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Monday
Sep212009

"Best of" Week: Reality Rounds

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For They Know Not What They Do

Our eyes meet briefly.  She is desperate, and scared.  I look away.  The pain is intense.  It makes it hard to think, hard to concentrate.  She is six months pregnant and in active labor.  There is no stopping it.  All is explained to her.  The slim chance of survival.  The enormous chance of death and profound disability.  “Do everything please.  My baby.”

We do everything.  The father watches us, stands over us and prays.  His infant could fit into his hand.  520 grams, barely a pound in weight.

We do everything.  Dry the infant with towels.  Careful.   Not too rough.  Do not want the gelatinous, friable skin to break and bleed unto the blankets. Listen for heart sounds.  Heart rate is barely 60 beats per minute.  No need for chest compressions.  We breathe air and oxygen into the tiny lungs.  Careful.  Too much air can blow a hole in the tiny lungs.  Too much oxygen can cause lung damage and blindness. We walk the wire.

The physician intubates the baby’s trachea.  The endotracheal tube is as small and narrow as a pen.  The heart rate rises.  Forgive me for sadness that the heart rate is increasing.

We rush the baby to the neonatal intensive care unit (NICU).    The baby’s heart rate is still low, in the 70’s.  We cannot detect a blood pressure.  We handle the baby gently.  Any sudden changes in movement and blood flow can cause bleeding in the fragile ventricles of the baby’s brain.   His oxygen saturations are in the 50’s (normal is upper 80’s and 90’s).  Forgive me for wanting to stop. We push epinephrine (adrenaline) into the tiny airway, hoping to increase the heart rate and circulation.  It works.  We flood the infants lungs with Surfactant, a soapy looking liquid medications, that keeps the baby’s alveoli (small lung sacs that exchange oxygen) from collapsing on themselves.  His oxygen saturations start to rise, 80%, 90%.  We decrease the amount of oxygen the baby is getting, so as not to further damage his fragile lungs.

Central lines are placed in the infants umbilical cord.  We check a blood sugar.  It is 12.  (Normal is above 45).  The clock is ticking.  Every second with no blood sugar feeding the brain, the cells will die.  We do not wait for the X-rays to start the IV fluids.  We give a bolus, a whopping two ml of D10W sugar water.

His blood pressure is barely detectable.  We give two boluses of normal saline, five ml each.  The blood pressure stays low.  We need to start a dopamine drip.  The central lines are not in good position. We cannot risk starting a vasoconstrictive drug in these lines. This could cause a vasospasm in the vessels feeding the infant’s intestines, starving these tissue of blood and causing them to die.    I start a peripheral IV in the baby’s arm.  His skin is see through, it is not hard to find a vein.  I cannulate the infant’s vein, which is as thin as a hair.  He does not flinch.  I flush the cannula gently with fluid.  The baby’s skin is so thin, you can see the flush of fluid travel in the vein, up to his heart.   Forgive me for being proud of this skill.

The father comes in the nursery to see his son.  He touches the baby.  The skin feels cold.  The baby lays under a radiant warmer, on a warmer mattress, and he is wrapped in clear plastic to prevent further heat loss.  The father talks and prays over his baby.  The baby twitches and squirms in response.  His eyes are still fused shut, he can not open them.  We council the father again of the possible outcomes for his son.  A 3% chance of survival while suffering profound neurological defects.  We explain the chances of infection, heart defects, bleeding of the brain, chronic lung disease, cerebral palsy.  The father nods his head.  He only sees his son, not the future, not statistics.  He wants everything possible done to save his son’s life.  Forgive him for he does not know, can’t possible know.

We continue to work on this tiny baby throughout the day.  Two nurses, a neonatologist, a respiratory therapist, constantly at the baby’s bedside.  Ventilator, central lines, peripheral lines, four IV pumps, cardiac monitors, leads, tape covering the baby’s arms, abdomen, and face.  He lays there motionless, as the best of medical care and technology fight to keep him alive.

Forgive us for we know what we do.

 

*** 

This post originally appeared on Reality Rounds on August 11, 2009 and was submitted by the author for “Best of” Week.

 

Prematurity is the single largest cause of infant morbidity and mortality in the United States.  The anonymous NICU nurse who blogs at Reality Rounds submitted this post as part of her continuing effort to educate the public on what it takes to care for these vulnerable patients.

 

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Reader Comments (13)

I can't know for sure what I'd do, but my husband & I agree (obviously not actually in the situation, although I can't see us changing our minds) that if we had a baby that was born before 28 weeks, we would let him or her go. The pain & suffering the littlest ones go through just to have even a remote chance is too heartbreaking. I don't even want to imagine losing a child (though I've been doing it a lot lately for some reason), but what happens to very premature babies to keep them alive seems too much like torture to me for me to want to inflict it on my baby, even if it meant letting him die.

September 21, 2009 | Unregistered CommenterLisa

What is the point of this? That we should do nothing and let the child die? That it is compassionate to wrap him in a towel and let him fade away? No. I completely reject that notion. My water broke at 23 weeks. Had I taken that view, my 4 year old son would be dead. It disturbs me to my core that some treating my son could have thoughts that he would be better off dead. He would not. We would not. You're right. You should ask for forgiveness.

September 21, 2009 | Unregistered CommenterLauren

Torture? Giving my son the treatment he needed was not torture. He is a happy, healthy 4 year old. His only issue from prematurity was a slight hearing loss. Such "compassion" results in sitauion like a dear boy in England who was born just days earlier than their artificial cutoff for treatment. He died after breathing on his own for 2 hours. Keep your compassion. I will do everything in my power to fight for my children.

September 21, 2009 | Unregistered CommenterLauren

Lauren, thank you for sharing your story. I think many of us cannot fathom what this is like.

September 21, 2009 | Unregistered CommenterClaudia

Claudia. I'm sorry that I've been so blunt. I'm very emotional about this. The idea that some of my son's nurses could have been thinking that it would be better for him to die gave me chills. So many of our friends and family members thought our son was going to die, and opined that perhaps it would be better if he did. My mom even brought up her friend's suicidal sister who had cerebal palsy and now wished for death. All the emotions I felt 4 years ago in defense of my son have come flooding back.

September 21, 2009 | Unregistered CommenterLauren

Lauren,
Honestly, the last thing I would want is to cause you more pain after all you have been through. I did not want these extremely premature infants to die. Not at all. I would not be a NICU nurse if that is how I feel. Being a NICU nurse is not a job to me, it is a calling. Caring for babies is my passion. The point of my post was to show the emotion and ethical dilemmas of working in the NICU. I had a lot of parents of extremely premature infants respond to my post. I am in awe of your strength and love for your children. I have always thought of it as an honor to care for these most vulnerable members of society, and to help nurture families. To think that I, and other NICU nurses, are being thought of as "wanting babies to die" is saddening.

September 21, 2009 | Unregistered CommenterReality Rounds

My step mother lost a daughter at 23 wks because her physician did not consider the fact that she had, had a cone biopsy done a year prior, and her cervix would not be able to hold the weight of a full term pregnancy. She and her husband opted not to try and save Lilly, because of the statistics, but she maintains that they made a decision that was right for them, and that it was an individual one. Lilly's footprints sit in a frame next to the ones of her two brothers who were carried to term and delivered via necessary c/sections because my step mother's cervix was stapled shut to prevent pre-term labor.

I don't know how I would make that decision. I THINK that because of my beliefs I would want to try and save the baby, but I would also NEVER want to support a life that wouldn't want to be.

A very powerful blog and blessings to the parents that inspire them, and the nurses that carry out the choices we make. I don't think that allowing a young life to fade gently would be any less hard for a nurse or doctor to watch than trying to save one against terrible odds. Thankyou for doing the job that I could not.

September 21, 2009 | Unregistered CommenterKM

I have two friends, who do not know of each other, who both had babies at 25 wks gestation in May of 2006 (while I was 25 wks pregnant with my son.) One baby was a boy, one baby was a girl.

3 years later both those babies are happy healthy 3 yr olds. You can see no difference at all between each of those micro-premies and my son born at 41 weeks gestation. If nobody told you, you'd never know they were each born 1 pound, and my son was born 8 lbs. In fact, because of the special care and attention they got, I think they're farther along than my own son. I know that the boy is at least potty trained, where my son is not.

I don't know what that says, but to me it says that it's worth it to try. So long as there's a shot, and what's being done to the baby isn't terribly painful, it seems like we have to try. I can't imagine these friends' lives without their pre-schoolers.

September 21, 2009 | Unregistered CommenterTheFeministBreeder

What a powerful post. Thanks for sharing, Jill. I've enjoyed hearing Reality Rounds' perspective. It has definitely given me a lot to think about.

September 21, 2009 | Unregistered CommenterBuscando la Luz

RR, I appreciate your clarification. What really upset me were the comments about the ambivilance to the rising vital signs. That really struck a cord because my son was born with an APGAR of 2, but within minutes was stabilized. It just haunted me to think of someone seeing him moments after birth, gray and listless, and not cheering when he began to improve. I very much appreciate all the work of NICU nurses.

September 21, 2009 | Unregistered CommenterLauren
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