New Dream Job

I told a friend that the ultimate dream job was third-string quarterback on a Superbowl winning team. I said you get a great salary, will never get called in to play and earn a Superbowl ring. He laughed. He said wouldn't you want to play in the game. And I said what for.
Well I think I changed my mind.
See I like attending deliveries. When I get called to a delivery it means that "something is wrong". The nurse or obstetrition is expecting the baby to have problems. So if your having a baby, I guess you don't want to see me enter the room. It is not that I want something to go wrong, it's just that if something is going to go wrong, then I want to be there. You see, I feel very comfortable at what I do. When I walk into that room I can see the nervous expressions from the family, respiratory therapist and nurses. Of course they relax a little now that I am there, but they are still worried.
When a baby is born, the baby has to adapt to life outside of the womb quickly. Lungs, which are filled with fluid after to dry out and fill with air. The heart which has been shunting blood away from the lungs has to redirect it into the lungs. The blood vessels in the lungs which have been clinched tightly closed now must dilate to allow the blood in. No longer getting oxygen or having their blood filtered by Mom, the baby has to make some dramatic changes, all in seconds to minutes. One of my jobs is to help the baby make those changes and I know how to do this.
So the other day at work I get called to attend an emergency c-section. When I show up, they are wheeling mom into the room and there is a lot of bright red blood all over the bed sheets.
The OB looks at me and says "Term, abruption and we can't pick up a fetal heart rate." I have about a minute to prepare because that is how fast a good OB can get a baby out of an awake mother. I ask the nurse to get o-negative blood, saline and epinepherine ready. I prepare an umbilical line ( a plastic IV tube that goes into the vein in the umbilical cord). The baby is handed to us. He is as white as a glass of milk, no movement, no breathing, no detectable heart rate. The resident tries to intubate. This is when you place a plastic tube through the mouth and into the windpipe in order to breath for the baby. She can't see the windpipe because of blood. I ask her to step aside. I ask the nurse to place the umbilical vein catheter in while I intubate. I then suction out the mouth look inside and see a small opening with the vocal cords lining each side. I place the tube into the mouth and though the opening. We start giving breath with a bag. What's the heart rate? Not detectable. Is the umbilical line in? No. Okay start chest compressions. The baby is mainly pale white and still does not move. While I was intubating I got a call from one of the other doctors that I work with. He starts telling me about another patient. I interrupt him to ask him to come down to the help with the resucitation. We are now giving oxygen, but if the heart is not pumping blood to the lungs, we are not being that helpful yet. My partner placed the Umbilical line in while I was managing the breathing. We continue chest compressions. First we give normal saline. We still don't have blood. We ask the OB to draw us blood from the placenta. Normally there should be a couple hundred cc's of blood in a placenta. Word comes back from the OB. The placenta is dry. There is no blood. We give a second dose of saline, followed by epinepherine. We have a heart rate. The baby is seven minutes old. At ten minutes the baby makes a gasp. The blood arrives and we give a bolus of blood. We then move the baby over to the intensive care unit.
Well we saved the baby for the moment but what we did not know at the time is what did we save? Years earlier I would have told you that this baby was too far gone to have any meaningful recovery. But experience has taught me that some babies are plastic. By plastic I mean that they bend rather than break. They recover well beyond what we would ever predict. The following morning, this little guy opens his eyes and is breathing on his own so we take him off of the ventilator. Less than one month later, he leaves our hospital and at the time of discharge he had a completely normal exam. He may still have problems, but he also might not.
I told my partners that I was going to retire, because I will never have a part in saving someone who was so dead again. This baby did not have a heart rate for 7 minutes and did not take a breath for 10.
I don't know how this boy would have done with another physician at his side. Maybe he would have done better, maybe he would have died. But I feel that I had a part in giving him a good chance at life.
So when I hear the call overhead "Code C in Labor and Delivery" do I want to be sitting on the bench.
No way. Coach, put me in. I want to play.

Be Happy

This little ditty is borrowed from http://www.radiohead.com/

Madison was born after a relatively normal pregnancy. But immediately we knew something was wrong. The baby did not move, cry or take any breaths. She had a good heart rate which told me that the placenta was supplying adequate oxygen and could thus not account for the most common reason why an otherwise healthy baby might be depressed at birth. She was immediately placed on a ventilator.

When she was about two days old I knew that she would die soon. She had not taken any breaths on her own since birth. She did not open her eyes and was in a constant state of flexion, with tightly pulled in arms and legs. There is a condition called hyperkeplexia where children will startle and flex up. It can even be fatal if they stay flexed too long and do not restart breathing before their brain suffers from acidosis and a lack of oxygen. I thought this girl might have a severe form of this condition. But kids with hyperkeplexia have normal intelligence and when not flexed are normal. These children have normal EEGs. We performed an EEG and found that Madison lived in two states: she was either seizing or had no brain activity. I tried Vitamin B and anti-seizure medicines. Nothing worked. Madison's brain did not work.

I sometimes wonder why a case like that of Terry Schiavo garnered so much attention since everyday many people are taken off of life support. I have withdrawn supportive care and continued comfort care for many patients. Despite the euphemisms we create, it is never easy. Still some cases are harder than others.

After many conversations with Madison's parents they decided that their daughter would not want to continue living in her current state. With her brothers and sister close by, we took the ventilator tube out of Madison's mouth and handed her to her mother. Madison immediately flexed and then turned pale. She never took a breath. Her mother held her close to her breast and cried that she was sorry. I knew that she was not sorry for what we had done, but was sorry that it had to be done. Madison's father put his arm around his wife's shoulder and his palm on Madison's back and quietly wept. Later I gave Madison's mother a hug and whispered in her ear. I told her she was a good mother to Madison and gave her everything that a mother could give to a daughter. Madison's brothers held her and cried. At just 9 and 12, I know that they should not have to experience such things so young. And yet so many children do. I know that no parent should have to make the decision to take their newborn off of life support and yet so many have. And I stand by, helping as I can. Taking solace in my purpose to help them realize as normal this completely abnormal event.

And I feel.... lost

New Beginnings

At first your eyes are closed, you are wet, cold and blinded by the bright lights and poor vision. Hands grab you, thrust you, warm and dry you. Welcome to the world.
I am 39. A neonatologist and father of five. I always wanted to be a rock star but have no talent other than being able to dance like a maniac with my eyes closed. Something I wish for all of you. As rock stardom was not in my future I entered medicine. Given the amount of vodka I was drinking, I more or less stumbled into it.
I was just called to the bedside of a baby that weighs 590 grams. Her skin is a rich pink and her belly protrudes and is shrouded in a purple hue. The small veins, which look more like river tributaries drawn on a map, are easily visible through her translucent skin. There is no hair to her body, although a small amount of thin, short bristles lay flat along her head. This girl was actually less than 400 grams at one time. A wee bit more than what Sean Penn will exhale when he dies but still far below the typical minimal survival weight. If she lives, and yes it is possible, she will be the smallest baby I had ever taken care of that survived. I think that in Japan a few babies born at 23 weeks have survived, but most of these babies don't survive the first day. This baby is much smaller than my youngest, an 18 month old that already weighs 30 pounds and wears size 8 shoes. There are big paws on this one.
We don't all come in to this world the same. We don't have the same opportunities. And yet must of us have a chance. I say most, because obviously some have no chance.
That's the way the Bee Bumbles.