Crozet Annals of Medicine: A Halloween Scare

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I hate room 610. Just walking by it triggers PTSD. I hate it when the nurses call me to room 610. Room 610 is the room in the ER where they bring the dying children. We have plenty of other rooms where we treat very sick children but 610 gets the worst of the worst. 

I was on duty in the pediatric ER last week when I looked up from my computer and noticed there were no nurses in sight. No techs either. Uh oh, the only place they could be was around the corner. Around the corner in room 610! 

I knew what to expect as I got up to go look for everyone. It was a tableau I had seen frequently in the last two months. The last two months we have been inundated with children sick with RSV, Respiratory Syncytial Virus. 

A child, 4 years old at most, was the centerpiece of the tableau. She sat bolt upright. Her skin was a mottled purple-gray. She gazed at me with a thousand-yard stare. Her face wore a defeated, exhausted-unto-death expression. She was breathing 80 times per minute or more, shallow breaths that did not provide enough air. She was suffocating. 

Other than her frantic breathing she did not move a muscle, she did not cry or speak even when the nurses stuck her arms searching for an IV. All of the little remaining energy she had was being used simply to breathe, simply to stay alive. Her head did not move but her gaze never left me as I moved about the room. She seemed to know I was the one responsible for saving her. 

I had plenty of help. A dozen or so capable staff hovered at the periphery of the tableau, framing the little one. Nurses, techs, pharmacists, respiratory therapists, X-ray techs, social workers, residents, medical students, all had come to help or just observe. Her overwhelmed mom sat off to the side, frightened, unable to speak or understand English. Silent tears ran down her cheeks. 

We gave the child oxygen and she did not improve. She worsened. We gave her high-flow oxygen and she did not improve. She continued to worsen. I called the Pediatric ICU, but they had no beds and could not help. We gave her breathing treatments for asthma and she worsened. 

Her chest X-ray showed pneumonia. Through an interpreter we learned that she had tested positive for RSV yesterday. This was a double dose of trouble. We added antibiotics to her treatments. 

As bad as she looked when she came in at least she was tracking me with her eyes. Soon, however, I noticed that she began to lose focus. She was getting sleepy. It was not nap time. She was unable to continue to breathe on her own but putting her on a ventilator carried extreme risk for her. Ventilators are not meant to breathe at 80 times per minute. 

She was just old enough to be a potential candidate for a type of ventilatory support called BIPAP and so as a last-ditch effort for this child, we tried that. BIPAP uses a tight-fitting facemask that requires some degree of cooperation from the patient and it was unclear if this exhausted and terrified child would be able to cooperate. 

Once again, I was fortunate to have plenty of capable help. An experienced pediatric nurse recognized the danger of impending death if this did not work and stationed herself to continually whisper in the child’s ear. 

“Wake up, Jasmin.* Take a deep breath for me!” 

She would gently shake Jasmin and repeat her coaching over and over again and gradually Jasmin’s respiratory effort strengthened. Hers eyes focused on me again, but this time I thought I could read a measure of confidence in them. The BIPAP was working. She was marginally getting better and she could feel it. 

I patted mom’s shoulder. 

“Esta bien” I told her, it’s ok. Fresh tears rolled down her smiling face. 

I excused myself from the bedside and went to find an empty space where I could breathe easily myself for the first time in hours. It would not do for the staff to see me unnerved. But I was, a little. 

RSV is a seasonal virus that usually attacks infants and very young children in the late fall and winter. While it can be severe, most cases are not, typically. 

This year is different. The cases came earlier and we are seeing older children like Jasmin and they are far sicker. Nationally, the pediatric ICU’s are full to capacity due to RSV, and that is unusual. I am getting calls from outside hospitals looking for ICU beds for kids, and our PICU is full much of the time. I have to say no to some very sick kids. 

No one knows why this RSV surge is happening, but it is likely that the social distancing and masking of the last three years has prevented cases of RSV in infants and toddlers and now there is a large pool of vulnerable children passing the virus back and forth easily. 

There is currently no vaccine for RSV despite 60 years of research. Multiple pharmaceutical firms have promising RSV vaccines for older adults that await final trial results. Most adults who get RSV have a cold-like illness but complications can be severe in the elderly or immunocompromised people. 

On a related note, I saw my first case of Influenza A this week. It’s coming, and predictions are that it will be an early and severe flu season. Please get your flu shot now! (And Covid booster.) We have seen from Covid-19 how respiratory viruses can overwhelm our hospitals and businesses. A triple threat from RSV, Influenza and Covid could make this winter a grim season, but it doesn’t have to be.  

*Not her real name  

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