by Pamela Grim
So there it is: five-minute APGAR score barely four.
Something else is wrong, you think. Something else has to be going on. This baby is pink, ventilating well, but still totally flaccid.
“I want to hold my baby,” the mother says.
“Yeah, yeah. In a minute,” you say mechanically. This baby should be alive and kicking. There is something more, something more. Think, you say again to yourself. This baby is going to die, or worse, live to be a vegetable. You can't finish the thought.
“What do you think is wrong?” Carol asks. “Why isn't he moving?”
“I don't know,” you bark out. You've given up the search for the needle. “Can I get a 23-gauge butterfly for this baby's head?”
Somebody hands you one.
You shout out to the desk clerk, “Any word about transport?”
“University called a few minutes ago. The team is coming back from Spit Bay. As soon as they unload they'll be here. They said to just hold on.”
Hold on, you think to yourself. Right.
You turn to the kind nurse. “What about the cord blood?” you ask.
She holds up a tube.
“Did you get two?”
“No,” she says, “just one.”
“Did you send it?”
She bites her lip and looks down at the tube. “You want it sent?”
“I wouldn't have asked for it if I didn't want it sent.” You say this nastily but instantly regret it. How often has this nurse been involved in a delivery from hell?
She looks devastated as she turns away with the tube in her hand.
…and she cares, you think to yourself. That's why you just so successfully made her feel bad. She wants this baby to live just like you do.
You turn back to the matter at hand, the IV. Helen has handed you a rubber band, and you stretch it over the crown of the baby's head. The veins pop up, good veins. You scrub a patch of baby scalp with an alcohol swab and then take the 23-gauge butterfly, pinching its plastic wings between your fingers, piercing the skin, aiming for a blue thread, a blue rivulet crossing the hairline.
You poke and miss, poke and miss. You can feel the nurses hovering over you while the hot light of the Isolette shines its full fury on the back of your neck. You feel burnt, roasted alive and exasperated. The vein in question just rolls and rolls away.
But you are good at this. You can do anything with your hands; you know that. You can get IVs into patients when nobody else can. Even just holding the butterfly between your fingers is soothing and comforting. Therefore you're not really surprised when on your fourth pass you score and a little spout of blood backs up into the tubing.
You are taping the IV into place as X-ray rolls up. Blood, blood, blood, you are thinking to yourself.
The x-ray tech looks down on the Isolette. “Ah,” he says, “just a little fellow.”
You look down on the baby again. His left hand is still twitching. A focal seizure? you wonder, but it seems more purposeful than that. It looks like a hand trying to reach out to feel. Blood, blood, blood, you chant to yourself. Or rather something within you seems to chant, something beyond your consciousness.
“What are you doing now?” the mother asks from her gurney.
“X-ray,” you say tersely. You can't even look at her. Blood, you are thinking. Blood. Sugar. Blood. Sugar. Blood sugar. What is this kid's blood sugar?
You remember now. You learned it for an exam, but more important, you saw it happen once at the university. It was a precipitous, disastrous delivery that resulted in an acutely asphyxiated baby. They intubated the kid just like now but also got a blood sugar. It came back zero, nothing at all, a surprise to everyone and yet not a surprise. Babies have only a small amount of sugar stored away for use during times of disasters. That particular delivery was so stressful to the child that he had used up all his glycogen stores—his reserve of glucose. He had nothing left.
Maybe now…
“We need a blood sugar,” you tell Helen.
She raises a finger as if to indicate: “Good idea.”
What else? you think. What else? You are racking your brains. Fluids? Electrolytes?
You are helping the x-ray tech position the little guy on the x-ray plate when Helen taps your shoulder. She raises the glucometer up so you can read the screen.
The digital readout says: 12.
“Twelve,” you say. “His blood sugar is twelve?” Normal is 80–110.
The baby is severely hypoglycemic. He has no blood sugar.
The answer to this baby's problem could be as simple as a little bit of sugar.
“Glucose,” you tell Helen with a kind of wonder. “The kid needs glucose.”
The nurses scramble for an ampule of dextrose while some where in your mind the chant sets up again. Dilution, dilution, you think, then you realize you need to dilute the sugar.
Helen mixes a syringe, half glucose and half sterile water. You stand over the baby watching as she slowly administers simple sugar water. You have never seen anything like it. The bluish-gray blush that had lingered at the baby's fingertips dissolves before your eyes. Then the left hand starts twitching again, but the movement is more complex this time. The child is reaching out. Then the other hand moves, twitching, spasming, and it reaches out as well. Both arms are up in the air and the legs are starting to kick and in a moment you realize you are seeing what you had always thought was one of the saddest sights in medicine: a baby crying, but crying with an endotracheal tube in place so that he cries without making a sound.
Now, it is a wonderful, wonderful sight.
“How's my baby?” the mother asks.
You don't even turn around; you just cross your arms and continue looking down at the baby. The kind nurse, whose name you never learn, turns to her and says, “He's doing good.”
You wipe your forehead, which is sopping wet again, and then look at your watch. You don't really see the time. It's as if you've been outside time ever since this woman came through the door. You look up at the monitor. Heart rate 150. Normal baby heart rate.
“What about transport?” you shout out to the clerk.
“They're unloading now. They said they'd be here in about forty minutes.”
“Forty?” you say. You were thinking something more like five. You look back down at the baby, all wiggly now, and pink. You can't wait to get him out of the ER before something else happens. But there's pride there. You can't help thinking what you are thinking, which is, I did this. Then you think aloud, “I should check the x-ray.”
It's up on the light box. You amble over and look up at it, squinting. You look first for the endotracheal tube, which has a little radiopaque stripe. It is well above the corina, the bifurcation point of the trachea. You look at the lungs and a casual glance at what's next, the ribs, the stomach. No mysteries revealed.
“We need a copy of this x-ray,” you say, still looking up at it. Marveling at it. “To go with the kid.”
The clerk from in front shouts back, “I gotta Doctor Hu or Hue or something, on the phone. He wants to hear about the patient.” Simultaneously Helen says, “The heart rate is dropping.”
You pick up the phone on the wall and have a distracted four-minute conversation with a doctor who speaks almost incomprehensible English and doesn't seem to understand you any more than you understand him. Meanwhile you stand there, staring across at the monitor. The heart rate drops as you watch. Once 150, it is now 130.
The unit secretary steps into the room with the results of the cord blood gas. You look down at them, frowning, but the results are really pretty good. The baby is acidotic—a touch on the acidic side—not too surprising, considering the nature of the delivery. The electrolytes, sodium, potassium, etc., are all okay. In short, nothing that needs correcting right now.
You look back up at the monitor, which now gives a heart rate of 120. You look at the baby, and maybe this is just your hyperstimulated imagination, but the baby looks a little bluer
again. As you stand there in front of the monitor, you watch the heart rate drop: 120…119…117…114. The baby is more restless as well, little hands raised in the air, fingers reaching out, folding, then reaching once more.
113…110…108…
This is not your imagination.
But still you stand there, lead-footed, gazing up at the monitor, your jaw slack, mouth dry, glancing occasionally down at the baby only to look immediately back up at the monitor, hoping. You unloop your stethoscope and start from the beginning, listening to heart sounds, lung sounds. You recheck the endotracheal tube—it could easily have slipped out of place, but no, the lung sounds are okay. The heart sounds a little more distant maybe—maybe—not sure. Could be. For sure, though, the hands are mottled, blue, frankly blue, almost vermilion, cyanotic.
“We should check another sugar,” you say, uncertainly. “Get a new set of electrolytes,” but you are thinking, No this cannot be. We brought this baby back. The baby was looking good.
105…104…102.
…99…98.
“What's wrong?” Helen wants to know. “What's happening? Why is his pulse rate dropping?”
“Is my baby all right?” the mother calls from her gurney. “My baby…”
You say nothing but lean over, plant your hands on the mat on either side of the baby and stare down at him. The baby looks slightly shriveled and much bluer for sure now. You prod the chest with a finger. The child stirs, arms waving still but more feebly.
97…94…
Your head hurts. It more than hurts, it feels as if someone took a hammer to the back of your skull, and a screwdriver to pry out each eye. You suddenly realize how tired you are—it's almost four A.M. now—and how ill-prepared you really are to be here. Six hours ago you thought you were on the top of the medical heap, at the peak of medical conditioning. Now you see your future as a long road of disasters striped with dense shadows of ignorance. You see the heart attack patient who goes sour, septic patients, asthmatic patients. All little catastrophes out there just waiting for you, and maybe you just won't know what to do.
“What is going on?” the mother asks. “Can I hold my baby?”
You ignore her.
“Excuse me, but it is my baby. I do have a right to hold it.”
Still, everyone ignores her. You continue to stand there thinking nothing. Nothing comes to mind. You have no idea what is happening. He was there just a minute ago. He looked so normal.
“Blood sugar 130,” Helen tells you.
It's not the blood sugar.
What? What??
You fumble for the pulse, first at the arm, but when you can't find it there you go to the big femoral artery located right at the crease of the leg. Nothing. There's nothing there.
Heart rate 80 now. No way to ignore this. Now it's 78…76…
A disaster. You move your hand up to the neck, to the carotid again, groping for a pulse.
“What's the matter with my baby?” the mother shouts. “What's going on?”
You turn your back to her. “Jesus,” you say aloud. Face it. The baby's heart rate is now 72 and you can't find a pulse. The baby has no pulse.
The baby is dying.
Through clenched teeth you tell Helen, “I can't get a pulse. We gotta start CPR.”
Helen is watching the monitor too. She looks as thunderstruck as you feel. “But he was okay,” she says. “He was okay.”
“We need atropine,” you say. You too are thinking, But he was okay. “And get some epi ready.”
Meanwhile Carol, the only one of the group who seems to be able to unstick herself from the floor, positions herself at the end of the Isolette. This may be the most soul-crushing thing you have ever seen. To give CPR to a baby this small, Carol holds the baby with each hand around his chest and squeezes the chest with her thumbs. The baby is completely limp. It looks dead.
“What are you doing with my baby?” the woman shouts. “What? What?” She struggles up from the gurney. “You are hurting my baby.”
She struggles up again out of the gurney and claws at your back, trying to catch at the belt on the lab coat.
“What are you doing to my baby?” She swings at you. “You're hurting my baby.”
“I'm hurting him?” you say, wheeling on her. “I'm hurting your baby?”
“You're killing him,” she screams back crazily. She must still be totally wired from the cocaine. “You are killing my baby.”
“Shut up,” you say, stepping over to the gurney. You bring a hand up. Your first impulse is to slap her, slap some sense into her, but instead you point your finger so that it is nearly touching her nose. You start speaking very quietly; this is just you and her.
“I killed your baby? I'm the one that killed your baby? I'm not the one who did crack my entire pregnancy, my entire life. I didn't get drunk every night and not give a damn about whether I was pregnant or not. I didn't have so little fucking idea of what I was doing that I never saw a doctor the whole time I was pregnant. I didn't stumble into a hospital that has no way to take care of me and has absolutely no way to care for a baby that's this sick. I didn't try to bring a child into the world that I have spent the last nine months fucking up. I didn't kill your baby. You killed your baby. You may as well have stuck a fucking gun in its face and pulled the trigger.”
You have been, as you talk, getting louder and louder, and by now everyone is standing frozen, looking at the two of you. Even Carol is staring at you wide-eyed, still pumping away at the baby's chest.
You prod the woman's chest with your outstretched hand. “Now, you sit there and stay quiet, because you were the one who was killing your baby and I'm the one that's trying to save its life. Okay?”
You stomp back to the Isolette. No one looks at you.
“Hold CPR,” you growl.
The monitor shows a heart rate of 75.
“Epinephrine,” you say, entranced by the monitor. Think, you say to yourself, think, think, think.
“I don't know what's the matter with this damn pop-off valve,” the respiratory therapist who must have arrived in the middle of all this chaos mutters. You just barely hear her.
The pop-off valve protects the lungs by venting the respiratory circuit should the airway pressures get too high.
“You are bagging too hard,” Helen tells her.
You look at Helen and then at the respiratory therapist. The answer is so simple it makes you want to cry.
“Pneumothorax,” you say in awe.
Everyone looks at you, blank-faced. Then they look to the respiratory therapist who, oblivious to it all, is still fussing with the pop-off valve.
“Pneumothorax. The kid's got a pneumothorax.” But as you say this suddenly you are not sure. It's possible, but there are other potential causes, all of which at this panic-stricken moment escape your mind. A pneumothorax is one thing, though, that could explain what is happening. It is also something you could fix.
You backtrack over to the view box and peer up at the x-ray. Was it there and you missed it? You search the image and think there is perhaps a little line there, in the apex of the left lung. Perhaps. Not clear.
A pneumothorax occurs when air is trapped in the lining of the lung. This can happen if the lung lining ruptures for any reason, and artificial ventilation is a very common reason. A simple pneumothorax causes the lung to collapse, making it harder for the patient to breathe. There is also a special kind of pneumothorax called a tension pneumothorax that can be more dangerous than that. Tension pneumothoraxes have a paradoxical effect. Every time the patient breathes, the amount of air in the lining of the lung increases, causing the lung to collapse more and more. Eventually the lung will collapse down to a useless stump. The more the patient struggles to breathe, the worse the pneumothorax becomes. The patient becomes cyanotic—blue. Having lost blood pressure, the heart can no longer pump blood.
If the condition is not corrected, the patient will die. Right in front of you.
T
he pressure created by the Ambu bag can easily cause the lung wall to rupture and a pneumothorax to develop. Maybe that's what happened here.
Treating it is simple. You must vent the lining of the lung so that the air can escape and the lung can, at least partially, rein-flate. This can be done most easily by “needling” the chest, which is exactly what it sounds like. You stick a needle in the chest wall between two ribs (second and third at the mid-clavicular line). The lung will remain partially collapsed, but the pressure in the lining of the lung will be gone. The patient can breathe again.
“Give me a twenty-gauge needle,” you tell Helen.
Carol is still doing CPR. You watch her for a moment and you doubt yourself, doubt the monitor, the Ambu bag, the needle. And yet, fiercely, you know you are right. There can be no other explanation.
Besides, you think, if it is something else, then the baby will he dead anyway.
“Hold CPR.”
You listen to the lung fields as the respiratory therapist bags. There are breathing sounds on both sides—that doesn't rule out a pneumothorax, though. The chest is so resonant that it's easy to be misled. You listen closely. It does seem to you that the lung sounds on the left side are a little softer than the ones on the right. “There,” you say aloud and point with the needle. You are talking to yourself, trying to steady yourself, steady your nerves.
A 20 gauge needle—a little longer than this baby's finger. You unsheathe it from its hub and brace your fingers against the baby's chest wall. It's all of one piece, aiming, inserting, pushing deep through the muscles, and then a slight pop. You are either in the lining of the lung or in the lung itself. The difference is literally life and death.