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.