Hello, Baby! Goodbye.

23 weeks, male, mom had prolonged rupture of membranes and chorioamnionitis - an infection of the fetal membranes and amniotic fluid. It doesn't get much more grim than that in the NICU. This baby has about as much chance as a snowball in Death Valley in August. The perinatologist's recommendation was that we simply do nothing. The parents want us to do "everything possible" and that's what we are going to do. The parents cannot possibly understand what "everything possible" means - or why we do it reluctantly, but with all possible skill.

It's not my favorite part of the job, this fending off death for a few hours until there is simply no more to do. Even more difficult is facing the parents and trying not to destroy their hope -- but trying harder still not to offer them hope that simply does not exist. They want so much for me to say "yes" when they ask if the baby is doing better now. He's not really. He looks it, but I've seen the lab results. I know about the unofficial, but devastating head sonogram - the docs haven't shared that with them just yet, so I dance quickly away from that minefield.

I see the dark spots - the petechiae and hematomas that result from the overwhelming infection that has destroyed most of his clotting factors and platelets. We're replacing fluids, platelets, red cells, electrolytes - but not as fast as they're leaking through his gelatinous skin and being destroyed by the infection. I handle his tiny limbs as gently as possible so as not to cause any more damage, but I must turn him frequently, because lying too still causes his head to flatten. I titrate his dopamine and give more boluses of saline solution and sodium bicarbonate to sustain his blood pressure and reverse the acidosis that will surely kill him if it is not corrected, but I know that his serum sodium is rapidly rising -- approaching dangerous levels and soon there will be no more to do.

An aunt comments that this place is filled with angels. I pause a moment and realize that she is right. It is alway so when one of these little ones hovers between life and death. Perhaps it is always so and I am most aware of it at such times.

With great reluctance, I try to start an IV in veins almost smaller than the catheter, because we must give insulin now, and it's not compatible with the fluids in the existing IV lines. I call the doctor to do it, because I cannot bear to try a second time when my first attempt fails. She is as reluctant as I, but there is no one to whom she can pass this. She succeeds on the second attempt and we are able to continue our efforts to postpone the inevitable.

I leave in the morning knowing that he will not be there when I return less than 12 hours later. My husband asks how I feel about this baby dying. My answer: I'm sad for his family, but happy that he has moved on to a better place.

I'm not exactly proud of myself

But I'm not really sorry either.

Early last month, I had blood drawn for what was to be my very last CEA level. Hopefully ever. Yes, that's Carcinoembryonic antigen. It was 4.9 when I was diagnosed with colon cancer 5.5 years ago. The highest it's been since then was in the range of 0.7. Until last month. It hit a whopping 1.9. Normal, but still enough to worry me a little, considering that for the last 4 years, it's been < 0.5. All I really wanted was to repeat the test, but my internist referred me to the oncologist who, for reasons unknown to me, did not return my phone calls. For 3 weeks.

I dropped by his office on Monday and asked the secretary whether he'd gotten the messages. She said she'd see if he had a minute to speak to me. Half an hour later, she returned, chart in hand, to inform me that the doctor said I had nothing to be concerned about. The result was normal. Wrong answer. Even from him it would have been the wrong answer. I can read lab reports and I've been very much aware of the normal values for this particular test for more than 5 years.

"Probably nothing to worry about, but if you'd like we can repeat it in a couple of months just to be sure" would have been OK, but by the time a patient, or in this case former patient, calls 4 times and drops by twice, with no response from the doc, sending out a secretary to pat her on the head is definitely NOT the best approach.

I don't remember everything I said, but the gist of it was that I didn't plan to bet my life that he was guessing correctly. Pretty much what I'd told the internist who thought I didn't need that first colonoscopy. I also remember demanding a copy of my chart. The secretary said she'd have to talk to her manager and 20 minutes later ushered me back to speak to the oncologist.

That's how I ended up in the PET/CT scanner this morning. Overkill, I know but I hope the doctor was right.


Update, 12/13: The doc called today. He was right. Now I just have to worry whether the insurance company will consider this medically necessary. If I have to pay for it myself, it will be worth it for the peace of mind - but don't tell them.

Thank you one and all!

Thank you for being so calm and reassuring when you answered my 911 call. Thank you for asking all the right questions to keep me focused and breathing. I was terrified.

Thank you for coming so promptly. It only seemed like forever - it was probably about 5 minutes.

Thank you for being so gentle with my son. He was frightened too. Probably not as frightened as his mom, but scared.

Thank you for not laughing when he scored his pain as a 2. We thought he was just being a tough guy. Fortunately, the truth was that your ice pack was pretty much all the treatment he needed.

I felt so bad when the little guy caught his foot in the strap of my purse and fell headlong onto the concrete garage floor. I was afraid he'd broken a bone or torn ligaments because he hit so hard. When his EMT brother cut away his sweats and we saw the rapidly swelling bruises, he ordered me to the phone to call 911 -- probably as much so Matthew wouldn't see how frightened I was as because we didn't think we could safely move him in one of our vehicles. Matthew thought the ride was "cool" - must be because you were so nice to him. Thanks for that too.

The Sword

I just came from Maddog Medic's story about Bouncing Babies and Bleeding Heads. I do like happy endings. He reminded me of episode at my house several years ago.

I left my youngest son in the care of his older brothers (then teenagers) while I was taking a shower. As I was getting dressed, the little guy started pounding on the bathroom door:

"Mom! Mom! Big brother cut himself ..........


With a sword!


There's blood everywhere!


3 big puddles!


Needless to say, I wasted NO time getting downstairs where I found.........



Not a drop of blood anywhere and the 2 older boys sitting at the kitchen table calmly discussing whether or not they needed to call 911.


I made the mistake of peeking under the dressing covering the wound. No, that injury didn't need a 911 call, but mom very nearly did. The brother who controlled the bleeding and applied the dressing is now a student in the paramedic program at our local community college. The other one is barely has a scar, despite the many sutures required to close the wound, and he's still collecting swords - but he has learned to be VERY careful with the sharp ones.

Apology

I had to turn on word verification on my comments section. I was getting spammed. I know some people have difficulty with the word verification, but I was getting tired of deleting a comment seconds after posting.

I hope this works. I hope my spammer smashes his/her knee on a big rock very soon. It wouldn't hurt my feelings if s/he broke a wrist in the process. Both of them, even.

Transition

Double whammy Friday night: Charge nurse AND admissions. Sometimes it's entertaining.

The shift started with a bang -- 2 high risk deliveries. First one, no problem. Second one, C-section. Baby was nice and pink, but wouldn't stop grunting. In case you've been out of pediatrics for a while, that's a behavior newborns display when they're struggling to get or keep their lungs fully expanded. The nurses in the well-baby nursery, very wisely, will not accept babies engaging in this particular activity. We suspected that this baby was just slow making the transition from intrauterine to extrauterine life, but after 15 minutes of stimulating (making him cry), suctioning (also making him cry), and applying PEEP (positive end expiratory pressure to help expand the lungs -- and make him cry), we decided that we'd have to take him back to the NICU with us.

Once there, we made the baby cry some more by drawing blood to send to the lab. This is jokingly called a "theraputic" workup when the baby ceases all disturbing behavior (grunting) after being caused to cry so much. Net result, we had a CBC (complete blood count) which had some minor deviations from the norm (13 bands) and a baby who was, by then, asymptomatic. The neonatal nurse practitioner on call decided to repeat the test in the morning, but went to bed without actually writing the order and I hustled the little guy back to the waiting arms of his mom - still in the birthing center.

6 hours later, the first year pediatric resident covering the well baby nursery sauntered into the NICU in search of the nurse practitioner. He allowed as how he wasn't sure whether to wake her, since she attended the delivery, or his senior resident. On the advice of the NICU staff, he was about to go wake his senior resident when I thought better of that suggestion and asked him which baby was causing concern. Baby #2, of course.

Since his concern was focused on that CBC, I thought I could put his mind at ease by assuring him that the nurse practitioner had already decided to just repeat the test. He was almost convinced, but there were these complications:

The baby was still asymptomatic, but there were factors in the mom's history that worried him. Did he know something we didn't? After reviewing his list of concerns, we found only one thing the nurse practitioner hadn't known - but we really don't worry about abnormal pap smears. He's certainly thorough - and concientious. He even listens to nurses. I think he might be a keeper. Oh and he did go order that repeat CBC.

Spruce Lake Outdoor School

I spent 3 days last week enjoying the wilds of northeast Pennsylvania with my 10 year old. OK, it wasn't really very wild. We slept in beds and used flush toilets and ate food cooked in an actual kitchen, but it was fun - and very educational.

That body of water in the picture? It's the lake. That speck in the middle of the picture? If you look very closely, you'll see that it's a 10 year old boy wearing a harness and a helmet and flying over the lake on the zip line. I think it was the high point of the trip -- well, that and playing air hockey with a friend during his few free moments.

My son learned quite a bit about how deer impact their environment and about how farm land returns to its previously forested state over a period of many years. I learned that while I can keep up with 10 year olds for about 2 hours in the mountains, 3 hours is a little more than I can handle without more advance preparation (training). Tripping over that log didn't help much.

We also had great fun studying "Skins and Skulls" and doing a little forensic study in a CSI format (Critter Scene Investigation). My son made his first attempt at the climbing wall and was very proud that he made it halfway up. Next year, the ceiling!

I learned some new techniques for redirecting challenging 10 year olds which will come in very handy in my Cub Scout den this year. I also learned that bifocals are a BAD idea when walking on uneven ground. I've fallen several times since getting the bifocals. Two falls in 2 days finally got my attention. Call me a slow learner. My knee will recover, according to the orthopedist. He advised me not to fall on any more big rocks. He didn't even snicker when he said it. Maybe I should try knee pads while I'm waiting for the new glasses.

IV therapy escapades - part II (Uh-oh!)

Me: "Uh-oh."

Patient: "That doesn't sound good. What do you mean, uh-oh?"

Me: "Just a little tape sticking here, really no big deal"

Patient: "You need to be careful saying things like that when you're working on someone's central line."

Me: "Sorry. I'm used to the babies in the NICU. They don't notice things like that. Thank you for the reminder that adults can actually understand what I'm saying."

Patient: Laughs "Just don't do it again!"

That was my first day on the IV team. I saw him many more times in the 3 years I worked there - he was a regular, and always with a central line. He never let me forget that intro, either.

Note to my co-workers

Those folks you think are weird? They just operate from a different set of instructions. They're internally consistent -- and right much more often than you think. No, I'm not "sucking up", I'm learning about THEIR database so I know how to negotiate with them instead of fighting. This isn't about me, it's about that baby in the bed.

Difficult? Them? Some of you folks make them look like angels. Unfortunately some of you folks also provoke bad behavior from them. Difficult? You haven't seen difficult until you've taken care of MY family. Just ask the HMO answer nurse who ignored my mom. Ask the interns and medical students who were involved with my husband's care when he had surgery. Ask the poor suckers who got stuck with me when I had surgery a few years back. Difficult? You don't know how lucky you are.

Negotiating instead of bullying, there's a concept. Did you notice that they've gotten more compliant with the plan of care? Did you notice that the baby is gaining weight now? Did you notice that she's doing better?

No it's not always easy, but the baby is winning. Besides, I've found that the parents are interesting, intelligent people with some ideas that could make for better care for some of our other patients. Yes, I know some of you have always thought I'm a little weird too.

Note to self

1. Check the gmail account.

2. Make a note of your password. Your brain is like a sieve some days.

IV therapy escapades - part I

Things have been blessedly uneventful in the NICU lately. The census was down to 10 last weekend and the babies are all doing well. I could tell old NICU stories, but instead, I think I'll share a few of my IV therapy moments.

A long time ago, in a hospital not so very far from my home, I took a PRN position as an IV therapy nurse. That means whenever they had a need and I had a few spare hours, I'd go do some stick-and-runs, change a few central line dressings, assist with central line placements, and generally lighten the load on the regular staff so they could do things like teach people how to care for their implanted venous access devices (Ports and Hickmans, mostly) once they got to go home with them.



As you doubtless know, patients have the right to refuse pretty much any intervention - provided they're competent to make that decision.

The patient's IV had infiltrated and the staff was waiting for me to restart it. I soon found out why they hadn't tried themselves. I didn't even get a chance to introduce myself when the man announced, "If you try to stick me with needles, I'm going to hit you!" As a rule, I'd just document the refusal and go on to the next patient, but I wasn't entirely certain that this patient was competent to make that decision. I was in no mood to find out if he meant what he said about hitting so I quickly made a U-turn and found his nurse. She assured me that he had been evaluated by the psych folks, that I could legally restart the IV without his consent if necessary, and that she'd find me some help to restrain him.

The help didn't look substantial enough to keep me from getting hit - and I really prefer the cooperation of the patient in any case. When I re-entered the room, I explained that Dr. "X" really felt that he needed his IV and that I didn't care to be hit. I suggested that instead of hitting, he could share his feelings about the procedure - in whatever vocabulary suited him.

He was quite cooperative after that. He spent the next 5 minutes telling me in very colorful language exactly what he thought of the hospital and of the nurses who'd been caring for him -- and Dr. X. He didn't swing at me, though. In fact, he held his arm quite still and even thanked me before I left.

The world is spinning a little faster

I got up on Wednesday and found that I couldn't quite keep up. Everything was spinning a little faster than usual. Blood sugar normal, blood pressure normal, no arrhythias even after a cup of coffee.

My head was a little stuffy, so I took some pseudoephedrine hoping it would help. Not much. I staggered through my day - including the retirement party for my husband Wednesday night.

Thursday, things hadn't slowed down, so I had my husband drive me to the doctor for a prescription which has slowed things a little. They had the CNN feed on there, covering the terrorist attacks on London. That certainly put my little inconvenience into perspective.

I got home and a friend had forwarded the email about the folks who survived 9/11 because of some minor "inconvenience". I'm sure you've all seen it. I usually grumble and delete things I've seen that many times, but it touched me that day in a way it had not previously.

Next, I checked a message board with a multinational presence to be certain that my friends there were safe. All were - and one had a brother-in-law who'd hadn't been in the World Trade Center on 9/11 because a meeting had been cancelled. This time, he decided at the last minute to telecommute. As someone there said, we're happy that her brother-in-law is safe, but saddened that someone's isn't.


My condolences to the people of the UK and to everyone who has lost friends or family in this assault on humanity. I'm a little late, but response to the suggestion at A chance to cut is a chance to cure I'm flying the Union Jack. I wish I'd thought of it myself.

Den Leader

Last week was Cub Scout Day Care week in our district. Officially, it's Day Camp, but many of the parents seem to believe that the requirement that they contribute some of THEIR time to the project is unreasonable. As a result, it's a struggle to come up with the 2-deep leadership required by BSA to protect the kids.

Why 2-deep? First, of course, having a second adult around provides a witness that the first leader didn't abuse or molest any of the kids. Second, it might just help to prevent any such abuse. Third, and perhaps more important, having 2 adults with each group of cubs means that one adult can deal with any emergency -- bleeding, fracture, seizure, allergic reaction, etc. -- while the other deals with the rest of the cubs and obtains any needed assistance.

Now that I've vented, I have to admit that I had a good time last week. This was my youngest son's third and final year as a Cub at Day Camp because he'll be a Boy Scout next summer. He may go back as a camp aide, but never again as a Cub. He begged me to be his den leader this year. I've always done something else at Day Camp and missed out on seeing his accomplishments. Not this year.

It was great to be there when he scored bulls-eyes on the BB and Archery ranges. He was happy that I was there when he singed his finger at the wood burning station and I was glad I'd served a term as camp nurse, so I was well practiced in saying "Yep, that's going to hurt for a while" without tears.

I feverishly searched the internet for skits only to find that my own Cub has a real penchant for adapting them to fit his den and his Day Camp. The skit was such a hit that his den mates wanted an encore.

I was exhausted by the end of the week, but it was a good tired. I had fun with the kids. I think I taught them a few things and I know they taught me a great deal. The parents who opted not to share this week with them have no idea what they missed.

Delayed Cord Clamping - benefits for preemies

Delayed cord clamping (30 seconds to 2 minutes after delivery) has been around for a while, but it hasn't been standard practice - at least not at my hospital - for preterm deliveries. That's changing thanks to some recent randomized trials on the subject. There have been several. They have different study criteria and slightly different outcomes. They all have one thing in common, though. There are benefits to delaying cord clamping for 45 seconds or longer, even when the baby is less than 30 weeks gestation.

45 seconds feels like a long time while you're waiting for the OB to hand over that preemie -- if you're used to the traditional quick clamp and immediate resuscitation. It was fascinating and a little scary to watch as the OB dried the baby, bulb suctioned his mouth, waited nearly a minute before clamping the cord and - unthinkable only a few weeks ago - offered the scissors to the father to cut the cord.

8 hours later, the admission nurse was still griping about the delay and the small study in Rhode Island found that "the DCC* group were more likely to have higher initial mean blood pressures and less likely to be discharged on oxygen. DCC group infants had higher initial glucose levels (*ICC=36 mg/dl, DCC=73.1 mg/dl; p=0.02)." and a meta-analysis of 7 studies found decreased need for transfusions and decreased incidence of intraventricular hemorrhage.

Risks? Apparently nothing significant was discovered over the course of several studies and hundreds of preterm births - both vaginal and C-section.


*DCC=Delayed Cord Clamping. ICC=Immediate Cord Clamping

A quiet night

NPC 24 weeks, FDIU. Ominous words appearing on the monitor screen listing the patients in the birthing center.

NPC - no prenatal care at 24 weeks gestation. That's not terribly uncommon in our part of town. Some of our moms show up for their first prenatal visit fully dilated at term.

FDIU - fetal death in utero.

The nurse from the birthing center called for our help. The baby had died some time prior to 24 weeks and she needed a more accurate weight than they could get on their scales. Could she use one of our scales?

Sure, come on over.

340 grams - about 11 ounces.

Do you think the baby has some kind of syndrome?

He looks pretty odd, but he was breech and the cervix had trapped the head for over an hour.

No, I don't think it's a syndrome, but I don't think we should take pictures for the mom to keep either.

We need some kind of memento. Footprints?

Tiny footprints - and perfect palmprints. Both smaller than my fingertip. Think she'll notice that I missed a toe on that left foot?

Probably. Now I wish we'd tried again. It was a quiet night.

One, two, three......four, five!

I work in a level 3+ NICU. We do nearly everything the largest NICU's do except some of the more complex surgeries and ECMO. We're not one of the biggest ones, our average census is 12. On any given day, we have anywhere from 3 to 23 babies actually in the NICU. Life is painfully boring at times, and a frantic whirlwind of activity at others. Fortunately, we have several staff members who are willing to come in at a moment's notice when it starts hitting the fan. Oh, and thank God for agency nurses who'll do that too!

On a recent night, we started the shift with 11 babies and 5 nurses. The board in the birthing center was full, and I was the lucky person in charge. It was looking like an average, reasonably steady night. Looks can be deceiving. The outgoing charge nurse mentioned that the only apparent "threat", the mom of the triplets had been having a few more contractions, but the perinatologist was hoping to get her quieted down again. He'd been able to do that for 6 weeks, so we weren't too worried. Everyone else in the birthing center was either full term or delivered already.

I made out the patient assignments and the phone started ringing as I tried to get 8pm cares done on my patients.

First, the nursing supervisor: Did we want an extra nurse for night shift? One of the agencies had called to offer us one. There was one nurse from the pediatrics unit available to relieve the evening shift nurse in the step-down room with the bigger babies, but nobody else if the triplets came. It was Memorial Day weekend, so only one of the nurses willing to come in on short notice was in town and not already working. I asked the agency nurse's name and immediately agreed to add her to the staffing pattern.

Moments after the nursing supervisor hung up, the birthing center called. We had an hour to get ready. Triplets. 28 weeks.

We've done this enough that we have it pretty much down to a science, but it's always an adrenaline rush. The admission warmers had been set up for days. The respiratory equipment was in place, and we knew who we needed to call. The back-up nurse quickly agreed to come in and even arranged for a secretary to come with her. She arrived just in time to check her admission bed and get her gown, cap, mask, booties, and gloves on and head over to the OR with the rest of the team: 2 more nurses, 3 respiratory therapists, 1 nurse practitioner, 1 neonatologist, and 2 pediatric residents. Once we were in place, the OB started and we very quickly had the babies stabilized and ready for transfer.

We have 3 transport isolettes, but we prefer to use our lightest one for trips around the corner from the OR to the NICU. As charge nurse, I had shuttle duty. That was my aerobic exercise for the night, or so I thought. The triplets were quickly settled into place, lines inserted, and respiratory support in place. They were started on CPAP, continuous positive airway pressure, to help keep the lungs expanded and ease breathing. The remaining staff adjusted assignments to cover the other babies. Things were looking good. Did I mention that looks can be deceiving?

The evening nurse offered to stay over a couple of hours if we needed her, but the triplets had been settled in so quickly that it didn't appear necessary -- until she tried to walk out the door. I caught the call from the birthing center just as she walked past me. Another patient had just arrived, 34+ weeks, in very active labor, 4-5 cm dilated and the first baby was breech. We had about 30 minutes to set up for that delivery. I interrupted the report to shout at her receding back "Please don't go!"

Did I mention that I love my co-workers? She stayed. Until 5.

At 34 weeks, babies can be practically ready for the well-baby nursery - or they can be quite sick and need full ventilator support. More commonly, they're in the middle. They just need CPAP. We had used the last of our older machines for the triplets and there was no time to rent, so we quickly got approval to bring out two new machines we'd just been oriented on - a couple of days ahead of schedule. Kudos to our respiratory therapy department for having them ready!

That delivery went smoothly, and thanks to the additional staff, we made it through the night. A week later, all 5 babies were doing well, but the census had expanded to 18. This could be a long summer, but I certainly won't be bored.

Virgin Birth

MaddogMedic had me laughing out loud about Peanut butter balls. That reminded me of a time I just couldn't laugh.


The NICU was small, but crowded, with 3-4 other nurses doing patient care nearby. The baby weighed about 8 pounds, and was only in the NICU for a more-or-less routine sepsis workup due to maternal history. I wasn't particularly busy with patient care, so I had time to listen to his mom, the only visitor in the NICU that late on Christmas Eve. She told me that most people didn't want to hear her story.

Once I'd heard it, I wasn't too surprised by that. You see, she'd never had sex. Never. She explained that her father didn't believe her, but her attorney did. Her OB believed her, but the neonatologist didn't - and so on. The conception didn't require technology, and her definition of sex excluded anything that didn't involve penetration. As she went through the details of who the father was, and just how the baby had been conceived, my co-workers disappeared one by one. I could see them laughing through the nurses station window behind her. Fortunately, they regained their composure before she got up to leave.


3 years answering a suicide hotline, I thought I'd heard everything. I guess not.

Requiem

Robert Louis Stevenson. 1850–1894

Requiem

UNDER the wide and starry sky
Dig the grave and let me lie:
Glad did I live and gladly die,
And I laid me down with a will.

This be the verse you 'grave for me:
Here he lies where he long'd to be;
Home is the sailor, home from the sea,
And the hunter home from the hill.


One part of our homeschool curriculum is memorizing poetry. That always goes better when my 9 year old son chooses the poem. He was enraptured by this one when he heard John Wayne recite it in a movie he watched with his dad. We let him stay up too late last night and watch the A&E movie based on John McCain's autobiographical Faith of My Fathers, where the poem appears again. Today he was tired and a little cranky from staying up too late, but no less enthusiastic about the poem -- or the movie. He'll have the poem memorized in a day or two, but I'll be answering his questions about POW's for quite some time.

Why that silly title?

Tiggers don't jump, they bounce!

That's a phrase from a book I read too many times to my youngest son. He's tired of hearing it. It still brings back fond memories. I'm hoping my grandchildren - sometime in the distant future - will like the book as much as he did.

It also is a warning. I expect this blog to be quite eclectic, reflecting my experiences and interests: homeschooling mom, wife of a soon-to-be retired federal employee, Cub Scout leader, night-shift NICU nurse, and much more. It will probably bounce from one subject to another with little rhyme or reason.