There are a few medical phrases built around jargon of ‘if you know, you know’ and one of my least favorites is ‘crash landing’.

If a child needs dialysis because the kidneys are shutting down in an emergency situation, you know and it hasn’t always ended well. The child is puffy, eyelids shut, tears that cant be expelled, swollen tummy, legs, and arms fat with fluid and the worst of all, every time you poke the skin with a jelco waiting for that flash back of blood confirming you are in a vein, serous fluid pushes back instead. It’s a dreadful feeling watching a child bleed fluid and drown internally.

Dehydration and shock scares me but overhydration and cardiac failure scares me even more. I guess because you can’t take it back. Once its in, its in. and then you rely on the kidney to filter and excrete which takes time and somehow the fluid reachers the lung in no time.

I was still training to be a paediatrician at the time and due to my fear of overhydration, I would start every call in the Paediatric ICU with a white board marker, examining and marking off livers and listening to lung bases and feeling pulse volumes. I always told myself that knowing the ‘baseline’ helps me to gauge 2, 4, 6, 19, 24, 32… hours down the line, I don’t know if it was true. The mothers/caregivers always looked at me strangely when marking off the liver but no one has ever objected once I explain I am looking for ‘organ swelling’.

The nephrologist was a beast. In a good way. He was intense, factual, and often the one browsing notes and looking for non-sensical writings to question, of which he would always find. ‘Who examined this patient?’ -Everyone would avoid eye contact. ‘Who did the pre-clerk?’-Everyone would gently shake heads and raise eyebrows. ‘Which registrar wrote these blood results in? -Everyone looked at the next person. My pulse always quickened on a round and I should have excellent vagal tone by now, but I don’t.

The baby was expanding in front of my eyes and Lasix just wasn’t cutting it anymore. The nephrologist probably saw it coming before I did but I was still hopeful. I counted urine drops in the catheter and flushed a few times making sure its patent. The catheter cant be blocked every 5 minutes, I thought. I drew another U&E and waited at the lab. ‘Potassium, urea and creatinine urgently, please’. My feet were sweaty and my kidneys were fine because I needed to pee.

When I saw 754 I called the nephrologist immediately who said ‘crash landing dialysis’ in an emergency situation. he was in the car, on the way. We must dialyze. I went up to explain to the parents and they knew things were going south when they saw how the baby had trebled in size. Ventilation was a nightmare. ARDS was coming hot and fast and the ossilator’s pumping, swishing and noisy sounds carried on. Lasix infusions maxed out, inotropes, watchful waiting. Agony. Dialysis started and I watched the catheter pipe waiting to see a drop of urine. I was so excited when I saw the drop, I almost felt we were winning. Hope.

The nephrologist adjusted multiple solutions and did calculations, trying to explain everything, I couldn’t absorb much. I just wanted to see more urine, as simple and complicated as that. Sats were dropping, the lung flooding worsened and poured out into the pleural space. Bilateral chest drains later, the sats picked up and the baby looked like he was shrinking a tiny bit, or was it just me? I didn’t know.

I attended to others and admitted 2 other patients while popping in every 10 minutes to check the catheter bag. ‘Did we empty any urine’ I asked the nurses, secretly hoping he urinated so much that we were forced to empty the bag. ‘No, I did not empty’. Eish.

When I saw the sister at the entrance of the door, I smiled. She’s probably here to let me know he urinated! I smiled.

Come quickly, RESUS.

I knew it was ‘touch and go’ with that creatinine but we always hope for more go.

I found the Sister doing CPR and I joined. Defib ECG T waves fine, Gas run, K=8. Shifted. ?was the tube blocked by the flooding secretions, lines in working order. A, B, C, D, E, F, G, H, I…Airway, breathing, circulation, disability/glucose, fluid status, gastrointestinal, hemo-dynamics, infection. Chest drains in working order, perfusion still compromised. The nephrologist arrived and saw us doing CPR. He looked at us with a sadness emotiness. We knew at this point, he was simply not going to make it.

After all the resuscitation efforts, I noticed the baby’s swelling again. The absolute horrendous sight of a little body going through so much pain and physical discomfort. The swelling was so pronounced, my handprint on the sternum area remained molded in his chest as I was doing chest compressions. When he died, the surrounding tissue never retracted and my handprint did was still there as the tissue slowly died and the skin changed colour.

After counselling the parents and family, I went back to the baby to check if my handprint was still embedded on his chest. I dont know why it disturbed me so much but it did. So abnormal, unnatural, evidence of effort but also failure to save this boy.

Disturbing but also, comforting to know we did all we could but he still died.