Failure To Thrive

“My God,” breathes my partner, Terry Parker. “Who the fuck would do something like this?” He shakes his head, his voice laden with anger. A vein bulges on his forehead and the muscles of his jaw bunch as he talks. The fury on his face belies the gentleness of his hands as he tenderly loops an oxygen cannula over the infant’s ears.

Afraid to trust myself to talk, I attach the lead wires of the cardiac monitor to the adhesive electrodes before I attach them to the baby’s slack, translucent skin. With a child this small and fragile, pressing them on could leave bruises.

With a career of any length in EMS comes a certain measure of psychological protection against the brutality man can visit on his brother. All the calls blend together in a vague morass of mangled meat, broken glass and cries of pain in the back of your mind, and they don’t even spoil your dinner. You do what you can, and you move on.

Except when it’s a child.

Rule #1 in the male ethos is Do Not Harm The Weak. Even among the world of criminals, those who harm women and children are considered beyond the pale. One especially does not harm one’s own wife or children. Men are supposed to protect the ones they love. One reason I got into EMS was the desire to care for people who could not care for themselves.

It is this knowledge that causes my hands to tremble a little bit as I attach the electrodes. I can put a mask over my features while I go about doing my job. I can even smile, if the situation demands it. It’s quite convincing.

My hands are my tell. Those who know me well, and there are precious few, know to watch my hands. It’s in them that you can see the rage that I can’t mask. When I’m trying to master a bestial urge to do harm to someone, it bleeds over into my hands. They know what to do even when my brain is pleading restraint.

“He’s going to Oneida North, to the PICU,” Jay Taunton, the ER charge nurse, tells me quietly. “Dr. Bellard is accepting.”

Donna Bellard will be all over this. She’ll see this for what it is, and there will be hell to pay.

“Where are the parents?” I ask mildly. At the word ‘parents’, Terry snorts in disgust.

“Grandmother is outside in the waiting room. The mother should be back any minute.”

“They don’t fucking ride in my ambulance,” Terry states vehemently, and a little too loudly.

“You said we could ride with him,” says a voice over his shoulder as a young woman walks into the room. She looks accusingly at Jay.

She looks normal enough, just trashy. People like her should have to wear a brand, so we can recognize the monsters among us.

“You take your own car. And don’t follow us too closely. As a matter of fact, don’t follow us at all. Just ask for directions to the PICU when you get there,” Terry orders, making no effort to conceal the hostility in his voice. I throw a warning glance his way.

“I’m not leaving my baby,” she tells me flatly, looking to Jay for support.

How motherly, for a woman who has nearly starved her own baby to death. And I’m with Terry on this. I don’t want you in my rig.

Jay looks from me to her, and makes his decision. “The paramedics have the final say. You take your own car to Oneida North.” He keeps his voice even, but his face communicates clearly whose side he’s on. He can’t resist adding, “It’ll be a while before you can see him anyway. The people with Child Protective Services will want to have a word with you.”

She glares at him defiantly, and he stares back, arms folded across his chest. She looks away first. “I brought his car seat,” she tells me.

“Keep it,” I tell her shortly. “We won’t need it. We have a papoose harness we attach to the stretcher.”

“He likes his mobile,” she protests, indicating the brightly colored Fisher Price doohickey hanging from the handle of the infant seat.

Bullshit. Right now he barely has the strength to breathe.

“It’ll just get in the way, and I can’t resuscitate him sitting in an infant carrier.”

She just looks at me uncomprehendingly.

“He’ll probably die on the way to the PICU,” I explain bluntly, hoping to wound her in some way with the words. “I’ll need to have him on a firm, flat surface to do CPR.”

Her eyes tear up, and she flees the room, but not before first kissing the baby on the forehead and whispering softly to him,” You hang in there, little man. Mommy loves you.”

I stifle the urge to vomit.

After she’s gone, Jay finishes giving us report. “She claims he’s been eating regularly and drinks formula without any problems. He got sick over the weekend and has had vomiting and diarrhea since Friday. We’re calling it failure to thrive.”

‘Failure to thrive’? Like it’s this baby’s fault he’s a living skeleton? They were starving this kid to death, pure and simple.

“He didn’t get like this in a fucking weekend, Jay,” I tell him. “He didn’t get like this in a month. How much does he weigh?”

“Just over nine pounds. He weighed almost seven pounds at birth, and should’ve doubled that by now. Fourteen pounds or thereabouts, and he’s almost five pounds below the curve.”

“You called CPS for real?” I ask.

“Yep,” he confirms, “for all the good it will do. She has three other kids, all of which have been reported for neglect in the past. We know her well here. CPS places them with their grandmother who, unless I’m mistaken, is now living in her daughter’s spare bedroom.”

“So the kids are still there in the house. What a fucking joke.”

“I know, I know,” Jay sighs. “This time we reported the grandmother, too. She was stupid enough to list herself as an alternate contact, with the same physical address. Maybe this time we can get the kids removed and into foster care.”

“What was his blood sugar?” I want to know.

“Seventy,” Jay answers tersely. “I figured it would be lower.”

“Why no IV?” I ask as Terry straps the papoose harness to the stretcher and opens the Velcro flaps. It’s designed to fit over the mattress of the neonatal isolette in our NICU transport rig, to keep the tiny infants secured should the ambulance come to a sudden stop.

“We wanted him out of here in a hurry, and the acceptance came faster than we anticipated. I can help you get one before you roll with him,” he offers.

“I’ll get an IO in the truck,” I decide, looking down at the infant as I fasten him gently in the harness. His skin is translucent, every vein visible. Problem is, they’re also tiny. His skin hangs loose in folds on his arms and legs, and every rib stands out. His head looks abnormally large. His respirations are labored, but I notice no wheezing or nasal flaring, no stridor or grunting. He just looks as if he is too weak to breathe effectively, which is probably true. He looks like one of those little toy gnomes with the wild hair, except that this baby is nearly bald.

Babies are supposed to be r
oly-poly and chubby at his age. He should be babbling and cooing, not staring around wildly, with his head lolling around like a bobble head doll. KatyBeth looked healthier than this when she was born.

“That’s what I told the Doc,” Jay tells me. “We requested you specifically. Your dispatcher gave us some hassle about it.”

I’m too busy and too worried to register it as a compliment. Normally, Huge Corporate Behemoth EMS would have sat on this transfer for an hour, unwilling to take a 911 truck out of the rotation rather than page out a transport team.

We got the call on my personal cell phone rather than the company pagers. My supervisor had asked our location, and I had told him what he already knew; we had just cleared from our lunch break and were only five minutes from St. Matthew’s. He’d gone on to ask if I’d be willing to take the call, even though I wasn’t next up in the transfer rotation. Normally when our supervisors ask you to volunteer, it effectively means ‘do it or you’re on my shit list for the rest of the shift.’ Bubba was different. If he asked a favor, it was just that; a personal request for a favor, one he’d repay one day. So I took the call.

I’m wishing I hadn’t now, though. Terry rolls the stretcher into the truck and I clamber in behind it, scrambling for an IV setup before he even gets the stretcher latched into place. I motion for him to climb in behind me as I search through the cabinets. “Get me a BVM and lay out my airway kit, would you?”

Terry efficiently does as he is asked, ducks out the side door, and in thirty seconds we are pulling out of the ambulance bay. Before we even leave the hospital complex, I have an intraosseous needle in the kid’s left tibia. He barely flinches when the needle pierces the bone. He has not uttered a whimper or a cry since I first laid eyes on him less than twenty minutes ago, just looked around with that wide-eyed, desperate stare.

The intraosseous needle protrudes from his leg far more than it should, even with the needle shroud screwed down as far as it can go. It just stands up there, precariously in place, much like a nail that hasn’t been driven all the way in. There’s no fat there to help hold it in place, and I’m afraid to let it go to reach for anything.

Cursing under my breath, I hold the needle with my left hand and scramble through the cabinets with my right, searching for gauze to use for padding. I find a box of individually wrapped 4×4 gauze squares, and manage to overturn the box and shower the stretcher with the individually wrapped packets. I tear open several of them with my teeth and manage to extract them from their wrapping, and I fold them, wedging them under the flange of the needle shroud. Still holding the needle with my left hand, I open a roll of gauze and quickly wrap yet more gauze over the flange, making several wraps all the way around his leg. Only then can I let go of the needle to tape the gauze in place.

Law #7 of EMS: A good tape job will fix almost anything. That is, if the tape doesn’t rip his fragile skin off when you finally get around to removing it.

I draw up a fluid bolus through the three-way stopcock and push it in. It takes only a few seconds. Perversely, when you’re administering fluid to a child who weighs half what he should, administering IV fluids only takes half as long. I am not in the mood to be thankful for small favors.

I quickly scramble back to the captain’s chair at the head of the stretcher, and watch the baby’s breathing closely. My intubation equipment is laid out on the head of the stretcher, right above his head. Terry has laid out the laryngoscope, a couple of tubes, KY jelly. I have capnograph tubing to monitor exhaled CO2. A suction catheter. A bag mask resuscitator. Tape. All carefully prepared and standing ready, in the devout hope that we will need none of it. That’s EMS Karma; if you have it ready, you won’t need it. If you really need it, it will be in the bottom of the bag or the very back of the hardest-to-reach cabinet. That assembled laryngoscope is my talisman to ward off Bad Things.

Still labored, and getting irregular. Fifteen minutes through rush hour traffic to Oneida North. God, I hope we make it.

I open the manila envelope with all the paperwork in it, scanning quickly through the baby’s lab results and documentation. The story of an innocent child’s abuse at the hands of his mother is all laid out right there, captured in numbers and dry medical prose. None of it would mean anything to a jury. Precious little of it means anything to me, to be honest. I’m a pretty fair hand at interpreting lab results, but I can’t make much sense of this picture. There are too many values accompanied by a LOW or HIGH modifier. The only thing I’m able to glean is the baby’s name, Benjamin.

It’s a mixed blessing. He’ll be harder to forget with a name to go with his face.

Train wreck. Too many things wrong at once. So what now?

I pick up the BVM and gently squeeze a bagful of air into his lungs. My left hand dwarfs his face as I hold the mask in place.

You manage the ABCs, just like you’ve always done. Get him to the PICU alive. Piece of cake, AD. Just breathe.

I gently squeeze the bag, trying to time the ventilation to coincide with his own sporadic attempts at breathing. I settle into a rhythm, and Benjamin’s oxygen saturation and heart rate mercifully remain steady.

The hum of tires over ridged pavement makes me look up, and I peer out the back window to see we’ve turned onto the interstate, and Terry is driving down the breakdown lane, passing the stalled rush hour traffic. Every thirty feet or so, there is a segment of experimental surface, designed to rapidly drain rainwater from the roadway. Our tires passing across it beats a steady tattoo of hums. It’s a pretty decent rhythm to ventilate by. After sixty seconds or so, he seems to perk up a bit and breathe a little better. I take the opportunity to check circulation while he’s making a decent respiratory effort on his own.

Five minutes, maybe seven. You’re gonna make it there, Benjamin. Just keep trying.

Benjamin is too tiny for even our infant BP cuffs to fit properly, and I usually don’t pay much attention to blood pressure in babies his age anyway. I feel instead for a brachial pulse, pressing the inner surface of his upper arm, between the biceps and the triceps. My fingers seek for a pulse, obliterating it with too much pressure. He’s just so frail, that even the gentle pressure of my fingers is enough to occlude the artery entirely. I close my eyes and concentrate, wishing I had the hands of a pianist instead of the blunt instruments I was born with. I lighten the pressure of my fingers, and the pulse suddenly appears, thrumming life against my calloused fingertips.

One-seventy, but strong. Or does it just feel that way because there’s no fat in the way? He could use some more fluids, though. His heart rate should have come down after that bolus.

I peel back his diaper to find it dry. There is a dark stain in it, still smelling strongly of concentrated urine. Someone has put a wee bag on him, a tiny little adhesive bag designed to catch urine in infants. There is an opening for the baby’s genitalia and an adhesive border designed to stick to the surrounding skin. This
one is empty. His skin hangs in loose folds, his hipbones prominent under the concealing diaper. Benjamin’s inguinal ligaments, which normally would be buried under baby fat, stand out like ropes under his slack skin, like a bikini photo of some anorexic actress.

Only this baby didn’t choose to starve himself to the point of death. His parents did it to him. Goddamn them.

I draw up another fluid bolus, turning the stopcock and pushing the fluid into his marrow cavity. As thin as he is, I can almost imagine seeing his veins engorge as the saline reaches his circulatory system. Instead, my reward is seeing his heart rate slow over the next three minutes, finally settling at one-fifty or so, and steady.

Doing good, kid. Keep fighting. We’re almost there.

As I move back up to the captain’s chair, I peek through the window between the module and the cab. I can see Oneida North in the distance, the hospital tower looming over the surrounding forestland. We’re close, but with the traffic at a standstill, it will still take us another few minutes to travel the last mile and a half. The highway north out of town is clogged with commuters heading to the bedroom communities on the north end of the parish.

We have lights and siren, and Terry is using both, but right now my ambulance doesn’t feel very mobile. The rig slows down drastically as Terry is forced to yield for people turning off the main highway, or the occasional panicky idiot compelled to swerve into the path of an ambulance. The staccato tattoo of tires humming over the experimental pavement slows to a crawl, too slow to ventilate by. I find my own rhythm instead.

Little guy, I’d like to choke the breath right out of your parents, because they don’t deserve to draw breath on this planet, and if I were you I wouldn’t waste my breath on either of them…

The truck lurches as Terry cuts the corner a little close on the turn into the Emergency Department, running the rear wheels over the curb. “Sorry!” he calls back apologetically.

“The lump on my head accepts your apology!” I retort, grinning as I roll up my airway kit and stash it on the bench seat. I toss the BVM onto the head of the stretcher and remove the bag of IV fluids from the clip on the ceiling.

“The fucking parents are already here,” Terry reports darkly as he opens the rear doors. “God only knows how they managed to beat us to the hospital.”

I say nothing as I follow the stretcher out of the rig. For the past fifteen minutes, I’ve at least been able to concentrate on doing my job. Now I have to face his parents again. I don’t trust my ability to control my temper.

In front of our rig, there is a jacked up Ford pickup sitting in the middle of the ER ambulance entrance with its emergency flashers blinking. Benjamin’s mother is leaning against the wall outside the security doors. With her is a thin guy with a ponytail hanging out of the back of his greasy ball cap. His hands are dirty, and a Confederate flag tattoo adorns his right forearm. He’s wearing a tattered tee shit with a big cotton boll on the front, with the caption “It’s a white thing. You used to pick it.”

Benjamin’s loving daddy, no doubt.

“Oooh, my baby! What happened?” sobs his mother accusingly, leaning over the stretcher and smearing big crocodile tears all over his forehead. It’s an Oscar-worthy performance. Terry and I don’t even break stride, forcing them both to walk alongside the stretcher.

“Hey, hold up a minute,” the father says angrily. “We wanna see our boy!”

“He’s unstable,” I tell him tersely as Terry keys our pass code into the security keypad. “I had to help him breathe all the way over here. They’ll wind up putting him on a ventilator in the PICU. We don’t have time to stand in the hallway and visit.”

“On a ventilator?” Trailer Trash Mom wails in anguish, following us into the ER entrance. “What does that mean? He was breathing just fine when I left him!”

“He wore out,” I tell her, and then let my mouth run away with me, “probably because he has no energy reserves. Lack of food will do that to you.”

“Now what the fuck does that mean?” explodes Racist Dad. “What you trying to say?”

I ignore them both and keep walking, cursing my runaway mouth and my temper. My hands are shaking again.

“Hey big boy, I’m fuckin’ talkin’ to you!” spits Racist Dad as he grabs my left arm. I stop walking, jerking Terry to an abrupt halt.

“Let. Go. Now.” I tell him through gritted teeth, with all the menace I can muster. We lock eyes, and I silently will him to get stupid. I’ve got eight inches and 100 pounds on him, and the vision of his skeletal kid still swimming in my brain.

Go on, swing. Take a shot, Redneck Boy. Please give me a reason.

Racist Dad blinks first, and snatches his hand away, masking his cowardice with a contemptuous sneer. “This ain’t over, old son!” he shouts at my back as Terry and I pause at the ER exit, waiting for the doors to swing open. “I’m reportin’ yer ass, and I’ll have yer fuckin’ job!”

The doors swing open, and we almost run headlong into the security guard going the other way. He’s puffing as if he’s been running, and he has his radio in one hand. He looks at Terry in surprise, and his eyes narrow as he looks over my shoulder at the scrawny redneck standing behind me with his chest bowed out.

“Problem, AD?” he asks suspiciously.

“Yeah Tommy, these people are lost,” I answer, jerking my thumb toward Racist Dad and Trailer Park Mom. “They either need an escort out of the hospital, or directions to the PICU waiting room. Whichever.”

“No problem,” he growls, striding purposefully into the ER. Tommy is a retired cop who no longer carries a gun, but he’s still formidable. We were mortal enemies in my teenage years. Many were the times he rousted my friends and I for loitering at the usual teen hangouts. A few of them, punks like Racist Dad, were brave enough to take him on. Usually only once.

In the PICU, Dr. Bellard greets us grimly outside Room Six. Apparently, the anger is still pretty obvious on my face.

“Problems?” she asks, concerned.

“Not so much with him,” I sigh. “I gave him two fluid boluses, and his perfusion’s okay. Had to assist his breathing a little bit, too.”

“Why didn’t you intubate him?” she demands.

“Because I was able to ventilate him just fine with a mask,” I reply defiantly. “You want I should do something invasive to the kid just because I can?”

And just like that, she backs off. “All right, AD,” she says, laying an apologetic hand on my forearm. “You did good. Nobody likes these kinds of calls.”

Donna Bellard and I have a strange relationship. She’s the local expert on child abuse and neglect, and her testimony in court
is devastating. Prosecutors love her. She’s a little strident in her opinions, however, even going so far as to say that spanking your child constitutes abuse. We’ve clashed, often heatedly, yet I’m about the only medic she’ll ask to guest lecture in any of her courses on the subject. Right now, I’m glad Donna Bellard is taking care of this kid.

“Just put his parents in jail when it comes time to testify,” I sigh. “We’ll call it even.”

“You got it,” she promises.

I unwrap Benjamin from the papoose, place him gently on the scale sitting at the bedside, and hand off his IV fluids to a nurse whose name I can never remember. As soon as I roll my stretcher away, a swarm of nurses descends on his tiny frame, assessing, weighing, measuring, drawing blood. Dr. Bellard calmly gives orders, stethoscope pressed to Benjamin’s chest.

You’re in good hands, Bemjamin. Let’s hope it stays that way.

I pull up a chair at the nurse’s station and write my run report, filling the entire narrative section and a full continuation page with all the facts while they’re still fresh in my head. I choose my words carefully, trying to stick to cold, clinical terminology while still painting a clear picture of Benjamin Braelyn Parker’s condition, a picture that even Joe Sixpack can easily understand.

The voice of my paramedic instructor rings in my head as I write. Write it so that it can be understood by twelve people too dumb to know how to get out of jury duty, he had told us repeatedly, and for God’s sakes, spell correctly.

I finish my report, clip the pink carbon copy to Benjamin’s chart, and follow Terry downstairs in silence. Racist Dad and Trailer Park Mom are nowhere in sight, but their redneck mobile is still blocking the ambulance drive, doors locked and engine off.

“Hold up a minute,” I order as Terry starts to back out of the ambulance drive. “I’ll be right back.” I trot back into the ER and stick my head through the doorway of the nurse’s lounge. Tommy the security guard, chatting with a nurse over a cup of coffee, looks up quizzically.

“Hey Tommy,” I grin wickedly, “there’s a big redneck mobile out there parked illegally in the ambulance drive. How about having it towed?”

“And I don’t see anyone around here it might belong to,” he winks conspiratorially. “Yeah, towing it seems like a fine idea.”