Duty Hours Pre-Form Part 3: Panic! At the NICU.

*Names and details changed to protect anonymity. . . you know the deal. . .

image credit - premature baby in NICU

By the time I reached my final year of residency, very little scared me.  As a fourth year veteran in a combined Internal Medicine and Pediatrics residency, I had faced my share of medical emergencies and had weathered some substantial storms.  My training took place in the 90's, so none of this medical experience was limited or abbreviated by the need to scurry out of the hospital to adhere to duty hours restrictions.  So by that last year? Chile, please.  My motto was (with a dust of my shoulders) "Bring it on."

Every three months we alternated between rotations in the Pediatrics department and the department of Medicine. In the first two years of training, those "switch months" were terrifying. As an intern, that first change over in October landed you squarely in a foreign land, kind of like a new kid in school that started three months late.  You'd be asking dumb questions about fluids in infants or trying to calculate dosages per kilo in 175 pound adults.  Not cool.  The second year was tricky, too, because it was punctuated by a belated introduction into the supervisory role.  All of your classmates in the un-combined programs had already gotten a six month jump on you, so here you were fumbling with finding your mojo as your interns gave you a hairy eyeball. It was just as rough as it sounds.

But then came fourth year. That glorious fourth year.  You were now the "super senior" and big man/woman on campus. . . the person they woke up late at night to get the impossible procedures . . .the one that incited cheers from trembling interns when they discovered that it would be you bringing all of your mojo to their night on call.  Yeah, baby.

One night in the late fall during my fourth year, I was the senior resident on call in the neonatal intensive care unit (NICU.)  The NICU at this particular hospital was a level III which meant that, with the exception of complicated surgical needs, most of the medically complex babies born at our facility stayed right there. There was no life flight helicopters to rescue us from the sickest of the sick or the tiniest of the premature.  And although I said that very little scared me by this point, a rough night in the NICU was the one thing that absolutely did. Scared the absolute crap out of me.

Babies. There's just something about babies that haven't lived their lives yet and the parents who are counting on you to do everything that always kept butterflies in my stomach all night long whenever I was there. We carried this pager called the "code pink" pager when we were on call. No, it wasn't pink or anything, but it did scream like a banshee whenever some mama was delivering a baby with any inkling of a potential complication.

Most times it was simple stuff. The cesarean sections were the easiest of all -- baby with a big head that wouldn't pass through mama's narrow pelvis. C-sections always got us called just to be on the safe side. Fortunately, all that meant was chuckles with the anesthesia team, smiles with the nurses and coos at the new baby who'd just been lifted out of a bikini incision.  My favorite part was seeing the mama's face when someone showed her the baby.  I liked being that someone, so usually leaped at the chance to swaddle the little pumpkin and whisk it over to the other side of the blue curtain as the proud papa smiled too.

The meconium-stained amniotic fluid calls were more complicated. You could arrive to a baby in major respiratory distress or find a bouncing baby with nothing but stained finger nails. Meconium is the fancy name for the poo that the fetus is supposed to hold until after the big arrival.  If the baby is under some stress, like infection or some issue with mama's health, they let it go in utero. When the water breaks, that greenish fluid signals the OB to call us for back up--and to get that baby out of there quick.

Then there were the premature deliveries. Those dear, dear mothers sitting in bed strapped to a monitor and praying to God that the baby wouldn't come out.  In these cases, we would follow our attending and fellow into the room and speak with the mom about what to expect. Mom would get steroids to help the baby's lungs to speed up at maturing while the high risk OB team would do all they could to keep the fetus in mom as long as possible. But in the times where the delivery was inevitable, for the most part we were ready.  Ventilators and infant warmers rearing to go and bad ass NICU nurses ready to pounce on that baby until it was medically copastetic.

This night we'd hustled over to a few c-sections and one or two meconium fluid deliveries. At least one of those babies had some complications, so it required us to put in lines and figure out the ventilator settings. We got that baby stabilized and later we admitted a 29 1/2 week preemie that, other than being a little on the small side, was doing fabulous. Combine this with the babies already in the NICU and our hands were full. Even though all of these things had us hopping, for the most part, it wasn't too bad of a night. And even better, the neonatal ICU fellow on call with me--Shanthi--was one that I trusted. She was smart and organized and not the the least bit lazy. All was well with the world. Especially since I had her with me in the one place in the hospital that challenged my sphincter control.

It was after midnight and finally things were slowing down in the unit. "Let's get some sleep while the getting is good," said Shanthi in her melodic Indian-slash-British-tinged accent. "You guys go to bed."

"No, Shanthi, I'll stay in here and crash in this recliner chair out here. Besides, you know the nurses call the resident for the minor things not you. Here--give me the call pager." I wiggled my fingers and opened my palm. "No worries. I'll call you if something's up, alright?"

She paused for a moment and then it registered. I was a fourth year. A super-duper pre-chief residency senior, no less. She smiled in acknowledgment and unclipped the pager from her hip.  Before I knew it, she and the intern had disappeared into the call rooms. I kicked off my clogs and hoped no one could smell the sweaty call-night feet that immediately wafted up toward my nose. I thought about putting them back on, but before I could I fell fast asleep in a snap.

I have no idea how long I was sleeping. I know it was long enough to feel good and short enough to not want it to end. Like always, at first I dreamed about placing arterial lines with 24 gauge needles and remembering the steps to neonatal resuscitation. Then I'd float off into some other magical place with no pagers and no post call clinics. . . . .

First came the sirens on the pager. Then came the voice of the operator blaring through the tiny device:

"CODE PINK! CODE PINK! EMERGENCY DEPARTMENT! UNKNOWN DATES!  CODE PINK! CODE PINK! EMERGENCY DEPARTMENT SIDE A! UNKNOWN DATES!"


Unknown dates?!? Crap!

"Unknown dates" was the worst. It was the most like Russian roulette of all the NICU situations in my opinion. There was no way to predict what you'd get. Either it would be an unfortunate teen who'd concealed a term pregnancy from her (also unfortunate) folks with basically no complications or a very early delivery that came so fast that there was no time to get a history.  The latter these two was a bullet straight to the brain. And unknown dates in the EMERGENCY department? That was the nail in the coffin.

Before I knew it, my stinky feet were stuffed into those clogs and I was off running like Flo-Jo toward the ED.  I could scarcely hear the NICU nurses -- one running steps a few steps behind me and another getting an infant warmer ready.

Once I pushed open the heavy door leading to the stairwell and made it down a couple of flights of steps, it dawned on me. I was the only doctor running. I knew Shanthi had been working so many wretched hours when I made a rookie mistake--taking the code pagers and assuming nothing could go wrong. Normally, she would have never agreed to such a thing. She was too responsible for that. But Shanthi was a second year NICU fellow and I was a fourth year Med/Peds resident. Technically, we were only one year apart in our training so she gladly bit when I offered. Plus she was so physically and mentally exhausted that her body melted at a chance to sleep perchance to dream.

Once I reached the corridor heading to the ED, the reality of what I might find began to press on me like some oppressive weight. I started reflexively praying for it to be nothing serious. I felt a tiny bit relieved when Olivia, one of the most bad-ass NICU nurses ever (wait, are there any other types of ICU nurses?) came jogging up beside me.

"Any clue about this mom?" she said.

"None at all," I replied still panting and heart feeling like it would jump out of my chest.

"Where's Shanthi?" Olivia queried with widened eyes.

I could feel the panic rising up in my throat as we neared the A side of the ED. "I have the code pagers. Shit, Olivia. I need someone to call her once we see what's up."

"NICU TEAM!" we both announced to the crowd of Emergency Department faculty and residents surrounding the patient. The crowd parted like the Red Sea to let us in. One of my buddies who was a senior ER trainee was gowned and gloved, prepared to catch the baby. She nodded in my direction and I returned the favor. An OB/Gyn resident was quickly getting ready to take her place at the foot of the bed.

I surveyed the setting. This mother was no teen. She looked to be in her mid-thirties and my chest started immediately hurting when I saw the tears squeezing out of the sides of her eyes. A tiny gold band on her left finger caught my attention. I didn't see her husband, but this did not look like what she had in mind at all.

"21 to 23 weeks according to dates. Prenatal care out of state. Here visiting a friend for the weekend. Water broke and started contracting and dilating. She's been given magnesium already but she's dilating and completely effaced." My ER friend was all business when she told me the little history she knew. Her voice was steady and staccato and she spoke like it was into a radio and not in earshot of the pregnant mother. It was a lot to take in.


"Shit." I realized I'd said this out loud but honestly? So much chaos was going on in there that my one expletive paled in comparison to the others flying around.  In came two more NICU nurses, Jasmine and Alice with the infant warmer and Marge the respiratory therapist extraordinaire preparing themselves for the delivery.  Marge hands me a pair of sterile gloves, a size 0 laryngoscope, and quickly began attaching things for an imminent intubation.  I had intubated many many babies by this point, but unknown dates always freaked me out.  I followed what I'd been taught and stood ready to secure an airway for this likely very premature baby. My heart was already pounding in my chest; I was sure anyone nearby could not only hear it but see it lifting my shirt off of my chest.

Because, see,  there was something else to all of this. Those gestational dates. 21 to 22 weeks. Somewhere in the gray zone for viability and a not gray zone at all for medical complications. Shit, shit, shit.  I looked around to see if somebody had called Shanthi but no such luck. Everything after that happened in slow motion.

The OB resident couldn't even get into place before this extremely premature baby came sliding out into the sterile gloves of the ER resident. More of those tears squeezed from the mother's eyes and the minute I saw that baby, I swear I wanted to do the same thing. She couldn't have been more than 22 weeks. A gelatinous little angel with skin as transparent as Saran wrap, fused eyelids, and the tiniest human chest I'd ever seen pulling hard over even tinier lungs for air. Her swollen genitals made me pause for moment before affirming that it was indeed a girl. An extremely premature girl. They positioned the infant right in front of me. . . all I needed to do was intubate.

My heart and hand froze for a split second as I looked at this sweet, sweet baby. . .pulled out of the oven waaaay before she was fully baked. Shit. I didn't want to be a part of this. I felt like I was going to suffocate from the fear and also from all of the people moving around me. Shit. She was no bigger than the center of my palm. This was crazy. Damn, this baby wasn't ready to be here. She wasn't. I glanced once more at her already grieving mama. Grieving the normal new mama life that she had envisioned and trembling with fear at what this new reality would be. Water broke. Out of town. No birthing plan or funky reggae music blaring in the delivery room. No husband coaching or grandmothers squealing in delight. Shit.  Once more I looked at her baby--all of this taking place over the course of a second--and something in my head questioned whether a resuscitation in a neonate this premature was even ethical.  I wasn't sure -- which to me was instinctively telling.

But there wasn't time for all that. Before I could even think further the scope was in her minuscule mouth and my eyes were fixed on her bleating pink vocal cords. Marge placed the endotracheal tube squarely in my hand and in the blink of an eye she was connected to a ventilator and off we went to the unit. Whether her mother liked it or not.

Shanthi met us the minute we stepped off of the elevators. "Jesus, Kim!" she gasped incredulously while staring at the baby and helping push the rolling warmer, "Heavens. What were the dates again?" She was saying the first thing that came to her mind when seeing this terrifyingly small newborn. I didn't blame her.

"22 weeks?" I answered flatly. Shanthi raised her eyebrows at me. "Okay. Maybe 21 and a half? I don't know. There was no history." I felt my lip quivering and quickly bit down on it.

21 and a half weeks. But what was I supposed to do? Say no right then and there? Shut the whole operation down and be the horrible devil that gave up hope? I knew this was complicated, I did. But something told me that doing everything wasn't necessarily the best option. Especially since the mom wasn't in on it all. This sucked. Royally. Shanthi knew that so she backed off.

The baby was here and alive and under our care so we leaped into action. In went the lines in her umbilical vein and artery. Every few seconds we checked the results of the blood gases sent to assess ventilatory status.  Baby P.  We worked on Baby P until the morning teams came in.

Shanthi and I spoke to Baby P's mom early that morning. Eyes bloodshot, body haggard and now with feet so sweaty and dog tired that I could smell them straight through my clogs without them even being off.  I did my best to explain what had gone on to Baby P's mom, and learned that morning that baby P was a little under 21 1/2 weeks gestation.  Shit. This was mom's first pregnancy and things had been going well. Turns out she had something called cervical insufficiency--where the cervix can't hold the baby inside once it reaches a certain size and weight. Most moms don't know they have this problem until it's too late.  Fortunately, the next time around (if there is one) mom can have her cervix secured surgically with a cerclage.

But now her extremely premature baby daughter was here. And just like me in that ER, what was she supposed to do? Give up on her first and potentially only baby? Hadn't we given her a promise that this could all work out okay since we went full guns blazing to keep her alive? Yes. She was here. Intubated and filled with tubes, fighting for her life.

Since I admitted Baby P, I was the primary resident caring for her. My attending that month was a hard core NICU guy and never even considered backing off with our heroic efforts once we learned that she was less than 22 weeks. Nope. That ship had sailed already.

Baby P lived nearly nine days. Her brief life was tortured, the majority of which was at my own hands.  She fought horrible infections, coded nearly every day, only to be brought back to life for a few more moments. Her brain bled two times and her little body seized repeatedly. Every single day that I cared for her, I'd steal away to sit in the call room or a stair well to cry. Trembling into my hands and apologizing repeatedly to Baby P and her parents quietly in the dark. Praying in simple language and feeling on the brink of nausea. Trying to forgive myself for intubating her that day and wishing I'd had the courage not to...or to at least present "nothing" as an option.

Two calls later, Baby P's heart stopped beating. Just like that. This time, following the parents' wishes, we didn't code her. Instead we all enveloped the parents in a giant, exhausted group hug. All of us weeping for reasons that you'd have to ask each individual to explain, but weeping all the same and not even trying to hold it back.  Me, the NICU nurses, Shanthi, and Marge huddled around the parents as they finally--for the first time in 8 days--got to hold their baby daughter. It was awful.

What had we done? What had I done?

I had to get out of there. I remember running out of the NICU. Past the nurses' station and past the waiting areas. Down the hall into the corridor. Just running and running. Out. I had to get out of there. I needed air. I needed out. I got outside and paced in the biting Cleveland autumn air. I folded my arms hard over my bare arms and tried to ignore the chill climbing into my scrub pants.  I felt like I had fought against God and against nature and lost. And whether you believe in God or nature or both, fighting them just feels inherently wrong. Unsettling and wrong.

Those 8 1/2 days haunted me for a long time. In fact, I cried while writing this because I could see those fused eyelids and air-hungry chest like it was yesterday.  All over again, I wished I had been with my fellow and not alone. I know that she would have put her foot down. I believe that. And smug me-- thinking our one year apart was no big deal-- learned a huge lesson that night. It WAS a big deal. A huge one. And yes, I realize that some 21+ weeker baby born under similar circumstances somewhere has a testimony and THEY made it and are alive and "just fine." I am sure that baby exists, but I also know that there are several others who don't have that testimony. Or they made it alive but no one would describe the outcome as "just fine." Not one bit. My guess is that those individuals might be easier to find than the former.

Medical training is wonderful and horrible. A lot of the decisions that get made are quick calls from one person, and they can change everything. Experience plays a big role in how ready you are to make those calls and that day, I needed back up.

At the end of that month, I asked Shanthi how she felt about Baby P and what had transpired. She began weeping and saying she was sorry for leaving me that night. She said she never should have let me take her pager. She was the NICU fellow in house. Not me.

"Would you have resuscitated her?" I had to know.

Shanthi looked down at her fingernails and sighed.  Finally she locked eyes with me and shook her head no. I swallowed hard and tried to fight the hot tears that began rolling down my cheeks as I nodded in agreement. I knew that answer before I even asked.

Things have changed since then. Now, a level III NICU is staffed with board-certified neonatal intensivists overnight. With enough experience to feel more confident in their judgment calls than I was as a resident. And when you're talking about little babies in very high stakes situations, that's probably how it should be. At least that's what I think.

The moral of this? I don't know. I guess I just needed to get the story out. Because medicine? Medicine is some serious shit.

***
Now playing on my mental iPod. . . . "Ready to Go" from Panic! at the Disco.