When Julie was 10 weeks along in her pregnancy she received the wonderful news that she was pregnant with twins; a girl and a boy. When she was 16 weeks along she received the devastating news that something was wrong with the girl. She had a severe form of holoprosencephally; her brain had not developed normally. Julie was told that her daughter would likely die before birth or in the delivery room. When I was asked to speak with Julie, I explained that her daughter may live as long as a year but this news did not take root. Julie was now 36 weeks along and had been thinking for the past 20 weeks that her daughter could not survive. She had undergone a process of denying the very existence of her daughter. There were express instructions for the ultrasounds to not include the girl. Julie and her husband did not tell friends that Julie was having twins, not even to their own children. Julie found my news very troubling. I had to ask her what she wanted me to do for the girl in the delivery room and she said “Nothing invasive.” I explained that if the baby was crying I had to do something and we agreed on comfort care. What I would soon discover was that while we could all agree that we did not want the baby to suffer, nobody could agree on exactly what “comfort care” was and at times it seemed to be anything but comforting.
Comfort care means proving a comfortable environment so that the baby does not experience pain. It also means providing adequate pain control and nutrition. It does not mean intervening in a way that would extend her life, though.
The little girl did cry at birth and we did suction out her mouth, wrap her in a blanket and give her to her father to hold. Was cleaning out her airway comfort care or was it an intervention that prolonged her life. Should we let her gag and possibly aspirate her own secretions. Many of the routine things we did, we did because they were life sustaining interventions.
I asked the father if they had picked out a name for their daughter and he said Michelle. Michelle was not ready to go yet. Michelle would sleep. She would wake and cry when she was hungry and she settled down when you fed her or held her. She particularly liked to be sung to. She had hydrocephalous which meant that her head seemed to bulge out over her eyebrows. When my wife saw her for the first time she said that she looks like an alien; and she was right.
The obstetrician seemed upset that the baby was alive, it was her after all who assured the mother that the baby could not live. The mother held Michelle once but could not bring herself to hold her again so Michelle stayed out in the nursery while the son stayed in the room with the mother. I felt for the mother; I could not imagine how one would start to form a bond with one infant while knowing that another was dying.
Michelle wanted to eat but could not eat. She had a large facial cleft which meant that her mouth and her nose came together in four flaps. One had to drop the formula into the hole and Michelle would attempt to suck, often choke but eventually consume a few drops. She seemed to be in discomfort so the nurse asked if we could give Tylenol. I could not see how it would hurt. The obstetrician said “You don’t honestly think she can feel pain.” I said “I don’t know what she feels, but I know she settles down when you hold her or sing to her so she must have a sense of her surroundings and she seems to have feelings.”
Placing the drops in her mouth was not working. After thirty minutes she could barely consume a half ounce and she kept choking and coughing. Finally I talked to the parents about options. They were adamant that we perform comfort care only. I explained that Michelle was a few days old and there was no way to predict how long she would live. I told the parents that in my opinion we should put a feeding tube down and even consider surgery to place a gastric tube for feedings if Michelle was still alive at a month. I explained that Michelle would likely die from her breathing becoming irregular and then just stopping. She would eventually just stop because the parts of her brain that control breathing were not well formed. The feeding tube would not extend her life but make her life more comfortable. I could not allow a baby to starve. The parents understood and agreed. They didn’t want their daughter to be hungry either. Whether Michelle could feel hunger or not I could not say but she did fall asleep after her first tube feeding and sleep peacefully for the first time in two days.
Even though Michelle spent most of her time in the nursery she did not go for a lack of affection. Her father held her when he could, the nurses caring for her held her and on occasion I would sit and hold her. Nurses brought her clothes and a few came in on their days off to hold and feed her. This little baby who looked so strange and could not even eat on her own had given all of us something very special. By taking care of her, we seemed to be healing something inside ourselves. What I did not know at that time was that she had a few more gifts to give to me and my family.
Friday, June 4, 2010
Tuesday, March 23, 2010
Going for Donuts
“Can we go to donuts in the morning” Christian asked. About twice a month I take the kids to donuts before school. They ask more often but I try to limit it for nutritional reasons. My wife thinks that I take them too much as it is. So the other night when my son asked if we could go for donuts I said “maybe” and he knew that a maybe was as close to a no as he was going to get. He would ask again in the morning and I would say “Not today, bud, maybe next week.” Anyway, after asking he went to bed and I stayed up watching the television before going to bed myself.
The call from the hospital came at four in the morning. A woman with twins, one healthy and one with holoprosencephaly, had shown up in labor and they were going to perform a c-section. They wanted to know if I’d come in for the delivery. Of course I said. Probably the thing I like most in my work is attending a delivery. There is so much excitement in the room. If all goes well I get to see a life enter the world and be part of one of the most important events in people’s lives. If there is a problem and the baby is sick, well then I know what steps to take to hopefully make things better. For this case there would not be much for me to do, but I knew the nurses wanted me there to help things go smoothly.
In truth, I had forgotten that she was out there in the community. The mother with the twins. I had met with her a little over two months before the delivery. That was when the Obstetrician called me and asked if I would talk to a woman with twins. One of the twins was healthy and the other had holoprosencephaly. Holoprosencephaly is a deformity of the brain in which the cerebral hemispheres fail to divide. Like most conditions in medicine, there is a wide range in presentation with some babies looking perfectly normal and having mild mental problems to those that are severely affected with obvious physical and neurologic abnormalities. These severely effected babies often die shortly after birth. When I met with the mother two months prior she said she understood that her infant was severely affected and would not survive the delivery. I tried to explain to her that there were limits to prenatal diagnosis and that I had seen babies live up to a year even when they had major abnormalities. I explained that no one could predict how long her little girl would live. I then asked how she would like for us to care for her daughter and she stressed that we only provide comfort and not perform any resuscitation.
The delivery was by c-section and the boy was born first. He came out crying, active and pink. There was a quick cheer in the room and the Obstetrician held him over the curtain so the mother and father could see him. She then handed the little boy to a nurse who placed him under a warmer. I checked him out with the nursing staff. We warmed him, dried him and rubbed his back. We suctioned out his mouth, gave him a shot in the leg and one of the nurses made footprints on a thick, paper card. He was doing just fine. Next the Obstetrician pulled out the girl and handed her to a nurse who then laid her under the warmer. The newborn had a small, thin body. Her head, however, was quite large. She had hydrocephalous, so her face was of normal size but her head swelled out above her eyes. Babies with severe holoprosencephaly also have midline physical defects and this little girl had closely spaced eyes and a large cleft so that her mouth and nose came together to a central whole. Flaps would open and close around this central hole when she cried. Her cry was hoarse but she was quite active. “What should we do?” one of the nurses asked. “Well, we should rap her in a warm blanket for starters,” I said. We also put a cap over her head. I motioned for the father to come over. He was a quiet and gentle man. He looked at his son first. He placed his hand gently on his head and smiled. Then he asked if he could hold his daughter. I said of course and we handed her to him. He held her, looked into her eyes and told her that she was beautiful.
Before leaving I walked over to the mother who was lying on the operating table looking into a blue drape. I told her that her son was healthy and doing just fine. She smiled and I could see the joy in her face. Then I told her that her daughter was severely affected but alive. She was breathing on her own and active. We could both hear the girl’s raspy cry. I told her that I did not know how long she would live and that she was being held by her father. The mother’s smile vanished. For a moment she had forgotten about the second twin and was allowed to enjoy her son’s birth, but that moment passed quickly. I asked her if she wanted to see her daughter and she shook her head “no”. “I can’t” she said and then added “thank you” probably not really knowing what else to say. She looked away from me and into the blue curtain and I watched as a tear formed in her eye and rolled down her cheek.
I walked out of the room and looked up at the clock. It was a little before 7 in the morning. I had time to get home and get the kids ready for school before coming back to see my patients. On the drive back home all I could think about was the mother and her twins. Carrying them both throughout the pregnancy knowing that one was healthy and that one was sick. Then having to be in the delivery room, overcome with joy for the birth of her son and yet filled with loss for the terrible affliction suffered by her daughter. I thought of how fortunate I was to have five healthy children and I decided that I was going to take them to donuts.
The call from the hospital came at four in the morning. A woman with twins, one healthy and one with holoprosencephaly, had shown up in labor and they were going to perform a c-section. They wanted to know if I’d come in for the delivery. Of course I said. Probably the thing I like most in my work is attending a delivery. There is so much excitement in the room. If all goes well I get to see a life enter the world and be part of one of the most important events in people’s lives. If there is a problem and the baby is sick, well then I know what steps to take to hopefully make things better. For this case there would not be much for me to do, but I knew the nurses wanted me there to help things go smoothly.
In truth, I had forgotten that she was out there in the community. The mother with the twins. I had met with her a little over two months before the delivery. That was when the Obstetrician called me and asked if I would talk to a woman with twins. One of the twins was healthy and the other had holoprosencephaly. Holoprosencephaly is a deformity of the brain in which the cerebral hemispheres fail to divide. Like most conditions in medicine, there is a wide range in presentation with some babies looking perfectly normal and having mild mental problems to those that are severely affected with obvious physical and neurologic abnormalities. These severely effected babies often die shortly after birth. When I met with the mother two months prior she said she understood that her infant was severely affected and would not survive the delivery. I tried to explain to her that there were limits to prenatal diagnosis and that I had seen babies live up to a year even when they had major abnormalities. I explained that no one could predict how long her little girl would live. I then asked how she would like for us to care for her daughter and she stressed that we only provide comfort and not perform any resuscitation.
The delivery was by c-section and the boy was born first. He came out crying, active and pink. There was a quick cheer in the room and the Obstetrician held him over the curtain so the mother and father could see him. She then handed the little boy to a nurse who placed him under a warmer. I checked him out with the nursing staff. We warmed him, dried him and rubbed his back. We suctioned out his mouth, gave him a shot in the leg and one of the nurses made footprints on a thick, paper card. He was doing just fine. Next the Obstetrician pulled out the girl and handed her to a nurse who then laid her under the warmer. The newborn had a small, thin body. Her head, however, was quite large. She had hydrocephalous, so her face was of normal size but her head swelled out above her eyes. Babies with severe holoprosencephaly also have midline physical defects and this little girl had closely spaced eyes and a large cleft so that her mouth and nose came together to a central whole. Flaps would open and close around this central hole when she cried. Her cry was hoarse but she was quite active. “What should we do?” one of the nurses asked. “Well, we should rap her in a warm blanket for starters,” I said. We also put a cap over her head. I motioned for the father to come over. He was a quiet and gentle man. He looked at his son first. He placed his hand gently on his head and smiled. Then he asked if he could hold his daughter. I said of course and we handed her to him. He held her, looked into her eyes and told her that she was beautiful.
Before leaving I walked over to the mother who was lying on the operating table looking into a blue drape. I told her that her son was healthy and doing just fine. She smiled and I could see the joy in her face. Then I told her that her daughter was severely affected but alive. She was breathing on her own and active. We could both hear the girl’s raspy cry. I told her that I did not know how long she would live and that she was being held by her father. The mother’s smile vanished. For a moment she had forgotten about the second twin and was allowed to enjoy her son’s birth, but that moment passed quickly. I asked her if she wanted to see her daughter and she shook her head “no”. “I can’t” she said and then added “thank you” probably not really knowing what else to say. She looked away from me and into the blue curtain and I watched as a tear formed in her eye and rolled down her cheek.
I walked out of the room and looked up at the clock. It was a little before 7 in the morning. I had time to get home and get the kids ready for school before coming back to see my patients. On the drive back home all I could think about was the mother and her twins. Carrying them both throughout the pregnancy knowing that one was healthy and that one was sick. Then having to be in the delivery room, overcome with joy for the birth of her son and yet filled with loss for the terrible affliction suffered by her daughter. I thought of how fortunate I was to have five healthy children and I decided that I was going to take them to donuts.
Saturday, June 6, 2009
Hope
When I got the call, I was in a book store trying to find some X-Men comic books for my kids, Marcus really likes Wolverine. It was the Doctor working the day for one of the hospitals that I would be covering in the next hour. He said that he had just arrived home when he was notified that a woman presented in labor. She was 25 weeks along and fully dilated. She had a bulging bag. He could go in but it would likely take him an hour to get there with traffic. He asked if I would mind covering the delivery. “Of course not,” I said. “You’re off in an hour anyway and stabilizing that kid’s gonna take longer than an hour anyway.” Anyone who works with babies knows that a 25 week infant can easily fit through a 10 cm hole. If the mother was fully dilated she could deliver at any moment without even knowing it. I was closest, so I went in.
The pregnancy was not complicated. Mom had regular visits with her Obstetrician and no problems had surfaced. She simply felt some pelvic pressure earlier in the day and went in to see her Obstetrician. He performed an ultrasound which showed a fully dilated cervix and hourglass membranes. This means that the sack around the baby was half in the uterus and half in the vagina. Each was filled with fluid and so it looked like an hourglass on ultrasound. While in the hospital, the woman’s uterus started to contract forcing all of the fluid into the part of the sack that was in the vagina. Now the infant had no fluid around her and she started to feel the pressure. Her heart rate started dropping and an emergency c-section was performed. I was glad that I went in.
The baby was delivered and placed under a warmer in front of me. She was as small as a soda can with thin skin and fused eyelids. She was not breathing and her heart rate was low. The color quickly drained from her body and she looked lifeless. The first person to try to intubate her couldn’t see the vocal cords. When you place a baby on a ventilator you have to pass a tube into her mouth and through the vocal cords. This space in a 25 week infant is 3 to 4 mm wide. When the first attempt failed I placed a mask over the baby’s nose and mouth and began giving breaths. This does not work as well as having a tube in the trachea in small babies. While bagging breaths in, I took up my position at the head of the bed and asked for a clean tube. I then looked into the mouth and placed the tube in. I knew it was in. We started forcing air into her lungs with the bag now attached to the end of the tube. Her heart rate was low and her color remained bad. She was about a minute old. We still had time. I asked the nurse to place a catheter in her umbilical cord while I pushed air into her lungs.
“I need two mls of surfactant” I said. Surfactant is a protein that premature lungs are missing. It helps them to open and close more easily. It increases the amount of surface area where air can come into contact with blood thus improving oxygen delivery to the baby. I put that into the tube and forced it down with more breaths.
The c-section rooms are small at this hospital and about two feet from me I can see the Mom’s face and the father sitting beside her. They are looking at me. I smile.
“What’s our heart rate?” I ask.
“About 50,” says a nurse.
“Okay, begin chest compressions.”
“Is that UVC in yet. “ UVC stands for Umbilical Vein Catheter. It is a plastic tube that is placed in the umbilical vein, the largest and easiest venous access point in a newborn.
“Almost”
“Okay. Give me a dose of epinephrine.” I place the clear liquid in the endotracheal tube and slowly bag it into the lungs. It’s supposed to make its way to the heart and speed it up. Only it works better if it goes directly into the blood. No response. I keep bagging.
“Are we giving a hundred percent oxygen?”
“Yes.”
“Is the UVC in?
“Yes.”
“Okay give 10 ml’s of normal saline.”
A syringe is passed from one nurse to another where it is attached to the end of the umbilical catheter and delivered. “Given,” one of the nurses says.
“And our heart rate?” I asked.
“Still 50,” the charting nurse said.
“Is there a sat monitor on?”
“Yeah, but it’s not picking up.”
“Okay give a dose of epinephrine through the UVC.”
The dose is given and at the same time I start bagging with higher pressures and the infant’s heart rate starts to rise. It hits 80 and then quickly jumps to 140. Was it the fluid, the epinephrine or the higher ventilator pressures? I’m not sure. But the heart rate is good. The baby starts to move her arms. I even think I can feel her suck on my index finger that is still holding the endotracheal tube securely in her mouth. “Okay” I say. “Let’s go.”
We tape the tube and line in place and start to move out of the room. The baby is about 7 minutes old.
I look at the parents. They look worried and confused like they are out of their bodies and viewing these actions from someplace far away.
“Your daughter’s alive but she is very premature and very sick,” I quickly say. “Right now we are breathing for her and we have a good heart rate. We will do everything that we can for her. Right now I need to go with her into the unit.” They don’t say anything as I walk away with the baby.
The hospital that we are at can’t take care of a baby this small so I need to transfer her to another hospital. I happen to be the doctor on there too.
We stabilized the baby, replaced the umbilical lines adding one in the artery in addition to the vein. We then sent her to the other hospital, where I drove in my car to accept her. Once there I made sure she was secure for the rest of the night before laying down myself. I reviewed her orders, her fluids and her labs. But most important, I checked on her many times. While performing one last examination she reached up and grabbed my finger. I know that the baby’s reach was a reflex and not an intentional gesture but in it I felt hope.
The pregnancy was not complicated. Mom had regular visits with her Obstetrician and no problems had surfaced. She simply felt some pelvic pressure earlier in the day and went in to see her Obstetrician. He performed an ultrasound which showed a fully dilated cervix and hourglass membranes. This means that the sack around the baby was half in the uterus and half in the vagina. Each was filled with fluid and so it looked like an hourglass on ultrasound. While in the hospital, the woman’s uterus started to contract forcing all of the fluid into the part of the sack that was in the vagina. Now the infant had no fluid around her and she started to feel the pressure. Her heart rate started dropping and an emergency c-section was performed. I was glad that I went in.
The baby was delivered and placed under a warmer in front of me. She was as small as a soda can with thin skin and fused eyelids. She was not breathing and her heart rate was low. The color quickly drained from her body and she looked lifeless. The first person to try to intubate her couldn’t see the vocal cords. When you place a baby on a ventilator you have to pass a tube into her mouth and through the vocal cords. This space in a 25 week infant is 3 to 4 mm wide. When the first attempt failed I placed a mask over the baby’s nose and mouth and began giving breaths. This does not work as well as having a tube in the trachea in small babies. While bagging breaths in, I took up my position at the head of the bed and asked for a clean tube. I then looked into the mouth and placed the tube in. I knew it was in. We started forcing air into her lungs with the bag now attached to the end of the tube. Her heart rate was low and her color remained bad. She was about a minute old. We still had time. I asked the nurse to place a catheter in her umbilical cord while I pushed air into her lungs.
“I need two mls of surfactant” I said. Surfactant is a protein that premature lungs are missing. It helps them to open and close more easily. It increases the amount of surface area where air can come into contact with blood thus improving oxygen delivery to the baby. I put that into the tube and forced it down with more breaths.
The c-section rooms are small at this hospital and about two feet from me I can see the Mom’s face and the father sitting beside her. They are looking at me. I smile.
“What’s our heart rate?” I ask.
“About 50,” says a nurse.
“Okay, begin chest compressions.”
“Is that UVC in yet. “ UVC stands for Umbilical Vein Catheter. It is a plastic tube that is placed in the umbilical vein, the largest and easiest venous access point in a newborn.
“Almost”
“Okay. Give me a dose of epinephrine.” I place the clear liquid in the endotracheal tube and slowly bag it into the lungs. It’s supposed to make its way to the heart and speed it up. Only it works better if it goes directly into the blood. No response. I keep bagging.
“Are we giving a hundred percent oxygen?”
“Yes.”
“Is the UVC in?
“Yes.”
“Okay give 10 ml’s of normal saline.”
A syringe is passed from one nurse to another where it is attached to the end of the umbilical catheter and delivered. “Given,” one of the nurses says.
“And our heart rate?” I asked.
“Still 50,” the charting nurse said.
“Is there a sat monitor on?”
“Yeah, but it’s not picking up.”
“Okay give a dose of epinephrine through the UVC.”
The dose is given and at the same time I start bagging with higher pressures and the infant’s heart rate starts to rise. It hits 80 and then quickly jumps to 140. Was it the fluid, the epinephrine or the higher ventilator pressures? I’m not sure. But the heart rate is good. The baby starts to move her arms. I even think I can feel her suck on my index finger that is still holding the endotracheal tube securely in her mouth. “Okay” I say. “Let’s go.”
We tape the tube and line in place and start to move out of the room. The baby is about 7 minutes old.
I look at the parents. They look worried and confused like they are out of their bodies and viewing these actions from someplace far away.
“Your daughter’s alive but she is very premature and very sick,” I quickly say. “Right now we are breathing for her and we have a good heart rate. We will do everything that we can for her. Right now I need to go with her into the unit.” They don’t say anything as I walk away with the baby.
The hospital that we are at can’t take care of a baby this small so I need to transfer her to another hospital. I happen to be the doctor on there too.
We stabilized the baby, replaced the umbilical lines adding one in the artery in addition to the vein. We then sent her to the other hospital, where I drove in my car to accept her. Once there I made sure she was secure for the rest of the night before laying down myself. I reviewed her orders, her fluids and her labs. But most important, I checked on her many times. While performing one last examination she reached up and grabbed my finger. I know that the baby’s reach was a reflex and not an intentional gesture but in it I felt hope.
Thursday, June 12, 2008
Delivery Room Zen
I was talking to a friend who had a rough week. (My wife once asked me if I had a rough night at work and I said "yes, but I know that there are those who had it rougher because I was taking care of them"). My friend had taken care of a little girl who was born with grossly underdeveloped lungs and died. There had been no amniotic fluid around the baby from about 18 weeks and the girl's lungs did not develop. My friend told me that she told the family that while their daughter was here only a brief time her life was still significant.
I have told families something similar in the past. I like to think that regardless of the length of a life, 1 minute vs 100 years, its importance can be the same. That a baby who dies shortly after birth can still be a significant and positive member of that family.
Later in the week, I was called to the delivery of a baby being born 3 months early. Mom had presented in premature, active labor that morning after an uncomplicated pregnancy. The Obstetrician tried to hold off the delivery but the mother progressed and as the baby was breech a c-section was performed. In a normal vaginal delivery the head comes out and then as the body is thinner the rest of the baby practically shoots out. When the baby is breech it is possible to deliver the body and then the cervix clamp down around the neck and the baby become stuck and suffocate, hence the reason for a c-section. But this can happen in the c-section also, not that the cervix clamps down, but that the body comes out of the incision site and the head is stuck. And that is what happened.
The baby was stuck, body out and head inside...so I had some time to think.
I had my intubation tube, laryngascope, oxygen mask and equipment all checked. The warmer was on, we had sterile towels, a bulb suction, two nurses and a respiratory therapist. We were ready for the baby, the baby still wasn't coming. I thought "What would those OB doctors do if I jumped in there and pulled the baby out myself. I decided to concentrate on my breathing. Breathing in I am refreshed. Breathing out I smile. Then I thought "What would a Zen master do in the delivery room?" The Zen master has no training in Neonatal Resuscitation. He may see life and death as two sides of one coin. Really no different except for our earthly perspective.
So back to the question "What would the Zen Master do?"
Well I thought a Zen Master might welcome the baby into the world, concentrate on their own breathing and help transition the newborn into the next phase of her life, the afterlife. And that might not be so bad if everyone else held the same beliefs. The mother and father were happy to have a minute of life on this side of the coin.
I thought of my kids. Could I accept that? I know that I would try to accept it, but the truth is I want to see them play with blocks, smile when given a Popsicle, shoot a basket and write a report on Troy. I want to experience the whole side of this coin before turning it over.
So the OB finally pulled the baby out and placed her in front of me on the warm bed. She was small, thin, purple and not moving. No breathing. No gasp. No movement at all.
I was calm. I know what to do...its almost automatic. I suction her nose, mouth and then we put the mask to the baby's face and started giving her breaths of oxygen. I wait about 20 seconds and the infant's heart rate is still less than 80 so I look into her mouth and place a thin plastic tube into the upper part of her airway and we start giving breaths through the tube. Once intubated, the heart rate rises to 150. The baby starts to move and so do we. "Let's tape the tube and go" I say. We tape the tube to the baby's upper lip, but it is a little loose as the infant is still wet. I walk backwards as we push the baby through the hallway to the intensive care unit. The baby is on a tall table that has wheels. I am near the baby's head and I have my index finger in the baby's mouth holding the tube in place as we move. As we round the last corner to the unit I can feel the baby start to suck on my finger, it makes me feel good and I get the feeling that she will be okay. She'll have a little more time on this side of the coin. I only hope that later, she will think I did the right thing. That she will know that I did it for her and not for me.
I have told families something similar in the past. I like to think that regardless of the length of a life, 1 minute vs 100 years, its importance can be the same. That a baby who dies shortly after birth can still be a significant and positive member of that family.
Later in the week, I was called to the delivery of a baby being born 3 months early. Mom had presented in premature, active labor that morning after an uncomplicated pregnancy. The Obstetrician tried to hold off the delivery but the mother progressed and as the baby was breech a c-section was performed. In a normal vaginal delivery the head comes out and then as the body is thinner the rest of the baby practically shoots out. When the baby is breech it is possible to deliver the body and then the cervix clamp down around the neck and the baby become stuck and suffocate, hence the reason for a c-section. But this can happen in the c-section also, not that the cervix clamps down, but that the body comes out of the incision site and the head is stuck. And that is what happened.
The baby was stuck, body out and head inside...so I had some time to think.
I had my intubation tube, laryngascope, oxygen mask and equipment all checked. The warmer was on, we had sterile towels, a bulb suction, two nurses and a respiratory therapist. We were ready for the baby, the baby still wasn't coming. I thought "What would those OB doctors do if I jumped in there and pulled the baby out myself. I decided to concentrate on my breathing. Breathing in I am refreshed. Breathing out I smile. Then I thought "What would a Zen master do in the delivery room?" The Zen master has no training in Neonatal Resuscitation. He may see life and death as two sides of one coin. Really no different except for our earthly perspective.
So back to the question "What would the Zen Master do?"
Well I thought a Zen Master might welcome the baby into the world, concentrate on their own breathing and help transition the newborn into the next phase of her life, the afterlife. And that might not be so bad if everyone else held the same beliefs. The mother and father were happy to have a minute of life on this side of the coin.
I thought of my kids. Could I accept that? I know that I would try to accept it, but the truth is I want to see them play with blocks, smile when given a Popsicle, shoot a basket and write a report on Troy. I want to experience the whole side of this coin before turning it over.
So the OB finally pulled the baby out and placed her in front of me on the warm bed. She was small, thin, purple and not moving. No breathing. No gasp. No movement at all.
I was calm. I know what to do...its almost automatic. I suction her nose, mouth and then we put the mask to the baby's face and started giving her breaths of oxygen. I wait about 20 seconds and the infant's heart rate is still less than 80 so I look into her mouth and place a thin plastic tube into the upper part of her airway and we start giving breaths through the tube. Once intubated, the heart rate rises to 150. The baby starts to move and so do we. "Let's tape the tube and go" I say. We tape the tube to the baby's upper lip, but it is a little loose as the infant is still wet. I walk backwards as we push the baby through the hallway to the intensive care unit. The baby is on a tall table that has wheels. I am near the baby's head and I have my index finger in the baby's mouth holding the tube in place as we move. As we round the last corner to the unit I can feel the baby start to suck on my finger, it makes me feel good and I get the feeling that she will be okay. She'll have a little more time on this side of the coin. I only hope that later, she will think I did the right thing. That she will know that I did it for her and not for me.
Thursday, January 10, 2008
Do you want to believe in Miracles?
I often upset my parents by saying that if there was a testament to divine intervention than my life would be it. It upsets them because I follow this by saying that I do not believe in divine intervention and that I attribute my success to good luck. The fact that I ended up in the current position I hold and enjoying a career that I love was easily a million to one. I made multiple attempts to derail my cart and yet it always seemed to fall back on path.
For reasons that do not really concern this blog, I moved away from faith in my early twenties. Initially it had to do with trust issues and a lack of understanding of the bad that exists in this world. It is somewhat a clique to say that one sees an innocent suffer and stops believing in God. But given the mistakes that I have made, I will admit that it is hard to believe that God is intervening for me when I see those much more innocent than me suffering.
Still. I can understand that pain may be necessary for a greater good. So I can see God in a world that has suffering. And I can understand that the one suffering the pain may not see or understand the good that comes of it. Take a child with fever and a stiff neck. A lumbar puncture is necessary to diagnose the condition and guide therapy. The procedure hurts and there is no way the child understands why one doctor is holding them down while another jabs a sharp object into his back. But a greater good, not understood by the child is to be gained. God may work that way.
Yet I still do not believe. To be clear: it is not that I don't believe in God, it is that I don't believe that God makes direct influences into our lives. And it is not that I don't see things that defy my explanation. I have witnessed babies breath when I thought they would not. Infants near death who suddenly are better. However, every time one family experiences a miracle, I walk over to the next bed and see where one did not occur.
And still they come.
Jaydon was born prematurely at 27 weeks. When he was one day old the nurse tried to place a tube down through his nose and into his stomach. This is an NG tube, which we routinely place in premature babies to give feedings when the baby is too immature to nipple. Well with Jaydon the tube would not pass. It coiled back up through his mouth. So I was called to the bedside and I advanced the tube as far as I could until I started to feel resistance. We took an x-ray and the tube stopped midway between the mouth and the stomach. Jaydon had a tracheal-esophageal fistula with an esophageal pouch. This means that the tube that he swallows into does not go all the way to the stomach but stops in the chest. A second tube that connects to his trachea (wind pipe) goes to his stomach. For a better picture of this condition you can visit the UCSF web site. www.pedsurg.ucsf.edu/esophageal_atresia/ The problem is that the acid in the stomach may back up into the lungs and the secretions in the mouth will collect in the pouch and spill into the lungs. So this small 1 pound 6 ounce baby needs a surgery, and not just one. Well with a minor cardiac surgery added on he had three surgeries before he was a month old.
Shortly after his third surgery we saw something a little unusual. The diaphragm on his right side started to rise higher in his chest, causing his right lung to collapse. See the diaphragm must move down to increase the space in the chest and pull air into the lungs. For Jaydon, the right diaphragm stayed up rather than moved down.
We tried four or five times to take him off the ventilator and every time he failed. He struggled to breath and I kept blaming that right diaphragm. I had to reintubate (place a tube down through his mouth and into the upper part of his trachea) him every time. He would not come off the ventilator. So we placed a camera down into his airway and everything looked normal. Next we performed fluoroscopy. This is when we take a video x-ray of the lungs. We do not do this very often in small children because of the radiation exposure. An x-ray is a single picture. To create a motion picture, it takes hundreds of pictures. With the study we can actually watch the lungs open and close and the diaphragms move. Every time Jaydon took a breath his left diaphragm went down, but his right went up. It looked like a seesaw. I watched this for about twenty seconds. The study was conclusive, the diaphragm was paralyzed and the infant was ventilator dependant.
After the study we had a family conference and the pulmonologist, surgeon and myself (all having reviewed the study) agreed that a fourth surgery was necessary to tie the diaphragm down in the hopes that this would allow Jaydon to come off the ventilator. Reluctantly Jaydon's parents agreed.
The night before his surgery the nurse caring for Jaydon found him with his endotracheal tube out. He had coughed the tube out of his airway. Normally this would have caused his oxygen levels to drop and alarms would have sounded. But Jaydon was breathing comfortably on his own without any extra support. He was breathing as normal as any healthy, premature baby. He remained off ventilatory support until he went home one month later.
I can't explain what happened. I saw, with my own eyes that the diaphragm did not work. And I witnessed this test just three days before Jaydon coughed out that tube. I took Jaydon off the ventilator many times and he never lasted more than a few hours, even with lots of additional support. Yet here he was breathing comfortably without any support at all.
So was this a miracle. As I told you before I do not believe in miracles. And the God that looks upon me may be shaking his/her head in disbelief, but I will still have to chalk this up to one of those things that happens that I simply can't explain.
However if you want, you can use it to believe. I wont hold it against you.
For reasons that do not really concern this blog, I moved away from faith in my early twenties. Initially it had to do with trust issues and a lack of understanding of the bad that exists in this world. It is somewhat a clique to say that one sees an innocent suffer and stops believing in God. But given the mistakes that I have made, I will admit that it is hard to believe that God is intervening for me when I see those much more innocent than me suffering.
Still. I can understand that pain may be necessary for a greater good. So I can see God in a world that has suffering. And I can understand that the one suffering the pain may not see or understand the good that comes of it. Take a child with fever and a stiff neck. A lumbar puncture is necessary to diagnose the condition and guide therapy. The procedure hurts and there is no way the child understands why one doctor is holding them down while another jabs a sharp object into his back. But a greater good, not understood by the child is to be gained. God may work that way.
Yet I still do not believe. To be clear: it is not that I don't believe in God, it is that I don't believe that God makes direct influences into our lives. And it is not that I don't see things that defy my explanation. I have witnessed babies breath when I thought they would not. Infants near death who suddenly are better. However, every time one family experiences a miracle, I walk over to the next bed and see where one did not occur.
And still they come.
Jaydon was born prematurely at 27 weeks. When he was one day old the nurse tried to place a tube down through his nose and into his stomach. This is an NG tube, which we routinely place in premature babies to give feedings when the baby is too immature to nipple. Well with Jaydon the tube would not pass. It coiled back up through his mouth. So I was called to the bedside and I advanced the tube as far as I could until I started to feel resistance. We took an x-ray and the tube stopped midway between the mouth and the stomach. Jaydon had a tracheal-esophageal fistula with an esophageal pouch. This means that the tube that he swallows into does not go all the way to the stomach but stops in the chest. A second tube that connects to his trachea (wind pipe) goes to his stomach. For a better picture of this condition you can visit the UCSF web site. www.pedsurg.ucsf.edu/esophageal_atresia/ The problem is that the acid in the stomach may back up into the lungs and the secretions in the mouth will collect in the pouch and spill into the lungs. So this small 1 pound 6 ounce baby needs a surgery, and not just one. Well with a minor cardiac surgery added on he had three surgeries before he was a month old.
Shortly after his third surgery we saw something a little unusual. The diaphragm on his right side started to rise higher in his chest, causing his right lung to collapse. See the diaphragm must move down to increase the space in the chest and pull air into the lungs. For Jaydon, the right diaphragm stayed up rather than moved down.
We tried four or five times to take him off the ventilator and every time he failed. He struggled to breath and I kept blaming that right diaphragm. I had to reintubate (place a tube down through his mouth and into the upper part of his trachea) him every time. He would not come off the ventilator. So we placed a camera down into his airway and everything looked normal. Next we performed fluoroscopy. This is when we take a video x-ray of the lungs. We do not do this very often in small children because of the radiation exposure. An x-ray is a single picture. To create a motion picture, it takes hundreds of pictures. With the study we can actually watch the lungs open and close and the diaphragms move. Every time Jaydon took a breath his left diaphragm went down, but his right went up. It looked like a seesaw. I watched this for about twenty seconds. The study was conclusive, the diaphragm was paralyzed and the infant was ventilator dependant.
After the study we had a family conference and the pulmonologist, surgeon and myself (all having reviewed the study) agreed that a fourth surgery was necessary to tie the diaphragm down in the hopes that this would allow Jaydon to come off the ventilator. Reluctantly Jaydon's parents agreed.
The night before his surgery the nurse caring for Jaydon found him with his endotracheal tube out. He had coughed the tube out of his airway. Normally this would have caused his oxygen levels to drop and alarms would have sounded. But Jaydon was breathing comfortably on his own without any extra support. He was breathing as normal as any healthy, premature baby. He remained off ventilatory support until he went home one month later.
I can't explain what happened. I saw, with my own eyes that the diaphragm did not work. And I witnessed this test just three days before Jaydon coughed out that tube. I took Jaydon off the ventilator many times and he never lasted more than a few hours, even with lots of additional support. Yet here he was breathing comfortably without any support at all.
So was this a miracle. As I told you before I do not believe in miracles. And the God that looks upon me may be shaking his/her head in disbelief, but I will still have to chalk this up to one of those things that happens that I simply can't explain.
However if you want, you can use it to believe. I wont hold it against you.
Saturday, December 15, 2007
Birth Plans
Mention that you have a birth plan and most people who work in Labor and Delivery or Neonatology will cringe. It's mainly because we have all seen parents cling to their birth plan when we thought that it went against the baby's best interest. I guess in a way the birth plan alerts us that a parent will only be upset if things do not go as expected. See the birth plan presumes a healthy, uncomplicated delivery, that everything will go as planned. And well those of us who work in a Neonatal Unit live in a world where that rarely happens. Remember I am only called to the delivery of infants when something is going wrong.
Some medical people hate birth plans because they immediately presume that the family will be needy. I differ here. I must confess, I do not cringe when I hear that a parent has a birth plan. In fact, I think that when the delivery is uncomplicated, that they are great. The birth plan tells me that this family has put a lot of thought in to how they want this special moment in their life to unfold. To me, a birth plan is written with love. And I will always do my best to honor a birth plan. But once the baby is at risk, well... I throw the plan out the window. Because all of us who had older sisters with bad relationships know that love can be blind and does not always lead us down the right path. I would rather that a parent take a healthy baby home and be a little angry that I did not follow the plan.
So I was not at this delivery, but a close friend of mine was. The mother and father were very specific in their plan. They did not want any drugs used during labor. They did not want their infant to have chemicals in her when she was born. They want a vaginal delivery and for the baby to be placed to breast within one minute of birth. They did not want antibiotic creams in the eyes and they did not want a Vitamin K injection. They were young (twenties), educated, attractive and had private insurance. From the outside, it appeared that life was unfolding easily for them.
They parents also have an Obstetrician who wants them to have the experience they want. So when the labor stalls, the OB does not encourage the use of pitocin (a medication that stimulates labor). Instead he waits. He let the young woman push for over three hours. The infant is not being traced with a scalp monitor because the family does not want invasive monitoring. Instead a belt around the mother's stomach is used to monitor the heart rate. It is not uncommon for the belt to "lose" the baby's heart rate for several minutes at a time or pick up the mother's heart rate by mistake and give a false sense of fetal well being. The infant begins to have serious dips in the heart rate after one hour of pushing. The dips are starting to get longer and take more time to recover. Recovery is when the heart rate has returned to its pre-contraction rate, referred to as baseline and typically 120 to 160 beats per minute. One might think that a woman would never have a heart rate of 150, but during labor this often occurs.
The decelerations tell me that the infant is stressed. During the contractions the oxygen level dips and the heart rate follows. The fact that it takes longer for the heart rate to recover tells me that the time of hypoxia is becoming greater. My friend suggested a cesarean section and was quickly dismissed. This is not a Neonatologist's call (cop out). Okay, it is not my expertise (this is the truth). The Obstetrician has years of experience with laboring mothers that I d0 not. The Obstetrician has two patients and must consider both the health of the baby and the health of the mother. However one thing that I am certain of is that if this mother had walked in off the street, had medicaid and no relationshiop with the Obstetrician, she would have been sectioned two hours ago.
The baby was born vaginally after three hours of pushing. She was bruised, had a slow heart rate, was not moving or breathing and her color was grey. My friend placed a mask over the baby's face and immediately started giving oxygen. She began to pump the oxygen bag to force air into the lungs. The baby was still grey and not moving. At this time a minute had passed and the father came over to my friend and asked if his daughter could go to the mother's breast. My friend tells the father that his daughter was not breathing and that she needed to give the baby oxygen. And that she'll bring her to mom when she was doing better. The baby did not go to the mother's breast. She went to the intensive care unit. The father doesn't really understand, but the first flicker crosses his consciousness that something could go wrong. Could? Had.
The little girl ended up on a ventilator because she wouldn't breathe and she started to have seizures that were difficult to control. She was on high doses of Phenobarbital (anti-seizure medication), antibiotics and blood pressure medications. The following day I stood at the bedside with the father. She was a beautiful baby. Everything perfectly formed and developed. The father was heartbroken and sick. He looked at me. It's crazy he said. My wife didn't even take pain medications because we wanted everything in the baby's system to be natural and now you guys are giving her all these powerful medications. I share a sliver of his sadness. I say a sliver because I can never really know how he feels. I hope to never feel what he was feeling.
Many people blame the birth plan but I blame the medical system and the Obstetrician. As physicians we have abducated our position of authority. Birth plans are created for healthy, full term infants in the midst of an uncomplicated delivery. But plans must be flexible and must place the health of the infant first. As physicians and nurses who work in perinatology, we need to educate parents and risk losing friends in order to do what we know is best.
I think that every prospective parent should give thought to how they want their baby's birth to unfold. And that a birth plan is a good idea. But the first line should read: At the first sign of trouble tear this up and do whatever is necessary to preserve the health of my baby.
Some medical people hate birth plans because they immediately presume that the family will be needy. I differ here. I must confess, I do not cringe when I hear that a parent has a birth plan. In fact, I think that when the delivery is uncomplicated, that they are great. The birth plan tells me that this family has put a lot of thought in to how they want this special moment in their life to unfold. To me, a birth plan is written with love. And I will always do my best to honor a birth plan. But once the baby is at risk, well... I throw the plan out the window. Because all of us who had older sisters with bad relationships know that love can be blind and does not always lead us down the right path. I would rather that a parent take a healthy baby home and be a little angry that I did not follow the plan.
So I was not at this delivery, but a close friend of mine was. The mother and father were very specific in their plan. They did not want any drugs used during labor. They did not want their infant to have chemicals in her when she was born. They want a vaginal delivery and for the baby to be placed to breast within one minute of birth. They did not want antibiotic creams in the eyes and they did not want a Vitamin K injection. They were young (twenties), educated, attractive and had private insurance. From the outside, it appeared that life was unfolding easily for them.
They parents also have an Obstetrician who wants them to have the experience they want. So when the labor stalls, the OB does not encourage the use of pitocin (a medication that stimulates labor). Instead he waits. He let the young woman push for over three hours. The infant is not being traced with a scalp monitor because the family does not want invasive monitoring. Instead a belt around the mother's stomach is used to monitor the heart rate. It is not uncommon for the belt to "lose" the baby's heart rate for several minutes at a time or pick up the mother's heart rate by mistake and give a false sense of fetal well being. The infant begins to have serious dips in the heart rate after one hour of pushing. The dips are starting to get longer and take more time to recover. Recovery is when the heart rate has returned to its pre-contraction rate, referred to as baseline and typically 120 to 160 beats per minute. One might think that a woman would never have a heart rate of 150, but during labor this often occurs.
The decelerations tell me that the infant is stressed. During the contractions the oxygen level dips and the heart rate follows. The fact that it takes longer for the heart rate to recover tells me that the time of hypoxia is becoming greater. My friend suggested a cesarean section and was quickly dismissed. This is not a Neonatologist's call (cop out). Okay, it is not my expertise (this is the truth). The Obstetrician has years of experience with laboring mothers that I d0 not. The Obstetrician has two patients and must consider both the health of the baby and the health of the mother. However one thing that I am certain of is that if this mother had walked in off the street, had medicaid and no relationshiop with the Obstetrician, she would have been sectioned two hours ago.
The baby was born vaginally after three hours of pushing. She was bruised, had a slow heart rate, was not moving or breathing and her color was grey. My friend placed a mask over the baby's face and immediately started giving oxygen. She began to pump the oxygen bag to force air into the lungs. The baby was still grey and not moving. At this time a minute had passed and the father came over to my friend and asked if his daughter could go to the mother's breast. My friend tells the father that his daughter was not breathing and that she needed to give the baby oxygen. And that she'll bring her to mom when she was doing better. The baby did not go to the mother's breast. She went to the intensive care unit. The father doesn't really understand, but the first flicker crosses his consciousness that something could go wrong. Could? Had.
The little girl ended up on a ventilator because she wouldn't breathe and she started to have seizures that were difficult to control. She was on high doses of Phenobarbital (anti-seizure medication), antibiotics and blood pressure medications. The following day I stood at the bedside with the father. She was a beautiful baby. Everything perfectly formed and developed. The father was heartbroken and sick. He looked at me. It's crazy he said. My wife didn't even take pain medications because we wanted everything in the baby's system to be natural and now you guys are giving her all these powerful medications. I share a sliver of his sadness. I say a sliver because I can never really know how he feels. I hope to never feel what he was feeling.
Many people blame the birth plan but I blame the medical system and the Obstetrician. As physicians we have abducated our position of authority. Birth plans are created for healthy, full term infants in the midst of an uncomplicated delivery. But plans must be flexible and must place the health of the infant first. As physicians and nurses who work in perinatology, we need to educate parents and risk losing friends in order to do what we know is best.
I think that every prospective parent should give thought to how they want their baby's birth to unfold. And that a birth plan is a good idea. But the first line should read: At the first sign of trouble tear this up and do whatever is necessary to preserve the health of my baby.
Sunday, November 11, 2007
I can feel my heart beat
Babies that are born close to full term sometimes get in more trouble than babies born more preterm. This may seem odd and the reasons are many, but one problem in particular has to do with the muscles surrounding the blood vessels in their lungs. See the very premature babies (less than 30 weeks) do not have much in the way of a muscle layer to their blood vessels. Late preterm babies (34-37 weeks) and term babies have well developed muscular layers to these blood vessels. And when the baby develops acidosis or low blood oxygen, which occurs if they have any respiratory illness, these blood vessels clinch up and close off blood flow to the lungs making the baby even sicker. This is called pulmonary hypertension and can be fatal.Megan was born at 36 weeks and immediately started having trouble breathing. We placed her on oxygen blown up into her nose at high pressures. This allows her to breath more easily and increases her oxygen to help those blood vessels relax and open up. Well, she did well for about 24 hours and then I get called to her bedside because her oxygen level suddenly dropped. I walk (quickly) to her bedside and when she breathes I can see her pulling hard. The nares of her nose flare out and her belly caves in as she is using her abdominal muscles to help pull air into her lungs. I listen to her chest and while I can hear good breath sounds on her left side, I hear none on her right. On 100% oxygen her oxygen saturations stay in the 70's. You and I would be at 100%. Most of us get air hungry at 92%. I can see that she is hurting. I give her ativan and morphine to calm her down and ease her pain. I place a light against her chest and the entire right side lights up in a faint red glow. She has a pneumothorax. A pneumothorax is when a pocket of air has formed between the chest wall and the lung. It will push the lung over and can eventually collapse it.
So the baby is not doing well and we do not have time to confirm this with a chest x-ray so I ask the nurse for betadine, a butterfly needle and a syringe.
I pick the spot on her chest where I know the needle should go. I sterilize the site and we insert the needle. 80 cc of air comes out and her oxygen sats rise to 100% and she begins to breathe comfortably.
I have done this so many times before that I remain calm throughout. I could be ordering dinner off a menu. My pulse, naturally low stays in the 50's and my hands remain steady. I never raise my voice or even hint at the urgency that we all know exists.
So jump to my home where I am helping my seven year old with math. The problems involve counting by threes and I know Marcus knows how to count by threes. We work on problems for twenty minutes and I ask him what six plus three is and he says eight. Well I tell him "You know what six plus three is, we have been doing this for twenty minutes Marcus. One two THREE, four, five, SIX, seven, eight, NINE." So what is six plus three. And he says "Four". And I can start to feel my heart racing and I find my voice becoming much sterner and louder than I want.
So tell me how come I can stand at the bedside of a critically ill newborn without the slightest change in my emotional state but twenty minutes into homework with my son and I am a mess. It doesn't make sense. I am supposed to have perspective.
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