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PEDIATRIC PERSPECTIVE

How one doctor learned to accept parents in the ER

Over the past decade, hospitals have begun allowing a patient's relatives to watch resuscitations and other invasive procedures. In surveys, most families want to be given the choice to watch -- and once permitted, many accept. Yet many doctors like me have been suspicious of the practice, thinking that families can't handle the stress. While this protective impulse is noble, I'm gradually learning it's erroneous.

A couple of years ago, I was on call at a Navajo hospital in New Mexico when my pager went off summoning me to the emergency room. A 4-month-old girl was in cardiac arrest. I ran one block from my home to the hospital, stethoscope clanging around my neck, and entered the trauma bay.

The infant lay motionless while nurses scrambled to get intravenous lines into her arms. One of the hospital clerks stood by the bed. Reflexively, I issued some orders, pulled open the child's mouth with a long metal speculum, and passed a plastic breathing tube into the trachea. By then, the nurses still hadn't been able to insert an IV to give her medicine. So, following protocol, I jammed a nail-like IV directly into the infant's calf bone -- without anesthesia -- and heard a sharp pop as it entered the bone marrow.

We pushed adrenaline-like drugs into the marrow, and I began pumping the child's chest with my hands. Concern spread in the room, and several of us liberally cursed out loud: We were unable to get back any heartbeat. Yellow froth bubbled out of the baby's nose and mouth. We were losing her.

It was then I wondered why a clerk was present; clerks didn't usually attend codes. He didn't look well. Tears poured from his eyes. Horrified, I realized he wasn't there to handle hospital paperwork. The girl was his daughter. I was intensely worried for him: Could he handle what he'd seen?

He was clearly devastated. But he held his dying daughter's hand and saw how hard we tried to bring the girl back. At the funeral, he surprised me by saying he'd appreciated being present for his child's last moments.

If I'd asked him to leave, he'd probably wonder what I might be hiding -- and whether things were done right. In television portrayals of resuscitation, according to the New England Journal of Medicine, more than three-quarters of patients survive. In real life, though, only about one in 20 does -- so families may have unrealistic expectations. Seeing resuscitations may prove to them that everything possible was done.

Today, the conventional wisdom in medicine is that patients and families should decide for themselves what they do and don't want to see. Tremendous strides have been taken in giving choices to patients, which is a good thing. Not so long ago, for example, fathers were banned from delivery rooms. Last year, I was able to hold my wife's hand when she got a spinal injection before her caesarean section.

Allowing observation doesn't mean you should leave family members alone; many need help deciding whether they should stay. The American College of Emergency Physicians says about family presence: ''Like everything in medicine, nothing is absolute."

For example, my team was recently asked to see a newborn baby at a Boston hospital. The baby's heart was beating far too quickly -- almost 250 times per minute. An attending cardiologist and I rushed over and placed a special electrode down the baby's nose and down the esophagus, behind the heart.

We explained the plan to the baby's father, who watched us. With an electronic computer, we rapidly delivered tiny bursts of electricity through the electrode to fix the heartbeat. The painless procedure didn't work. For almost an hour, the father had watched us unsuccessfully try other maneuvers, and looked increasingly stressed. Only one option was left: Use the defibrillator to shock the baby's chest.

Getting shocked isn't pretty. We could have allowed the father to stay. But we felt that watching a newborn get shocked with paddles and jerk convulsively as the heart stopped briefly would be too much for him. We suggested that he leave, and he looked relieved to go. (In some situations, family members also are prodded to leave if their presence worsens the patient's stress, or if their excessive interference distracts the doctor.)

Still, I'm surprised by what parents appreciate seeing. Several months ago, a preschool girl developed acute heart failure after an operation at my hospital. As a team of cardiac surgeons literally opened her chest in the intensive-care unit and performed emergency heart surgery, the parents insisted on watching for hours. (During resuscitations, many hospitals like ours now designate someone to stand with the parents, and explain what's happening.)

No doubt the surgeons found it unusual to have parents watch them perform a heart operation where quarts of blood are unavoidably lost. Thinking this would be intolerable to see, nurses repeatedly asked the parents if they wanted to leave. Absolutely not, they said. Despite the gore, they wanted to be there to see the surgery that saved their daughter's life.

Ultimately, despite the misgivings doctors may feel at allowing relatives to watch medical procedures, it's the family members who must live with the choice, not the doctor. That's why they should make the call. One medical student wrote in the New England Journal of Medicine that witnessing ''the team crawling on top of my mother, stripping her, and pushing her chest [and] the sounds of her ribs breaking" was a sight he wishes he had never seen. But he doesn't regret making his own decision.

Neither do I. Several years ago, my father developed a rare scarring disease of his lungs. One day when I visited him, he suddenly couldn't breathe well. Panicked, I rushed him to the emergency room.

An X-ray showed a collapsed lung, and surgeons were called to put a tube into my father's chest. I asked to stay for the procedure. They let me, but soon after they started, I was called outside to sign some paperwork. Suddenly, I heard my father screaming in pain. I have never forgotten the sound. The local anesthesia didn't work properly. I went to my father's side and began shouting for morphine, forgetting that I wasn't the doctor. I held his hand and said everything would be all right. He kept screaming. It took five more minutes for the pain to stop.

Though still traumatized by these memories, I'm grateful I was there. Though we instinctively recoil from these situations, perhaps an even more primal impulse prevails in the end -- the need to accompany our loved ones in their darkest hours, so that we may offer comfort simply by being there, even when we can't change tragic circumstances.

Dr. Darshak Sanghavi, a clinical fellow at Children's Hospital and Harvard Medical School, can be reached at www.darshaksanghavi.com. 

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