The patient arrived in the pediatric intensive care unit one summer early in my medical training. The weather was still warm, although the unforgiving heat from earlier in the season had mercifully passed. The whole thing had been an accident: The child, a toddler, had been left in the car outside her father’s office, discovered several hours later when the father returned to retrieve a document from the back seat. Luckily, she was still breathing when she was found. But she was also seizing.
At the hospital, electroencephalograph leads were attached to her head and anti-seizure medications injected into her veins. Blood was drawn to monitor her electrolytes and other markers of internal organ damage and fluids were given. Her medical care was relatively clear-cut. It was the rest of the management, the parts that had nothing to do with drugs or drips or lab values, that led to stark divisions within the team. Was this a straightforward case of abuse? Neglect? A tragic but nonetheless innocent mistake?
Was this a straightforward case of abuse? Neglect? A tragic but nonetheless innocent mistake?
“I can’t imagine,” one nurse sighed, though from the forlorn gaze she cast toward the baby’s room made it clear that she was envisioning herself in the father’s place. Others stared in that direction with disdain, unwavering in their certainty that this accident -- if that’s what it was to be called -- could, and should, have been prevented. That this was not something that just happened to people, but was something distinct that people either did or didn’t do.
When a college friend came to visit a few weeks later, he asked whether my experiences in medicine thus far had increased or decreased my faith in humanity. I had no stock answer prepared; when most people inquired about my training, they wanted to know about the hours and the types of diseases that I encountered. His question has lingered in my mind, and even now I can find no clear answer. After only a few years of practicing medicine, I have witnessed and taken part in events that could easily sway me in either direction. What emerges from each, however, and what in its obviousness is rendered no less disconcerting, is the fact that terrible, unfathomable things happen to children and that oftentimes, adults play a major role in causing or preventing these tragedies.
As I attempted to answer his question, I brought up the case of the baby left in the car. Not just that baby, but the countless children locked in vehicles every year. The temperature inside a vehicle rises quickly and sharply, with the majority of this increase taking place within the first 30 minutes. On a hot day, this can result in temperatures well over 110 degrees, and cracking the window has almost no effect.
In 2012, 34 children died in the United States from heatstroke after being left in a car. In 2013, that number rose to 44. But the number of nonfatal injuries -- children left in cars who ultimately survived, although possibly with lasting sequelae, including damage to the brain, liver, or kidneys -- was far greater: between July 2000 and June 2001, the number reported was 9,160.
At the time of this tragedy, my husband and I were expecting our first child. Our impending foray into parenthood made the possibility of leaving one’s child in the car feel suddenly pressing and real; it was a mistake I could see myself making. I felt it viscerally on the morning that I arrived in the intensive care unit and learned this child’s story: a conviction that, regardless of my medical training, I could one day find myself in one of those rooms with my own child as a result of my own negligence
In his research for the Pulitzer Prize-winning feature "Fatal Distraction," Gene Weingarten, a columnist for the Washington Post, identified “a combination of stress, emotion, lack of sleep” -- all features of a physician’s lifestyle -- as well as an alteration in one’s normal routine as factors that contribute to such an accident. Who among us, no matter our line of work, can claim to be immune to any of these?
The closest we can get to ensuring that such an accident never occurs is by acknowledging the very possibility that it could.
My friend disagreed with my reasoning. His initial impulse, like that of so many involved in the tragic case, was that good parents are thoughtful enough, caring and careful enough, to avoid making such an error. That stress and distraction are not enough to cause such a lapse in awareness.
He had planned to travel home the next day. He was flying standby, and with three scheduled flights that day, he felt confident that he would be home by evening. But late in the afternoon he called to say that all three flights had filled, leaving him without a seat. He took the train from the airport back to our neighborhood, and when we picked him up, he was exhausted and frazzled. He had spent the day traipsing between terminals in search of a way home. And to cap it all off, he reported with a sigh, he had lost his credit card. In the midst of his interminable day at the airport, he had treated himself to a nice lunch and had forgotten to retrieve the card after paying the bill. He had remembered only after boarding the train hours later.
“I can’t believe it. I’ve never done that before,” he marveled in defeat as he recounted his mishap. “It’s such a habit to put it back in my wallet after signing the receipt ... I guess I just wasn’t paying attention.”
Forgetting your credit card and forgetting your baby are two very different things. But I see them as related, as two points on the same spectrum of what can happen when you are distracted and tired, when your normal flow of thoughts and actions has been disturbed. Retrieving both of them is so routine that it becomes possible to forget when your mind is occupied with something new or urgent. You don’t even think to double-check; you assume that you have carried out the task because you always have before, so there is no reason to question it.
I have made such mistakes myself, not only in life but also in medicine. I have dosed medications incorrectly, medications that I prescribe on a regular basis. I have forgotten to complete forms that feel so second nature that I could do them in my sleep. And I have found that I am most likely to make these mistakes when I am tired or not fully paying attention. Then I feel too confident and start to lose humility. When I don’t double-check.
“Trust, but verify,” they say in politics but also in medicine. Don’t doubt that your colleague has reported information correctly, but take the time to double-check. I would argue that the same applies to oneself: Have you chosen the right medication -- one that does not, for example, appear on the patient’s list of allergies -- and calculated the dose correctly? Have you completed the entire discharge form -- the one that you click through for so many patients each day that all of the sections begin to blur together? Have you taken your baby out of the car?
The time of year when such tragedies occur is now here. I now have two children and I pray that I never leave either of them unattended, in a car or anywhere else. But I don’t think I can say definitively that neither will ever happen. In fact, I check the back seat every time I leave my car, no matter the reason, even if I know for sure that I don’t have either child with me.
Why? Because I believe the closest we can get to ensuring that such an accident never occurs is by acknowledging the very possibility that it could.