I arrived to find a pink little infant boy being assisted with his breathing, as his tiny rib cage pulled hard to move air into his not-ready-for-this-world lungs. He was tiny but kicking. We've seen smaller, but few survive who are this young (28 weeks) here. His HIV-infected mom had been seen a few days ago with serious bleeding, but refused admission. Instead of the therapy that might have prolonged his 6+ month (28 week) gestation to a survivable 30 . . or stimulated the development of his lungs . . she went home and perhaps expected death. Last night she returned in late stages of labor and popped out a reasonably sized (1270 grams) 28 week boy.
A boy who proceeded to not cooperate with the program of living. An all night struggle. The parents said they could not afford the treatment (surfactant), about $200, which replaces the lung lining that is not yet developed in this stage. So we tried him on our bubble CPAP, oxygen and pressure to open lungs and help breathing. But he did not do well, and his xray showed significant respiratory distress syndrome, so after 2 hours I decided we should just give the surfactant anyway and dip into our Needy Children's Fund to cover it. This is not an easy decision as the funds are very limited, and using them on one baby means we won't have them for another. So I had to struggle: was this baby a good choice? Might he survive? It is very very hard at 2 or 3 in the morning, alone, to weigh this. I think it was his little kicking feet. He seemed to be a fighter.
Nothing is simple, I intubated him but thought I'd tape the tube in and get an xray, which led to the tube coming out, which led to more attempts and having to stop and resuscitate him several times, and help from a friendly anesthesia nurse who happened to be in for another C section in the middle of the night (bless Lucy). We gave the surfactant and he seemed to respond, his oxygen sat level was over 90 (good). Somewhere in there after attempting IV's in all extremities and finding the veins too fragile, I put in an umbilical venous catheter for the first time since residency (quick review of procedure in Harriet Lane and then forge ahead).
Ah, I thought, this has been a long night, the intern was busy elsewhere so I ended up writing up all the notes too, and by 4:30 I was walking out the door, tired but at least I felt we'd done something (evaluated four other sick babies over those hours too, several who were critical inpatients and one new admit).
Home, the prospect of almost 2 hours of sleep, climb into bed, pager goes off immediately, stat page to nursery. Seems the preemie didn't respond well for very long. Same trek, full moon, mysterious clouds, sleepy guards, back to the nursery. We checked everything we could, bagged some more, tried to get an ICU bed, but there was none available. In my heart I didn't think he was a good choice for the limited ICU resources either. 28 weeks, four days at home with mom bleeding, no steroids, poor response to surfactant . . . so with a heavy heart I brought the mom in to see him for the first time, in case it would be her last. We stroked him, and watched him struggle with oxygen sat levels down in the 70's. Not good. I pulled each nurse aside, explained what had been done, asked if they had any other ideas, and made the hard decision for the team that we had reached maximum effort. Now it is in God's hands, I told them and the mom. Meaning in God's hands to die, I thought, though I prayed that he would live. We started calling the chaplain. I left at almost six, the full moon not quite setting, the birds beginning to stir. There was nothing else for me to do there, and I wanted to be home when the kids woke up (only one parent now, Scott is en route to WHM meetings in America). As I got them breakfast almost an hour later I called the nursery, a little surprised not to have been called back to his death, but realizing he might hang on for some hours.
How is our preemie? Oh, he's fine. What do you mean, fine? Well, his sats are over 90%, and he looks comfortable.
This baby may or may not survive in the long run. He has far to go. Is his life worth $200? An all-night effort? Is it worth that even if he doesn't live more than a day or two? Did I make the right decisions? One can always choose life whole-heartedly, but in a limited-resources setting one life might cost another. He is occupying our last incubator. The next baby might not be able to get the surfactant because he did. I might have caused his parents longer agony and larger bills, which in this HIV-positive family might impact the health of the three children they already have.
When I put him in God's hands, I didn't really hope for a lot. God doesn't always plan things the way I do, and my prayers have become less certain of their outcome. God's hands did not imply that I was, or am, sure of his survival. But God knew our limits, and with at least our one available incubator and medicine and oxygen and tests and warmth, I think we were meant to offer all we had. Perhaps it was a widow's mite that will be multiplied to life. Perhaps not. This baby's worth is equal to mine, or the President's, or the richest man alive, so we trust that if God does not heal him now, it is not a matter of being unworthy, but a matter of mercy and a better plan.