"Tag-g-g! You're it!" This was not what I was expecting when beckoned into my patient's room. He had been coloring with crayons and waved me into the room as I walked past.
There's an adage in pediatrics that, compared to adults, kids get sick faster. They have a lot of physiologic reserve, so they are fine... they are fine... they are fine... until they are not. Accordingly, if a patient suddenly looks worse on the general pediatric floors, don't ignore it - they may need the ICU and soon. But the corollary is that children often quickly turn the corner toward recovery too.
As kids get sicker and get better they are moved in and out of the intensive care unit. The move to "the unit" is usually pretty quick. We always have a bed or two ready to emergently accept patients and can speedily adapt our nursing distribution to cover the other patients while we stabilize the new kid. Moving to the general floors, however, can be a bit of a waiting game. The stars need to align to have an appropriate room, bed/crib, nurse, and doctor ready at the same time to safely transfer care. And there's less urgency because the child's clinical condition is necessarily stable or improving for them to be leaving the ICU. Worst-case scenario, the child is getting a higher level of care than they need while they wait to transfer.
As I reach to tag my patient back, he squirms away in his hospital bed and stutters, "No tag-g-backs!" I'm a little shocked that he had thought this through so well.
While we grumble about how long it takes to transfer kids out of the unit, sometimes it's nice to have a relatively healthy kid around for a while. After all, everyone in the PICU has trained in general pediatrics first, so we've played games to get our physical exam more painlessly, chatted about Paw Patrol and Frozen ad nauseum, gotten countless high-fives, and waved "bye-bye" leaving each room*. When most of your patients are either heavily sedated or just too sick to have normal kid interactions, you have to take every opportunity to remind yourself what you're working so hard to restore to your patients: the simple joys of being a kid.
I snap my fingers and facetiously say, "Drat!" I scan the otherwise empty room for someone else to tag."G-go g-get the n-nurse!" he says excitedly.
That morning, the unit had an honor walk. This is the solemn event when all the available staff in the unit line the hallways to bear witness to an organ donor being escorted by their family to the operating room. It is such a hard decision that no parent expects to have to make. To be an eligible donor, the organs must be in pretty good condition, so these are usually children that were healthy and vibrant a few days ago until some tragic circumstance changed everything.
In this horrible moment, we - and by "we" I mean very experienced social workers - ask these parents to consent to sending the body of their recently deceased child, still in the hospital bed on "life-support," to undergo one last surgery to scavenge the usable tissues and ship them out to other nameless patients in desperate need. We try to remain as neutral as possible while presenting the choice, so as not to bias them towards doing something they don't believe in or will regret. But everyone involved is hoping beyond hope that they will say yes. It is so tempting to walk these parents to the opposite hallway in the unit were a patient and their family has been waiting for months for a new organ - their only chance for continued survival.
As I run out of the room and towards the nurses' station, the patient's nurse looks up with mild concern. "What's going on? Do you need something?" she asks."I just needed to tell you that..." [I poke her shoulder] "you're it! No tag-backs!"
An honor walk is an emotionally taxing event to participate in. The ICU can usually pause for a moment, but it doesn't stop. Other patients need our help and they can't wait for us to collect ourselves before returning to the job at hand. The ICU is always in motion. There are always new kids coming in and improved ones going out. There are always unstable patients that you need to pass-off to the night team, who will pass them right back to you in the morning, having taken the next steps toward whichever outcome.
But even knowing the emotional toll that participating will take, when you have taken care of a patient that eventually has an honor walk, you kind of want to be there when it happens. You may have been with that family as they arrived, as they were told that their baby wasn't coming back from this, and sometimes (as was the case for me today) you may have been part of the team that did the brain death exam. When those patients head to the OR for the final time, you kinda hope to be stuck holding the hot-potato; you gladly allow yourself to be "it" in the game of Tag.
"What?!" the nurse yells, so that our patient can hear, giggling in his bed. She storms towards the room on faux-outrage, "You got the doctor to tag me?! Well, you're it again! No tag-backs!"
TILIF: The pores of Khon are connections between alveoli (tiny air sacs) in the lungs and appear around the second year of life. A similar structure called the canals of Lambert connect bronchioles (the smallest air tubes of the respiratory tree) to adjacent alveoli. The canals develop around age 6. These two structures allow for the passage of fluid and bacteria, possibly contributing to increased risk of pneumonia, but they also allow for connections between adjacent parts of lungs, which decreases the risk of lung collapse or atelectasis, which is seen more commonly in children than adults.
*Teenagers particularly enjoy when you wave bye-bye
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