He burst into my emergency room and hurried toward me: a tall, square-shouldered man with his young son squeezed tightly to his chest. “This way,” I said. “You’re OK, pal; you’re OK.” The child looked about 6 and appeared unhurt.
“We don’t know what happened,” the father began as he eased his boy onto a stretcher. “He and his friends were playing on the sidewalk. It was getting dark. They said he fell through a metal basement-delivery door in front of a store.”
“Did he hit his head?” I asked. “Any loss of consciousness?”
The father seemed unsure, so I turned to the boy. “Did you slip, buddy? Do you remember what happened?”
“I fell,” he whispered.
“Did you hit your head? Your belly?” His eyes were fixed on his father. He said nothing. The nurses undressed him. His vital signs were excellent: blood pressure a robust 120/86, heart rate a tad high at 106.
“Tell me if anything hurts, OK?” The boy seemed dazed, wondering whether he was hurt, in big trouble, or both. He was thin and bony, his skin almost translucent—there seemed no place for an internal injury to hide. While listening to his lungs, I noted a scrape on the boy’s rib cage, but that was it. He vaguely pointed to his left abdomen, but when I pressed there, no response.
The mother arrived. Wide-eyed but silent, she kissed him on the head. “So nothing hurts, right, pal?” I asked again. Was this a simple case of the wind getting knocked out of him? The boy stared mutely at his parents. He was lying too still.
The scrape was over the lower left rib cage, where the spleen lies. Children’s ribs bend more than adults’ ribs do; they tend to transmit, not absorb, a blow. I needed a look inside. I wheeled an ultrasound machine over and placed the probe over the boy’s left flank. A bright arc floated onto the screen—the diaphragm. I angled lower, and the spleen, gray and oval, emerged into view. Carefully scanning its contour, I saw no pools of black, the signature of leaking blood. All was well. Last landmark: the kidney.
Here, a maelstrom of black and gray filled the screen. What the—? I almost sputtered. Scanning quickly, I hunted for the kidney’s contour. Nothing. On the right flank, though, its counterpart popped right up. “I’m not sure,” I hedged to the mom and dad, “but there may be a problem with the kidney. We need a CAT scan.”
Their breath drew in.
The overhead monitor showed a steady blood pressure, but in bleeding children blood pressure does not drop gradually the way that of adults does. Their vascular systems constrict furiously to keep blood pressure up—until, suddenly, nothing.
A nurse and I hooked the boy to a portable monitor and quickly wheeled him to the emergency room’s CAT scanner. “I know it’s a little scary,” I told him as we laid him on the scanner gurney, “but we’re going to make you better, OK?” He nodded. Still a man of few words.
The scanner hummed. I huddled next to the technician to see the monitor as the first images came up.
“Jesus,” I muttered. The ultrasound had not lied. A huge, dark mass of blood—a hematoma—stretched from diaphragm to pelvis and appeared to represent half the boy’s total blood volume. A fragment of kidney materialized, its ragged edge showing where the organ had split.
“Fractured upper kidney,” the radiologist called. “Huge hematoma. Looks like he’s still bleeding.” A pulse of fear shot through me.
The management of solid-organ trauma has evolved over the past 20 years. The old attitude was, “when in doubt, cut it out.” Since then, trauma studies have shown it is often safe to wait and trust in the body’s clotting ability; clotting can preserve the organ and avoid the complications that might result from an operation. But this kidney looked like a goner, and the bleeding wasn’t stopping. A nephrectomy, the complete removal of the kidney, might be necessary to stop the massive blood loss.
My immediate problem: We had no pediatric surgeon.
The Berger commission—a new York State initiative to cut excess hospital capacity—had recently shut my hospital’s pediatric floor, which meant we no longer performed surgery on children. Any child requiring hospitalization is now stabilized by our pediatricians and transferred uptown to New York Presbyterian Hospital. City ambulances automatically take injured children to trauma centers, but my patient had been carried in by his dad. Had he been in critical condition, our adult trauma surgeons would have pounced. However, the normal blood pressure meant we theoretically had time to transfer him to a pediatric surgeon. But I had never seen an abdominal hematoma that huge. Would the blood pressure hold?