Destiny Herrera clamps her lips and scowls. No amount of coaxing or comical faces will persuade the 3-year-old to open her mouth, though she’s bleeding heavily from the site where her tonsils were removed at an another hospital just a few days earlier. Dr. Pamela Okada puts down her tongue suppressor for another time, moving briskly to the next patient on a steady night in the Emergency Department at Children’s Medical Center in Dallas.
Minutes later, with Okada engrossed in patient charts, a cry of “Nurse! Nurse!” comes from Destiny’s room. Eyes look up from computer screens in “the pit,” the nerve center of the Children’s ED, and Okada rises and hurries into the girl’s room.
Destiny has vomited so much blood that it fills a plastic pan and has splashed onto the floor. Okada glances at the blood. “Impressive,” she says after stepping out, confident the case is under control. Hospital staff quickly tidy the mess.
Even now Destiny’s jaw remains clenched, but with years of clinical experience Okada can visualize what’s going on inside. The scabs, or eschars, from the tonsillectomy apparently have fallen off, causing heavy bleeding, and the girl is swallowing blood. When her tummy fills, she vomits it up. And Destiny’s ordeal this night is not over, because she is steadily losing oxygen-carrying red blood cells.
Children are not just little adults, Okada explains in the spaces between at the busiest pediatric ED in Texas – with nearly 150,000 patient visits a year. They have their own needs, their own physiology, their own complications – like a kid who refuses to open her mouth, or a 3-year-old girl draped in her mother’s arms who couldn’t begin to put words to the excruciating pain of a sickle cell crisis. Listen to them, she says, however they communicate. Listen to their families, understand their concerns – because moms often do know best. These are the traits that make an outstanding pediatric emergency medicine specialist.
Oh, and train at one of the best pediatric hospitals in the country, one that’s always busy. And get accustomed to the pace – “It’s go-go-go,” Okada says.
Not everyone could stick it, but Dr. Okada seems to be tapping into a secret stash of adrenaline. A wife and mother of five, she works three 9- to 12-hour shifts at Children’s each week, does research and serves on the pediatrics faculty at UT Southwestern Medical School. She has so much energy to vent that she boxes in her spare time, hammering a personal trainer who doesn’t get to hit back, Okada notes with a chuckle.
Her colleagues are like her, literally walking miles in a single shift, oozing intensity one moment – abruptly ordering that a toddler be sent immediately to a critical-care room – then soothing a child with a plush toy the next. “We’re very ADD and we like to multi-task,” she says of emergency physicians. “We want to give 100 percent to families when they come in. This is our mission. This is our goal.”
She leaves out another component: Her effortless rapport with young patients. She puts nearly every kid at ease – even their anxious moms and dads. “I can imagine that I just never grew up,” Okada says. “I just love these little ones. They’re one of the amazing gifts God gives us.”
With Destiny stabilized for the moment, Dr. Okada checks in on Justice Young, a 17-year-old with a pulmonary embolism – a highly unusual condition for a kid. Justice’s dad, who just returned from an Army deployment to Afghanistan, tells Okada that he couldn’t get his son’s medicine right away because he had to wait for his paycheck. He warns the doctor that his son won’t take kindly to giving a blood sample.
When the dad steps out for a moment, Okada makes a joke of it with Justice. “Your dad’s so funny,” she says. “He says we’re gonna have to tie you down.” The blood sample is surrendered without incident. Later, Okada sends Justice to the ICU.
Soon afterward she visits a girl who slammed her finger in the front door, mangling a fingertip. Faith Wright, a willowy 6-year-old, exudes quiet bravery. With her bloodied, broken finger resting in a pool of sterile water, she smiles and responds politely each time Okada asks a question. Nestled in the bed beside her is a floppy white stuffed bunny whose only features are two beady black eyes.
“Is Bunny a girl or boy?” Okada asks, inclining to Faith’s eye level.
“A girl,” Faith says.
“She’s gonna be with you the whole time,” Okada says. She touches her stethoscope to the bunny’s chest, playfully examining her. “She has no mouth!” the doctor exclaims.
Faith giggles, for a moment forgetting the pain. Later, Okada explains, the girl’s predicament is worse than it seems. The fingertip is nearly severed at the joint, held in place only by the pad of the finger – and its essential blood supply. Okada hopes they can save the fingertip, which is obscured beneath a bulging blood clot.
After requesting someone to operate on the finger, Okada fills out electronic paperwork in the pit, manned by residents and fellows who work under Okada’s supervision. The Children’s Emergency Department is surprisingly compact and always bustling with nurses, techs, transport crews, families and siblings of sick kids darting by in pajamas with plunder from the vending machines. There are no windows and no sense of day or night; the ED ticks on, with physicians occasionally grabbing a cookie from a communal pile in a corner of the pit. Checking on patient after patient, Okada never betrays a single trace of tiredness.
She came by her passion for medicine through a tragic loss. When she was 6 and growing up in a Baptist pastor’s family in Southern California, her 3-year-old sister became severely ill with acute myelogenous leukemia. Pamela watched as an ambulance carried her little sister away; she never saw her alive again. She grew up wanting to become a doctor so she could “cure cancer in little children.” But while she was a resident in pediatrics at Harbor-UCLA Medical Center, doing a stint in hematology-oncology, her thinking shifted. “I bonded with the families and had a hard time separating my feelings,” Okada recalls. “Every time a patient died, part of me died too.” She went on to do a fellowship in pediatric emergency medicine at Children’s and found a specialty that fit her personality and lifestyle – by now she had two little ones of her own.
“My pager never goes off when I leave the ED,” she says. When she’s done with a shift, she goes home and takes care of her children. “I can have a balanced life.”
With Faith scheduled for surgery later in the night, Okada examines an 11-year-old boy who fractured his left shinbone. Javier Tamayo jumped off a playground swing and landed hard; now his swollen leg is propped on a stack of blankets.
Soon he is ushered into an X-ray room, where Okada puts the boy to sleep with ketamine, an anesthetic used in pediatrics. Ketamine “separates consciousness from unconsciousness,” Okada explains. Javier will be able to breathe on his own, but he won’t remember any pain. Diana Halback, a pediatric nurse practitioner in orthopedics, takes it from there, wrestling the boy’s bone back into place, checking its alignment step by step with a C-arm imaging machine. When the bone is set to her satisfaction, a cast is swiftly applied.
Okada is back in the pit logging notes when a nurse walks up and thrusts a hand-held hemoglobin scanner in her face. Okada locks in on the number: 4.9, an awful reading. Her face tenses; she jumps up and strides into Destiny’s room.
The little girl, so grumpy earlier in the night, has wilted into a listless state, her face a sickly yellow. Okada shoos any excess bodies out of the room – where the girl’s mother looks on silently, with worried dark eyes – and orders Destiny into a critical-care room.
Destiny has vomited so much blood that her hemoglobin, or red blood cell count, has dropped to a level low enough that she could go into cardiac arrest. Within moments the girl, still in pink pajamas, is whisked to a room with access to life-support systems. While nurses take their battle stations, Okada gets on the phone to find an otolaryngologist, or ENT, who will re-cauterize the wounds from Destiny’s tonsillectomy. With Destiny positioned for the best possible care – later in the night, an ENT operates on the girl, who is able to go home the next day – it is time to get Faith ready for surgery.
Faith’s mom and dad sit stoically at their daughter’s bedside, while Halback sets up to stitch the girl’s finger together. Dr. Okada speaks soothingly to Faith, who for the first time has grown tense, showing a bit of fear. The smile is gone.
Okada picks up the stuffed bunny and tucks it near Faith’s head. She finds an oxygen mask that fits the girl and puts her to sleep. Dad caresses his daughter’s forehead one more time, then quietly steps out of the room with Mom. Faith’s tiny orange loafers remain under a chair.
The minute the girl is unconscious, Halback picks up an instrument and begins pulling chunks of clotted blood from the finger. The extent of the damage is visible now: Faith’s fingernail is jutting like a hinge; the bone is broken.
At one point Faith wiggles her toes and lets out a small cry.
“Go back to sleep, Sweetie,” a nurse says.
Halback sews the fingertip together, confident she’ll recover fully, then encases her arm in a bright blue cast.
Minutes later in the ED corridor, Okada slumps down on a vacant stool for a few seconds. Her shift is coming to a close. For the first time the intensity fades, just a little.
“Oh boy,” she says. “It is crazy.”
