Lindy was a healthy, 18-month-old toddler who was struck by a car after chasing a dog out onto the street. She had no medical problems and a medical history notable only for in vitro fertilization as her means of conception. When paramedics arrived at the scene, she was apneic with evidence of a severe closed-head injury and bleeding from her ear. She was intubated and transported to a level I trauma center. On arrival, she had a blood pressure of 50/30 mm Hg and a Glasgow Coma Scale score of 3. In addition to severe head trauma, abdominal ultrasonography revealed evidence of intraperitoneal hemorrhage. She was taken to the operating room, where a liver laceration was repaired and an intracranial pressure monitor was placed. A head computed tomographic scan revealed diffuse bilateral edema, a skull fracture, and diffuse subarachnoid hemorrhage.
Lindy was jointly treated by pediatricians, neurosurgeons, and trauma surgeons in the intensive care unit (ICU). Overnight her intracranial pressure remained elevated at 50 to 60 mm Hg, despite maximal medical management, including mannitol and inotropic agents to maintain her cerebral perfusion pressure. She required transfusions of packed red blood cells and coagulation factors.
Lindy's parents were informed of her poor neurologic prognosis, and during the night her parents made the decision that they would like to donate her organs if she did not survive. The next day, the neurosurgical and pediatric attending physicians established the diagnosis of brain death. Lindy was maintained on inotropic agents and mechanical ventilation until the following day when, in keeping with the family's wishes, her organs were procured and transplanted into multiple recipients.
Dr W, the director of pediatrics at the trauma service, and Ms B, a social worker assigned to patients and families in the emergency department, were interviewed by a Perspectives editor. They, along with the team of practitioners who cared for Lindy and her family during her 36-hour hospital stay, faced a series of challenges that are explored in the following discussion.
MS B (SOCIAL WORKER): I was coming on to a shift at the hospital and we got paged, and the page was for a 910, which is a pediatric trauma. The charge nurse told me this trauma victim was an 18-month-old girl who had been hit by a car. We think the car was going about 40 miles per hour. She was thrown 20 ft. She had head contusions, and there was some bleeding from her ears. She was being taken care of by her grandfather…while her parents worked. He was in a state of shock, having heart palpitations and couldn't get in the ambulance with her so she was by herself, and I was eager to find the parents. After I had been searching for about 15 minutes the father arrived. I brought him back into a family ...