Gateway to Eternity

Today was non-stop, before I even made it to the hospital I was called about a new baby admitted during the night with complicated kidney disease and worrisome blood chemistries, but he soon proved to be one of the more stable patients of the day, which at this point 14 hours later sort of blurs into a continuous mix of babies with minimal gaspy sort of breaths, babies with failing hearts, babies with inexplicably low sodiums, babies with heartrending anomalies. And two babies who simply could not make it. Two deaths in one day makes for a very very draining time. The first was an infant only three days old, we got the call from casualty and my colleague wisely advised them to just send the baby on to nursery. Stanley came in, as most do, heavily bundled in multiple layers of clothing and thick blankets, which I peeled back as I started to get the story from the mom. But on peeling off his obscuring clothes I found a very yellow little 3-day-old, with short intermittent ineffective shallow breaths, and a quick listen confirmed his heart was dangerously slowed down. So began a several-hour saga of attempting to save his life, unsuccessfully it turns out. Anand intubated him, but the ICU could not help us, so we just kept squeezing the bag of oxygen to expand his lungs manually. Mom later told us that he had been febrile even when he was discharged from another hospital post-delivery, which is scandalous, ignoring a fever in a 1-day-old. So he'd spent 48 hours at home fighting off infection and losing the battle, until he was too weak to even feed. Looking at his scary-yellow glow we knew an exchange transfusion was inevitable, so we asked Paeds surgery to put in a line right away. Stanley had fluids and antibiotics and tests sent off, but just when I had finagled a ventilator on loan from the ICU and ordered the blood for exchange, Anand noted that in spite of pretty decent numbers on the monitor Stanley was no longer moving. He had no heart rate. So we gave CPR and 4 rounds of cardiac-stimulating medication with zero response. He was gone. His dad took the news harder than his mom, who had probably concluded in her heart since his day-of-life 1 fever that this child would not survive.

An hour or so later we were in xray with our kidney patient when we got the dreaded "999" pages to the nursery. Anand and I ran through the halls to find Nelly blue and limp. Nelly has been our patient since her birth more than six weeks ago. She was petite and fragile, with disfiguring clefts in her upper lip/nose on both sides, and some minor anomalies of her spine and fingers and toes. But her biggest problem was her heart, a hidden and serious malformation. We have walked a tightrope with her for the last month, titrating doses of cardiac meds, almost losing her numerous times, trying to get her to cardiac surgery experts (she's the one who came back after attempted transfer because the money demanded was impossibly high and the care less personal in Nairobi). Her beautiful mother and "do everything you can" caring father were constantly at her side. Usually when she became agitated and hypoxic her mother could calm her down and we would see improvement. But not today. Her heart just gave out, basically, becoming more and more tired, less and less functional, until it stopped. Her dad stood by us for the last hour or so of her life as we tried all we could do, and understood. Her mom simply cried her eyes out when it was all over, which is exactly what I would do. I love seeing how parents can wrap their hearts around a baby like this who is so tenuous and abnormal-looking, so precious and loved.

And while we were working on Nelly, an intern who was hovering nearby finally said "you're probably wondering why I'm here" (I wasn't, but that's OK) and told us the sad condition of a one-day-old who had also just come to casualty. I knew the nurses were at their limit (we had 20 on the service at that point) but asked if we could admit just one more . . and we cleared the body of the first baby away just in time to repeat the same story, newborn, high fever, not feeding, unwrap and find a baby convulsing and desperately ill. This one though was still breathing well, and still with a stressed rapid heart rate rather than a declining one. So our day ended with another all-out push to investigate and treat, to give fluids and antibiotics, to stop convulsions and modulate temperature. When I left about six this baby was still alive, so I'm hoping she can pull through. I thanked the bustling charge nurse for taking on yet one more admission, and we agreed that if we had declared the nursery full and transferred the baby from the emergency department to another hospital, she would have been dead before arrival. Still a very hard decision to make when we can barely manage the ones we already had. Not even mentioning the baby delivered in our own hospital this morning who would have died without resuscitation, or the one from yesterday with a similar story of rescue.

The nursery is an interesting place, in many ways a sort of intermediate station or gateway between heaven and earth, a territory where little bodies and souls seem to be only partly inhabiting one sphere or the other. A place where we watch in awe as the improbable healings occur, but also choke on our prayers with grieving parents as the reality of loss sweeps over them, where we clean up and move on to the next needy person.