William Lynes, MD
Fall 2008 - Volume 12 Number 4
The joyful holiday season was at its peak as the city busily celebrated a peaceful Christmas. The Emergency Department (ED) buzzed with the usual trauma. The crash rooms were full and blood splashed over linen-covered gurneys. A silly carol played overhead. Chaos then entered the ED with the arrival of a major motor vehicle accident involving an African-American family with a dead-on-arrival female, a severely injured male driver, and a gravely hurt five-year-old boy.
I had laid down for a few minutes of rest when I received the page. Not asleep yet, I returned the call to the ED. “This is Dr Cody, I was paged,” I replied in my most professional voice.
In this manner I became aware of the case that would change my life, an impersonal story repeated quickly over the phone system of a busy university hospital. As the intern on the urology service, the Chief Resident had paged to make me aware of the five-year-old boy, status post motor vehicle accident, with a left renal fracture. He indicated that they would emergently explore the boy in operating room two. I knew immediately that I was to make my way to the operating room (OR), write post-op orders, and follow the patient.
The boy was already on his way to the second floor OR, so I went up the back staircase, two steps at a time. I stopped in the locker room, changed scrub suits, rolled deodorant over my day’s sweat, and entered room two.
For just a brief moment I saw the boy in the hallway outside of the OR as he was wheeled in. He was a beautiful child lying quietly in a crib-type bed with an IV in his left arm.
He wore a yellow gown over a pair of blue-striped pajama bottoms with stretchy shoe covers over his little bare feet. The boy had big brown intelligent eyes and, what was most unsettling given his predicament, a peace and strength that was apparent from the moment I met him. I had a chance to tell the boy that I was Dr Cody as he was rolled into the OR.
He surprised me when he looked up at me, smiled, and said. “My name is Cody too!”
I touched his hand through the rails of his crib. Cody quickly grabbed my hand. I said, “Don’t be afraid, Cody. I’ll be with you.” He stared up at me and nodded his head affirmatively.
As they induced anesthesia I turned and reviewed the case’s x-rays. A kidney, ureter, and bladder (KUB) film showed a ground glass appearance to the left side of the abdomen and a fractured left 12th rib. A quick ED computed tomography (CT) scan showed a comminuted fracture of that kidney and a surrounding renal hematoma from the expected bleeding.
The kidney lives in the back of the abdomen tucked over the 12th rib, a rib that is short and protected. Only violent trauma causes that rib to fracture, violent trauma that nearly always severely fractures the kidney as well. Surrounding the kidney is a large perirenal fat pad encased in the tough layer of gerota’s fascia. When the kidney is injured bleeding occurs, the hemorrhage is contained and tamponaded by this fascia. During surgery this fascia must be opened to expose and examine the kidney, a move that releases the tamponade and can result in massive bleeding. The surgical goal in renal trauma is to not release the hematoma-filled area around the kidney before the vascular supply to the kidney can be identified and controlled. This is generally obtained by dissecting up the vena cava allowing the surgeon to identify the left renal vein and artery, and to place vascular vessel loops around them. This step will then allow quick clamping of these vessels if bleeding begins to get out of control.
Cody was explored through a midline abdominal incision beginning at the pubic bone and ending at the sternum. There was a left retroperitoneal hematoma surrounding the kidney; the spleen, liver, and other important organs free of injury. In the manner described, the left renal vessels were identified. With the blood flow controlled, the left kidney was examined. A severe comminuted fracture was confirmed and left nephrectomy was performed.
The next time I saw Cody was on rounds the following morning—Christmas day. He was sitting up in his crib bed with an IV running. He looked at us with some reservations but smiled a big open-mouthed smile when he saw me.
“Hi Cody,” he said.
The Chief Resident, other residents, and students turned to me; each laughing quietly. I was surprised that Cody would remember me from our brief contact in the hallway outside of the OR the night before.
“Hi Cody,” I said moving to his bed and lowering the crib-rail. I guided him to lie down on his back. “I am going to take down your dressing now. The tape will pull just a little.”
“I really like juice, Cody! Popsicles too,” he said with a big smile.
I was tired, having been on call all night, but something about Cody revived me. He was hurting and all alone; he had a quiet strength and the simplicity of a child that I had all but forgotten until that day.
As the entourage exited the pediatric unit, the discussion centered on what we were going to do with Cody. His mother had died instantly at the scene; his father was in a coma secondary to severe head trauma and on the neurosurgery service. I had checked into the man’s case; he was not expected to survive. In addition, Cody seemed to have no other surviving family.
I could not keep the boy out of my mind that day. I was busy as always, changing dressings, replacing an arterial line, seeing patients in the urology clinic, and completing all of the scut work from morning rounds. I wondered about him all day as I completed my job. I figured the boy was not aware of his mother’s death. Someone would have to tell him about this tragedy. I paged the Chief Resident asking whether I should break the news to him.
“You seem to have a good rapport with the boy,” the Chief Resident said to me. “Go ahead and tell him, if you feel you can. His Dad is not doing well I hear, so it would be better to let him know today. In a few days we might have to tell him about another death.”
Finishing afternoon rounds, I returned to Cody’s bedside. He was playing with a stuffed animal when I saw him. He smiled and waved to me as I walked up.
“Hi Cody,” he said to me.
I dropped his crib rail and rubbed the boy on his head; his short afro soft to my touch. He stopped playing with his stuffed animal and looked seriously at me with the slightest hint of a smile. I struggled to find a beginning to our conversation.
“Cody, are you taking those liquids okay?” I wondered.
“Salty,” Cody said repeating a complaint about clear liquids that I have heard so many times before. “But the nurse, the little one,” he said referring to his slight, blond-haired nurse. “The little nurse, she juiced me apples. They’re liscious … here drink some, Cody.” He said holding his cup up for me to see.
“Thank you, Cody,” I said, taking a pretend sip from his cup.
“Cody,” I said trying to gently change the subject. I broke eye contact with him and looked down at my feet. “Do you know what happens when someone dies?”
“Like Momma?” He wondered.
He looked at me seriously with his deep brown eyes. His answer was stunning. How in the world did he know what had happened to his mother? I stood looking silently at the little boy, wondering if social services had told him about the death.
“Yes, like your momma. Cody, did Mrs Gable tell you about her? Your momma that is, ah … you know … did she tell you about her death?” I wondered, referring to the social worker who had seen him this morning.
“Momma’s in heaven, Cody! She told me good-bye in the fruck,” the boy said. He was referring to the crew cab truck that he and his family were in that awful night. The boy looked up at me and sat quietly, waiting for my response.
I envisioned the twisted wreckage, the dying woman gasping out a last I love you to her only child. I looked to the boy who sat in his crib. His eyes met mine with an inner strength impossible for a child of five.
“It’s okay,” Cody said evidently seeing my torment with the thought of how he could remain so strong. “Heaven is fun.”
I looked at him with sadness not knowing what to say to him. Soon however, I found myself smiling. “Yes Cody, heaven is fun.”
Cody’s father died the next day. We found out on afternoon rounds, seeing our urology patients first and then making our way to the neuro-intensive care unit. My first thought was that the boy was an orphan now. After rounds I went back to the pediatric ward to try to tell him about this horrible event.
He met me with his usual big smile and as always said, “Hi Cody.”
I made the mistake of asking him what he wanted for Christmas, trying to divert the conversation away from my task.
“I just want Daddy back,” was his only request.
I looked at him and I felt a tear start in my left eye, a tear that I forced myself to suppress. I dropped the side rail of his crib and picked the boy up. We sat in a chair, Cody sitting on my lap.
“It’s okay,” he said to me, as usual he was totally aware of my anguish.
“Your father, Cody … he passed away, I am afraid to say.”
The boy looked at me, silent for the moment and then looked down at the stuffed animal. “What’s passed away, Cody?” He said quietly.
“Died, Cody, I mean died,” I said, not knowing what else to say.
As he looked up at me a smile came over his face. “Now Momma won’t be alone,” Cody said with a sincere look of relief on his face. “She would be lonely in heaven all alone, now Daddy is with her,” he explained.
My life is different now. Medicine had been my only goal for so long. Working and studying through college and then medical school; the hours of my residency were long and hard. I was so self-centered thinking only of myself. God put this boy in my life to tell me there was something much more important than medicine. When I adopted Cody, my life became more complicated, but he has taught me so much about character and love. I am writing orders now, sitting at another nursing station in another hospital five years later. Cody comes with me on my weekend rounds. His reward for being quiet during what is usually quite a bit of time is the choice of fast-food lunch that we will eat together that day. The nurses spoil him, bringing him a soda or a left-over breakfast roll. He has taken to collecting rolls of tape from the nurse’s station, tape that he can use to bandage one of his stuffed animal friends at home. I think now, as I look at Cody, Cody his name as it is now, that one day this exceptional boy might well be a fine physician. I realize, as he turns and smiles at me that knowing him has made me a much better one.