few compressions, looking at all the waveforms, anticipating, as if something on the screen was going to pop up suddenly and say EVERYTHING IS GOING TO BE OKAY. But it didn't.

I glanced beyond the bedside. There was a flurry of people bumping each other, asking for things, telling things, giving and receiving things. All of them were moving, but really had no place to go. This was the place. And in the far corner of the room, stood Mom and Dad.

In between the sink and recliner chair filled with clothes and books, they were the only people that stood still. Swollen feet planted in white socks. Their shoulders sagged.

I love you, I love you, Ricky. No, no, no. Mom and Dad kept on saying between sobs. I wondered if he could hear them. I wished he could hear them. Then I wished they would stop saying anything at all. I felt a rib give under my hands.

From the corner of my left eye, I saw Dad holding Mom upright by the wall. She wore red‐rimmed eyes and wet cheeks and took puttering breaths. Dad squeezed tissues in his hand, then into his eyes and nose and then back into his fist. They kept saying the words over and over, like they knew no other. I pushed harder and faster, but he didn't turn any pinker. Damn it. Damn it. There was plenty of noise, but above it all, I heard their voices. When I was told to hold compressions to check for a pulse, I stood still with my hands at my sides. I felt unnecessary. My precious little contribution to the commotion interrupted.

We all looked up at the monitor.

Stop, please stop. That's it, dad said, somewhere in the infinite pause. Mom still mumbled no over and over again. I turned to her and listened. I watched her pursed mouth and I imagined what it was Dad felt as he held her. Her body shook a Morse code into him, telling him it was time to give up. That it was over. That she couldn't take watching me pound away on her son's chest anymore. That it was okay to let Ricky rest. All the words that she couldn't find, or have the coordination to say, Dad translated for her.

He held her with a desperate grip, for a few moments longer. Maybe, the harder he squeezed, the more life he could push out of her, out of himself, and that effervescent pulse would find its way to their son's heart. But maybe all he could sense was her quiet internal whisper. And they told us again, as I remembered, just like all the soft conversations we had before in the back of the room, while Ricky slept, sedated on narcotics.

I put my fingers over his radial artery and closed my eyes.

Don't let Ricky feel pain, she said. It was the day we intubated him, only hours after he had been admitted.

Do what you can do, just don't Dad trailed off. He stared up at the ceiling and sighed. We listened to the gasp and hiss of the ventilator for a few more moments in silence.

We can try what you say, but no pain. We should know when to quitfor Ricky. Okay? Mom said, waiting for the tears as her nose moistened. She stared up at me.

Okay, I said. I nodded and stared back.

Dad squeezed her arm again, wrapped his around hers and massaged her. She had started to shake.

No pulse. I opened my eyes.

I stared at Ricky's face. His eyelids were half open, his lips were blue. No change on the monitor. I motioned to start compressions again.

Okay, Dad said.

Okay, stop! He's had enough. His dry lips and wet face moved and voiced the end. The room froze.

My muscles relaxed and I splayed my fingers wide, my way of showing that I was letting up. I watched myself lean back, unbelieving, and looked at the screen again. The rhythm drifted from pulseless electrical activity to asystole.

Mom and Dad simultaneously shut their eyes as if they saw something that we didn't and couldn't bear to see anymore. They opened them, looked at Ricky and slowly, as everyone stared, moved to the foot of the bed and began to rub his bare feet.

In subtle efficiency, the room was transformed. We turned off the monitors, we pushed out the carts and equipment, we picked up after ourselves, we dimmed the lights, we pulled the curtains and we left Mom and Dad with their son. Slow, deliberate whispers and motion now, it sounded empty without the background of rhythmic mechanical sounds. No dings, bleeps or rings; no pistons, suctions or pumps; only the occasional sound of tissue being ripped out of a box.

We sat with the family an hour later, in the conference room, to sign papers, for autopsy, for death certificates, for funeral preparations. Mom and Dad didn't know how to answer, and they drifted together to consider how they wanted Ricky's body cared for. Burial? Cremation?

I don't know, Mom said as she tried to fold the shredded tissues in her hand. He had a spinal rod placed his back years ago for his scoliosis. A titanium rod in his spine. Would that even burn? she asked.

We stared at each other, confused and unknowing.

We never thought of that, she said. She began to think out loud. If he were cremated, I don't think I'd want his spinal rod as a reminder. She cocked her head back. What a weird keepsake! She laughed, Where would I keep it? Above the fireplace? How odd. She rolled her eyes, and started to cry again.

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