A Tale of Two Presentations: A Day in the Life of an Emergency Medicine Pediatrician

Joshua M. Sherman, MD

Pediatric emergency medicine specialists often deal with life-and-death situations. These events are what they train for. They are what they live for. But every once in a while, a day’s events are so impactful and so thought provoking that the irony makes it almost impossible to digest. Let me share one such day with you in an effort to explain what pediatric emergency medicine physicians face more often than we should.

One day in a busy urban pediatric emergency department (PED), two physicians were doing their best to triage, evaluate, and treat some of the sickest and most vulnerable children in the country. One physician was called to the resuscitation room to meet a 3-month-old girl with a chromosomal abnormality that had left her with multiple congenital anomalies and a poor prognosis. The infant had just been discharged from the neonatal intensive care unit (NICU) 3 days prior on supplemental oxygen after having lived there for the first 3 months of her life. The infant presented to the PED in extreme respiratory distress approaching respiratory failure.

As the attending pediatric emergency medicine physician looked at this blue baby in front of him, he knew that this child surely would succumb to her illness if interventions were not started immediately. He quickly looked through the NICU discharge summary and saw an AND order—allow natural death, the equivalent of do not resuscitate.

Trained to save lives and not to allow babies to perish, he turned to the infant’s mother and asked, “Does this order still stand?” At that moment, the tearful mother said she wanted her baby to live, and that all interventions should be attempted. But as the physician and nursing staff prepared for the lifesaving intubation, the mother stood up and yelled, “Stop! I do not want this!” She renewed the AND order. The physician put down the laryngoscope and endotracheal tube that was about to be inserted. The baby and the family then were transferred to the NICU, where the infant was allowed to peacefully pass away in the arms of her family with social workers and clergy members present for support. This mother so badly wanted to be with her baby during the girl’s final moments.

That same day, as the other pediatric emergency medicine physician was starting her shift, she read the triage document for her next patient. She stared at the words, “safe surrender.” A mother had brought her healthy, beautiful baby boy to the PED that day to be given away. She wanted what was best for her baby, but after weeks of internal debate, she felt as if she would be unable to give the child the love and care that he needed and deserved. She wanted more for him in life than she could provide.

This infant was being taken in as the mother was walking out of the hospital.

The irony of these two tales is extraordinary: Two mothers, both battling internally, trying to decide what was best for their babies. Both unable to keep their infants, but for very different reasons.

Joshua M. Sherman, MD, is a pediatric emergency medicine attending physician at Children’s Hospital Los Angeles and an assistant professor of pediatrics at the Keck School of Medicine of the University of Southern California in Los Angeles, California.