Shaken Baby Syndrome
The Christmas season was in full swing, My NHSC colleague, Dan and I decided to thank the volunteer EMTs who staffed our town’s ambulance with a Christmas dinner at a well known and liked restaurant and bar in the next town.
Everyone arrived around 5:30 PM with their significant others. There was lively conversation, joking and laughter, a good time being had by all. Just as we all ordered our dinners, two EMT’s pagers went off and they jumped from their seats and ran out of the building. Within a few minutes, another EMT was paged, and he jumped up and ran out of the building. Dan and I looked at each other with a knowing look that said it was likely we were next to go. Suddenly, a county deputy sheriff came in and asked us to go with him, there was an accident with multiple injuries and we were needed in the ER.
We jumped into the sheriff’s cruiser and headed to the hospital, about 8 miles away, with siren blaring. The sheriff told us there had been a head on collision. The driver of one car, which had crossed the median line, was dead at the scene. He was later found to have been drunk. The other car was carrying a family with several children, parents and grandmother. The grandmother was dead at the scene. The parents and children were being transported to the hospital ER.
On arrival at the ER there were three children: two toddlers and an infant who was being held by the mother. They were ambulatory. The father was being wheeled in on a stretcher and was in obvious distress. The ER only had one room and bed. Dan and I agreed that I would take the father and he would assess the children and mother.
The father was hugely obese, weighing at least 400 pounds. He was stuporous and breathing rapidly. His BP was in the 80’s and his heart rate was rapid. It was obvious that he needed IV fluids immediately, as he likely had internal bleeding. We attempted anticubital access but failed. I called for a cutdown tray and while the nurse was getting that, I attempted a central internal jugular vein line, as his body mass made subclaviam access difficult. As I was in the process of inserting the line, the patient coded. This was within 5 minutes of his arrival in the ER. An ET tube was placed. CPR was performed while IV access was being attempted. There was no bone marrow access equipment at the time and that was not part of the ACLS protocol in 1982. We tried ET tube Epinephrine without success. MAST trousers were attempted but were somewhat ineffective as the patient was so large, they didn’t fit well. We were never able to get IV access and the patient was pronounced dead after about 30 minutes of CPR and line access attempts.
The mother and children had only minor injuries and were discharged with instructions for home observation. They were seen in the clinic the next day for re-assessment. The infant was three months old.
Three months later:
Our office got a call from Child Protection Services that three children were being brought to our clinic for physical exam assessments for child abuse. The children were being removed from their home. The children in question were the three children from the accident at Christmas time. The mother had hooked up with another man and there was suspicion that the boyfriend was physically abusing the children. My exam of the children revealed only minor bruises that I couldn’t definitively say were due to child abuse. The children were removed from the home anyway, but were returned to the home after 4 weeks.
Six months later:
One of my OB mothers had been coming in for pre-natal checks weekly since she was 32 weeks gestation. At 40 weeks, it didn’t appear that she was going to go into labor any time soon. I sent her up to Duluth to our back-up multispecialty group for non-stress testing on weeks 40, 41, 42 and 44. We didn’t perform C-sections since neither Dan nor I were trained to do that and there were no OB/GYN’s anywhere close to our town. I questioned why, at 44 weeks, they wouldn’t induce her. They said her “signs” were fine and I should send her back in week 45.
Two days after the 44 week non-stress test, the patient arrived at our hospital in active labor. We put her in the birthing room. Her and her baby’s vital signs were normal and her labor was progressing, but slowly. When she was 9 cm dilated, I ruptured her membranes, a common technique for speeding up the birthing process. The nurse and I were horrified to see that the amniotic fluid looked like thick pea soup. This is a medical emergency as the fluid was significantly meconium (fetal “poop”) stained due to fetal distress , and the baby was at high risk of aspirating the meconium stained fluid which results in a severe respiratory distress syndrome. I ordered the mother to be moved to the delivery room immediately.
I no sooner had that order been voiced when a nurse ran into the room and frantically said there was a 9 month old in the ER unconscious from a head injury. I had to triage the situation immediately. I delegated the woman in labor to the nurse, who, in her 15 year career, had delivered a few babies and observed many, and I ran down the hall to the ER.
What I found in the ER was the 9 month old child of the mother from the car crash and whose children had been removed from the home by Child Protection Services. The child was unconscious and had a dilated left pupil (commonly known as a blown pupil) indicative of enough intracranial pressure on the brain to move the brain inward and press on and put traction on the brain stem. This is a medical emergency requiring neurosurgery intervention. I got an IV in the child and pushed an appropriate dose of mannitol ( a drug that removes swelling from the brain) while ordering the ambulance.
The story from the mother was, the child was in a walker and accidentally fell down the flight of stairs in her home that went down to the basement. She swore there was no child abuse.
The ambulance crew arrived within 5 minutes. I picked up the child and ran through the ER doors and up into the ambulance. Just before the doors of the ambulance closed, the nurse to whom I had delegated the mother in labor, ran up to the back of the ambulance and shouted that the baby had been born, she had used the DeLee suction to clear the meconium stained amniotic fluid from the baby’s mouth and throat, and the baby was doing fine and had no signs of respiratory distress. We closed the ambulance door and sped away.
In those days, the ambulances had no significant medical equipment, just bandage material and an esophageal obturator airway. I placed the baby on her back, hung the IV and basically stared at her and took her vital signs and neurological status for the entire 80 mile trip while the ambulance screamed along at 90 miles an hour. We arrived at the Duluth hospital where we were met at the ambulance bay doors by a team of ER clinicians. After a rapid assessment in the ER, they whisked the baby up to the OR.
We got back to the ambulance and drove back to our town. Later that day, I got a call from the Pediatric resident who told me that the child had died. When they opened her cranium, she was bleeding from both sides of the brain from multiple small arteries that had been sheared, indicative of shaken baby syndrome. They had to transfuse the child with several units of blood but were unable to stop the bleeding and the child expired.
One month later:
I called the District Attorney’s office to find out if they were planning on filing charges against the mother or her boyfriend. The ADA said they couldn’t prosecute because the Medical Examiner determined that the likelihood that the injuries were caused by shaken baby syndrome was only 98% and the DA wouldn’t prosecute unless the ME said it was 100%. I was furious! Ninety-eight percent seemed high enough to me to prosecute! The ADA said there was nothing that could be done to go forward with an arrest and prosecution.
I continued to be this family’s Primary Care Physician. I had to put my feelings about the dead child aside and provide them with the care they needed. It wasn’t easy.