Early in the morning, a couple brought in their three-week-old baby girl. She was not breathing or moving. We started CPR, placed IVs and put a tube into her windpipe to breath for her. This is a big challenge in such a little person but all went smoothly. We then gave her medicines to get her heart beating again. It seemed like she was stabilizing when she just crumped and died, in spite of all we could do to save her.
Having little kids die is always hard. The pediatric intern was in tears and everyone was upset. The family seemed in shock. I did the best I could to help everyone deal with their emotions but I only had so much time as I had to turn back to my busy emergency department and get on to the needs of the other patients. The family was given as much privacy and peace as was possible to allow them to begin to grieve.
When someone dies, the charge nurse calls and talks to the coroner who decides what to do with the body. The body is released when there are no worries about why the patient died, no need for an autopsy and the patient’s doctor will sign the death certificate. Alternatively, the coroner can take custody of the body until the cause of death has been determined, usually through an autopsy.
In this case, the coroner decided the baby probably died of naturally causes and the body could be released. I spent quite a bit of time on the phone telling him I wasn’t comfortable with that decision. I told him we didn’t know why the kid died and they should do an autopsy. I specifically mentioned we had no way of knowing the kid had not been abused.
He wouldn’t change his mind and released the body. The parents refused permission for an autopsy. I was frustrated but felt I had done all I could do.
A few days later in the paper, there appeared an article stating that they arrested the baby’s father for killing her. I guess the radiologists noticed old rib fractures on the chest x-ray. That led to an autopsy that showed a skull fracture as well. There was no evidence of trauma on the outside of the body that would have given us a clue. That is not unusual for babies with trauma.
This case shows many of the challenges we face as emergency physicians. The medical part of the case was challenging. It is hard to provide critical care to such a little person. If the medical care is difficult, the social elements were even more so. Many of these challenges are out of my control, which leads to frustrations. In this case, had there been no visible rib fractures on the x-ray, no justice would have been done. This realization is very painful to me and makes the emotional part of my job even more challenging.
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