Medicine is in many ways a black art. It is not a science; it is an art guided by science. The guidance the science offers varies considerably from, for example, bone surgery to psychiatry, but the uncertainty is always there, even in the high-tech surroundings of the PICU. Our complicated machinery can mask the fact we occasionally are unsure about what we are doing and why. Sometimes we have almost no idea what is going on with our patients, a circumstance some doctors have trouble admitting both to themselves and to patients’ families. It is a difficult thing, at least the first few times you do it, to talk to a family when much of what you say describes your ignorance. With practice, though, it gets easier, especially when you know — really, truly know — that you can always do something to make a sick child more comfortable.

 If you want to read more about an in-the-trenches account of how physicians deal with uncertainties, I suggest Atul Gawande’s book Complications (Picador, 2002).

This week’s New England Journal of Medicine carried an excellent editorial by Dr. Robert Truog, a highly-respected medical ethicist at Harvard. It is about futility of care. Most experienced pediatric intensivists, myself included, have encountered situations in which we, the doctors, believe continuing to support a child is unethical because it is not saving the life but prolonging the dying, whereas the child’s parents believe the opposite—that it is unethical to withdraw life support because all life is sacred, no matter the circumstances. Sometimes these situations arise because poor communication causes families to distrust the doctors. But sometimes both sides understand each other clearly, but still disagree profoundly about the proper thing to do. What happens then?

Doctors often make the argument that we should not prolong suffering. Establishing if a patient is actually in pain can be difficult, and anyway we virtually always have the means to relieve pain in these situations. More telling to me is the argument that families cannot compel physicians to act unethically, and most of us regard futile care as unethical. Yet even then the physician can simply withdraw from the case, although from experience I can tell you it is difficult to find another physician to take on cases like this, and abandoning our patient without finding them another physician is clearly unethical (and illegal).

What to do? I have been involved in several cases like the one Dr. Truog describes. Thankfully, in all but one the family and the doctors were ultimately able to reach an understanding both sides accepted. In the one case in which we could not agree, nature ultimately decided things for us, as she often does.

Stories like these remind me that the pediatric intensive care unit is a place where, if we pay attention, we can learn a great deal both about life and about ourselves.

We have another child in the PICU who is there because of an overdose of medicine, in this case his grandmother’s antidepressant medication. I frequently see this scenario happen: parents are careful to keep all medicines locked away from curious toddlers, but then the child visits grandparents who, not having small children regularly around the house, are not so diligent. Many older persons take one or more of a wide variety of powerful medications that can cause serious or even lethal poisoning in small children. Child-proof caps are sometimes difficult for the elderly to open, so they may not use them. I deal with the results of what this can lead to at least several times each year. A parent whose small child spends significant time at another house, especially if someone living there takes medicines, should make sure those medicines are stored safely. Toddlers are amazingly quick at getting into trouble.

The best and fastest way to get advice about poisonings in children is to call your regional Poison Control Center. To make this easy to do, the telephone number is the same across the nation: 1-800-222-1222.