Indexing Title: DCHUA’s Medical Anecdotal Report [04-4]

 MAR Title: Wingless Angels and Impotent Gods

 Date of Medical Observation: February 2004

 Narration:

 A four year-old female was rushed into the emergency room after falling three floors off an escalator at a nearby shopping mall.  Her parents had been watching a public concert at the mall grounds and had transiently lost track of their child’s whereabouts.

 The patient’s face was so badly bruised she could barely open her eyes through swollen lids.  It seems that she had landed on her head and face without immediately breaking her neck.  She was brought in by a mall liaison on a stretcher with acceptable vital signs and still able to communicate the pain she was in.  The parents were indigent, while the mall liaison had his hands tied by management concerning a needed cranial CT scan and immediate neurosurgical consult.

 The patient quickly deteriorated in spite of supportive treatments given.  The anesthesiologist on-duty was finding it difficult to intubate the patient without undue manipulation of the neck, so the most senior surgeon on-duty attempted a bedside tracheostomy.  It was a bloody and fruitless exercise.  The anesthesiologist subsequently successfully put in an endotracheal tube.  Even with breaths of air being pumped into the small body, no improvement was seen or expected.

 Having done a bedside twist-drill trephining before on a patient with intracerebral hemorrhage, I was frustrated being unable to even roughly localize the lesion on the child, which when decompressed, might buy us some time.  The service consultant considered ventriculostomy but abandoned the idea considering the inadequate logistics.

 The mall liaison finally received word from management of their intention to shoulder the expenses for the needed diagnostic and surgical procedures after hours of prodding.  Whatever their reasons, they had chosen to bring the patient to the third nearest, but least equipped hospital.  The golden period had passed when the decision to transfer the child to their private hospital was given.  By that time, she was too unstable for transport and soon after passed away.

Insights (Discovery, Stimulus, REINFORCEMENT):

 Children can pass through between the bars of the railings in shopping malls.  An on-site inspection showed me where this could happen.

The mall management saved lots of money with the decision not to bring the patient to their usual hospital and with the delay to remedy the situation.  They also saved face by deciding on the latter.

 Not to be distracted or leave children unattended near potentially dangerous places.

Not to initiate procedures when not properly equipped for the task.

 The golden period of four hours for severe head injury uncannily outlined the course of the patient’s deterioration.

Emergency tracheostomy without proper equipment might be better done with a midline skin incision.

Initiating emergency procedures are fruitless if not properly equipped for the task.

We are oftentimes powerless to do what we know is needed by our patients.