Monday, April 02, 2007

Futility

Born too early and nothing is going right. Systolic pressure hasn't been above 20 in 8 hours despite dopamine and dobutamine. Hematocrit and platelet count are still dropping in spite of multiple transfusions. There was a brief resus earlier in the day - only one round of epinephrine needed to bring back the heart rate, but it really isn't looking good.

I glance up at the monitor above me and see one QRS complex on the left side of the screen. Our monitors are all interlinked and when an alarm goes off, everyone can see where the problem is. I hear, "Can someone get me an epi?" Calm voices, no anxious shouts, just a request for assistance. Most of us have been doing this a long time and we work well as a team. She has the epinephrine in her hand by the time I reach the bed seconds later.

The heart rate is still in the 30's so I start chest compressions and she draws up the epinephrine. Someone else picks up a clipboard and starts recording. The nurse practitioner asks for bicarb and another nurse has it in her hand, drawing up the dose.

6 rounds of epinephrine, at least 2 rounds of bicarb, 20 ml of saline for volume expanders. Hemoglobin is in single digits now. The blood pressure is better, but only with chest compressions. There has been no response at all to the resus drugs. I feel like I'm making a depression in the chest and realize that the baby is rapidly becoming edematous -- leaking all the volume expanders into the subcutaneous tissue. The blood pressure monitor on the arterial line shows a decline in the blood pressure although I have been very consistent with the chest compressions. 10 minutes into the resus, someone calls the neonatologist at home. He's on his way.

A blood gas to see how things are progressing - base excess of -20, pH so low there's clearly no point in continuing, but we can't stop until the neonatologist arrives to call the code. There's an occasional complex on the screen now, but when I stop compressions, there is no pulse. No audible heartbeat. It's pulseless electrical activity. I resume compressions and we wait. When the neonatologist arrives I stop for the last time.

Too little. Too immature. He never had a chance.

8 comments:

Karen said...

You do a tough job and you do it well. For whatever reasons they cannot all make it and that's so heart-wrenching.
God bless you for the care you give these little ones!

Genevieve said...

I don't know how you do it, and I'm thankful that I haven't needed your awesome skills personally. But I'm also very thankfuly that you DO do it... and humbled by your care for even the tiniest (and least likely to survive) babies in your charge.

Judy said...

They can't all survive. We usually have a pretty good idea which ones won't. Those we hope won't suffer too much while they are in our care. Sometimes they surprise us, though, and make it.

NNP said...

These are the days that not only the family needs comfort and "hugs", but so do we.

Labor Nurse said...

I agree with NNP. Here illustrates one of many reasons I don't do NICU. I'd have such a hard time doing what you do.

Judy said...

labor nurse,
And full term FDIU's aren't impossibly difficult? 4th and 5th losses from women who desperately want a baby? Abruptions where you're lucky to save the mom and baby has 0-0-1 APGAR scores?

I couldn't do your job either -- but I'm glad there are folks like you who can!

Hannah's Mum said...

I'm not a NICU nurse, just a one of the Mum's that went through it all.

I can't tell you enough how much we appreciate the work you do. One of the mums I know is eternally greatful that she had such loving and caring nurses by her sons side when he died. She lived hours away and wasn't able to be there with him.

I honestly don't know how you do it. It must seem such a thankless job sometimes. I read one of your more recent posts and I was glad to see that those 'updates' the mums send are regarded so well. I often worry that I'm just bothering our old NICU with stuff like that.

Judy said...

Hannah's mum,
You're definitely not bothering the staff with your updates. Even new staff members like to see the photos and letters from the families.