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Wednesday, January 18, 2012

A 24 hour life

Evil feels triumphant tonight, or at least impotence and ignorance.  

Twenty-four hours ago we were sitting around the table after dinner, serving tea.  Our friends the Wrights had just pulled in from a long day's drive from Karamoja (Uganda) to visit, and our friends the Barnes had been sucked into the party when they walked by with a young premed student delivering Birthday invites.  I had a page from the nursery to go over some labs, and was feeling pretty relaxed about the evening since things were going relatively well.  Then a few minutes later I got the "999" page that means "RUN".  I grabbed my coat and stethoscope and made quick apologies as I rushed out the door, trying to imagine which of the babies could be dying.

Into the humid warmth of the nursery, brights and steamy and slightly chlorinated, a jungly at-home feeling after rushing through the windy darkness of Kijabe.  I see our medical officer and two nurses huddled over the resuscitation table, and quickly glance around the room to see which cot or incubator is empty.  But it is a new baby, just delivered, pale and floppy and lifeless and bloody.  Very bloody.  Blood matts her hair, is caked in her ears, fills the suction catheter that vacuums her mouth.  I hear quickly that she was born dead, with no heart rate or effort to breathe.  But now a few minutes later her heart is beating strong, though nothing else seems to be happening.  No flicker of movement, no flutter of eyelids, no gasp of breath.  We dry and clean and suction and bag breaths into her lungs, over and over and over again, while her heart ticks steadily on.  I get more story that makes me suspect she may be a bit drugged from pain medicine her mother got, and after a dose of a reversal drug she does start to breathe.  In a full forty minutes though we're still floppy and in spite of lots of oxygen and help she is still blueish.  And if she was just punky from her mom's medicines, what's the explanation for all that blood?  I decide to intubate her to suction her airways better, and to try and improve her oxygen status.  I'm still not confident about many of my skills, including threading the airway of a slippery (usually squirmy, though this baby wasn't moving) phlegm-filled micro baby throat.  But by God's grace alone I get the tube in, and we suction some blood.  

And so the first hour ticks by, and before too long the second.  The baby is fighting a little now, moving her delicate arms.  She never really responds the way I would expect to all the efforts we make.  A fluid bolus seems to help.  We check her blood count thinking that if this is HER blood she lost, she may need a transfusion, but she doesn't.  Xray doesn't show any major lung problems, heart seems normal.  I take time to go find her mom and bring her into the nursery to see her baby, whereupon she turns and puts her arms on my shoulders and sobs.  I pray for her and stroke her back and try to sound hopeful, striking the right balance of sober and optimistic, your baby is very sick but so were all these others who are now improving.  The mom names her Victoria.  By ten pm we pack the baby into an incubator and wheel her up to the ICU to be kept on a ventilator, since she does not breathe well enough on her own to make it.  I'm home before midnight, leaving her pink and restful, opening her eyes, and I hope over the worst.  

By morning I've only had one call about her, and I am hopeful that whatever was wrong is getting better.  Then another "999" during rounds, I run up to ICU where the staff has accidentally dislodged her endotracheal breathing tube.  Not difficult to do since the margin between "in" and "out" is less than an inch.  I briefly consider keeping her off the vent, she is doing so well, but then her oxygen levels drop, and I realize she's not ready.  The medical officer tries to intubate without success and then everyone looks at me again, and I pray.  This time Victoria is actively fighting against me.  But I get the tube in again, and she's pink and as we put her back to bed, restful, looking at me.  Labs look OK, and though I'm still puzzled by just what is causing her problems, i don't really mind not knowing if she's getting better.  I order another xray to be sure the tube is back in the right place and go back to nursery.  

(Where, parenthetically, I find a surprise 32 week tiny bright pink baby boy just born . . whoops, we are out of incubators, so he has to rest on the resuscitation table while the one available incubator is fixed).

Before another hour is up though, I am back to ICU where her oxygen levels have plummeted.  I'm told the xray was OK but when I look myself I see a too-dark outline to the right lung.  Her lung has popped like a balloon, leaving a rim of air between the lung and the chest wall that compromises breathing.  And since we are pushing air into her lungs, we are making this worse minute by minute.  I call the paeds surg team to put in a chest tube, and am poised to stick a needle in myself but they arrive just in time.  

From there we never really regain our ground.  Another couple of hours pass, the chest xray with the tube in place looks great, but the baby doesn't.  Victoria is inexplicably dying.  

I usually look forward to my Wednesday afternoon sign out to Mardi.  Especially after being on call 3 of the last 4 nights.  I try my best to have everything sawa sawa and ready to go.  But today was not fun.  I hung around an extra hour but Victoria only seemed to be getting worse, and then it was time for Julia's soccer game, and I left.  Mardi messaged me not long after.  Victoria was dead.

She lived a day.  Not quite 24 hours, and I was with her a good number of those.  More than her mom was.  At first I wondered if we should even try to revive her, then I thought she would probably live and be fine, then I had no idea how to keep her alive.  

Part of my heart knows that the quote below is true. Right, temporarily defeated, is still stronger than the apparent triumph of death.  Victoria lives on, and waits for the resurrection.  Her name reminds me of 2 Cor 15--where oh death is your victory?  But I am wearied tonight by the lost battle, and though I'm thankful I was spared the final moments (thanks Mardi) it is still a sadness, hopes dashed.  Her mother will grieve this in some part of her heart throughout her life; I will probably barely remember this in a month or two, as another hundred babies pass through my hands.  

So tonight I honor one small life, a little broken body, a valiant struggle, and look forward to the place where death is no more.

1 comment:

Anne Dye said...

Prayers for rest, strength and encouragement coming your way. We too, look forward to the place where death is no more.