The Yale Journal for Humanities in Medicine
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War and Peace
David Solarz
Elijah O., a 7-year-old African American boy on the liver transplant list with a history of TPN-dependent short-gut syndrome presented to the pediatric service with sepsis. He has four entry points to his body – 2 central lines that enter the superior vena cava, 1 NG tube, and an ileostomy, which drains the stool from his truncated bowel.
Elijah had been in and out of the hospital since he was prematurely born. He managed to keep up with his school work and school-mates. He even participated in organized sports, missing soccer and tee-ball games only for sudden admissions to Children’s Hospital. His single mother did everything she could to make Elijah’s life as normal as possible. She was Elijah’s best care-taker and captain of Elijah’s pediatric treatment team.
Elijah the patient was named for the Hebrew prophet (circa 9th century B.C.E.), who was to be the harbinger of the Messiah that would bring peace and tranquility to the world. According to the written verse, Elijah rode a flaming chariot to Heaven.
Upon admission to Children’s Hospital, Elijah O. spiked a 105 fever and grew yeast, Gram-positive cocci in chains and clusters, and then Enterococcus. His respiratory rate soared to 60 per minute and his heart rate peaked in the 150s. His blood pressure dropped to 78/43 (from 112/76) and his aPTT and PT were prolonged. His fibrinogen was low, and his D dimer and FDP’s were elevated. The team braced for the worse as we infused vancomycin, amphotericin B, and gentamicin IV. The pain in his lower left quadrant, which was tender and 2/10 on admission, had become unbearable to the point that a light touch lifted Elijah off the bed in a fit of screaming agony. He did not (or could not) open his eyes, and he mummy-wrapped his Sponge Bob sleeping bag tightly over his body and head so that we vividly experienced each shaking chill, each audible jaw-chatter, and each “I’m cold! I’m cold!” whimper beneath the blue and yellow sea of blanket; he fell in and out of consciousness.
Later that night, I ran to get a few Cokes and some Sour Patch Kids for the team, who had not eaten since the morning before and were all reaching the outer limits of hypoglycemia. It was 3 a.m. I got onto the elevator and Elijah O’s mother was getting off the elevator. Her sunken, swollen red eyes and tear-lined cheeks captured the entire team’s disposition.
I saw my 3 a.m. shadow, shiny nose, and black bags under my eyes as I stared into the elevator announcements board. My visage flickered at a steady cadence with the dying fluorescent elevator bulb. I thought about Elijah’s flaming chariot to Heaven, peace and tranquility, war and peace, and a nagging hypoglycemia. I thought about a phrase from Sun Tzu’s The Art of War, that “the true object of war is peace.” There was no truce in this war, no treaty to sign with the yeast and bacteria of the hospital, no more fight from a medical standpoint than what we pumped in through an IV bag. There was only the stamina Elijah could summon against a foe he had faced four times in the last year and a half.
The antibiotics slowly infused and circulated through Elijah’s blood a few hundred or so times. The medicine perfused all of his most vital organs, yet his fibrinogen was low, his D-dimer remained elevated, and his fever was still hovering at 104. Who knew whether the fever, chills, generalized pain, and renal failure were manifestations of sepsis or amphotericin B? I slipped away to write a progress note.
The team was run ragged. It wasn’t the lack of sleep or food (which had been bared so many times before), but the emotional fallout of one sick boy despite our best efforts that wore on us. He was still shaking, cold, and in pain.
In medicine, expectations do not always become reality...
I returned before 9am rounds and was shocked to see Elijah sitting up in bed, smiling, and playing with a green Tonka truck. His sleeping bag was rolled back, and his eyes were bright. I checked to make sure that I was in the right room, and then I double checked my pulse to see if I was the one that decompensated last night. The LLQ pain had resolved. He was afebrile with stable vitals. The tangled web of IV infusion lines assembled with haste lay like a bowl of spaghetti on his lap. I checked his heart, pulses, lungs, abdomen, and sent cultures of 2 of his 4 entry points – all clear. My eyes had been swelling since I saw him in bed. I offered him a Winnie the Pooh sticker, and he said the only words I heard from him other than the haunting whimper of “I’m cold! I’m cold!” “I’ll have the one with the big heart.”
I quickly walked to the bathroom and cried – part joy, part relief, part exhaustion. Cheers to the one with the big heart.
Published: February 8, 2004