High risk, p.22
High Risk, page 22
“Prepare the surf,” Verona said. “Harper, listen to both sides.”
The respiratory therapist placed the breathing device on the tube and breathed for the patient. Michael went to place his stethoscope on the chest and stopped. The diaphragm of his stethoscope was larger than the baby’s chest.
Verona shook his head and passed his tiny neonatologist stethoscope to Michael. “Use mine.”
Michael listened to both sides. “Breath sounds on both sides… I think.”
The neonatologist wisely took his stethoscope back and rechecked Michael’s work. “Okay, secure the tube, and surf down the tube.” Respiratory taped the tube around the lip, calling out 7 centimeters at the lip, which matched Michael’s card. The nurse gave a clear whitish fluid to Dr. Morgan who used a syringe to administer into the tube. Respiratory therapy replaced the breathing apparatus, and they waited a few seconds.
“Alright, Harper, tell me what’s surfactant and what it does,” Verona asked.
Michael had to think for a second. He was in the middle of his first micro preemie resuscitation, and the attending was pimping him right now. “Surface tension. It fixes… it decreases the surface tension in the lung. Babies at this age don’t make any, so we need it for air to cross from the lung into blood.” He had studied this in preparation for his upcoming shelf exam.
“Good. Apgar 7,” Verona said conversationally as they watched the oxygen saturation slowly climb from the 70’s into the mid 80’s. “What is most surfactant made from?”
It was hard to think since Michael was in his first rodeo. Verona was nonchalant, as if this were so simple. Then again, for him, this was an everyday occurrence, essentially a walk in the park for him. “I don’t know.”
“Ground up cow and pig lung,” Morgan answered for him. “What minute are we at?”
That was directed at RT. “Almost to 7,” she responded, pulling the clear isolette to the warmer, the same isolettes Michael had posed with for photos last month.
“Harper, if you could grab the chart, let’s lock and load,” Verona requested.
It was absurd to say ‘lock and load’ about a two pound baby wrapped in saran wrap moving into a clear box. On the other hand, it was a baby born three months too early. Crazy.
“Good boy,” Verona said to the infant. Only then did Michael compute the gender of the baby. The neonatologist had a few words with the new parents. The shell-shocked dad, wearing the OR white ‘bunny suit’ over his street clothes, snapped a few cell phone photos.
Michael remembered to grab his delivery cards, wiping off the blood with a sterilized wipe. They walked down the hallway with the plastic transport isolette. He and Morgan pushed while respiratory therapy kept breathing for the patient. Verona trailed behind them, issuing rapid-fire orders to what Michael assumed was the receiving team.
Morgan confirmed his suspicions. “The NICU residents will take over here. He’ll oversee the admission and come back over if we need help. He should be here for the 24-weeker.”
They entered the two sets of double doors into the NICU, which Michael had only seen from the outside. A space-aged-looking set of clear boxes and machines breathing for similarly tiny infants. They rolled their way to an empty bed space with a small baby-sized ventilator.
The NICU residents were waiting for them. Morgan gave sign-out, repeating instructions Verona had already given. “I need you guys to place umbilical lines, get a chest x-ray, initial labs. Pace yourselves because you got a couple more like this schedule tonight. Not including what is going to walk in off the street.
The two residents and the fourth-year medical student exchanged long-suffering glances. “Got it. Try to keep us updated.”
“What are umbilical lines?” Michael asked when they walked back to L and D. Verona stayed behind to supervise.
“The umbilical cord has one vein and two arteries in it. You can place a really big IV down it. You can’t easily get an IV and their arm or leg, so we put in umbilical lines. We’ll get better access later if they live.”
“You think the baby’s going to make it?”
“There’s ‘making it’ and ‘making it.’ Baby had steroids first, so it improves his chances. But he’s still a 26-weeker and a White boy. They do the worst.”
“So it’s a bad time to be White?” Michael said.
“It’s going to be a long road for this one. There’s solid chance of a brain bleed. Or his intestines might get infected and get cut out. We can almost never save anything under 23-weeks. Just too small and their lungs aren’t there. You’ll see.” She visibly forced herself back into her regular smiling self. “Okay. One down. More to go. We should eat now. Before it gets bad.”
They never got to eat because the 24 and 30-weekers went in rapid succession. Michael became more familiar with APGAR scoring, the 10 points covering infant’s appearance, pulse, grimace, activity, and respiration. A 21-weeker did walk in off the street, and they weren’t called to that delivery. Verona came by and quietly entered the room without them.
“We aren’t going in?” Michael stopped by the door.
“No. He’s going to confirm its too small to survive. If we had three or four more weeks, we might have had a chance. He’ll measure its foot and give it back to them. He needs us to run to other deliveries,” Morgan explained. They stood quietly outside the door and watched the nurses come by with a black bow to affix to the door.
“You guys do this every day?” Michael asked. The room was ominously quiet, even from outside the door.
“Not every day. Just once every fourth night if you’re on service. The neonatologist is on call once a week.”
The night had no desire to end because the hits kept coming.
After another 30-weeker delivered at 0200, Verona was his regular self while Morgan and Michael were obviously dragging. “Aren’t you glad Molla gave you her cards?”
“Yes. She warned us it could be hard.”
“Last day on call, isn’t it? Of two in two months?” Verona remained chatty.
“I know, med students are wimps. My first night wasn’t so busy,” Michael admitted.
“Don’t worry. It’s always darkest before dawn.” Verona checked his watch, “Which would be in five hours.”
“Is that your version of encouragement, sir?” his resident said, wearily.
“Only way to get through nights like this. Part doctor, part priest. ‘Down once more.’”
It took a few seconds for Michael to understand the reference. “Phantom of the Opera this late at night?” Michael said.
“Finally, someone gets me,” Verona showed some humor. “You youngins don’t know the classics.”
Considering Dr. Morgan was a second-year, probably twenty-seven years old, she wouldn’t get it. Michael’s dad had forced Joshua and Michael to listen to the strains of Andrew Lloyd Webber wherever he drove. Joshua had blown up Michael’s phone with messages years ago when Norm Lewis was cast as the first Black Phantom.
Verona didn’t get to say more because his bat phone rang and the overhead speaker blared.
“Code blue Bed 17.”
“It’s the 26-weeker. Hold the fort,” Verona yelled and sprinted back to the NICU.
His trail of dust had barely died down when another alarm went off. “C-section STAT.” A gurney with a pregnant woman was rolled by down the opposite hallway with a line of nurses, both OB residents, and the MFM attending, Akimova, close on their heels.
They galloped to the OR, masking and gloving. This C-section was very different because the staff moved like a hive of bees in all directions at a frantic pace. The incision had already been done, and the mother was under general anesthesia now.
“What’s going on?” Morgan asked, a hint of panic in her voice. Michael set the cards back on the isolette.
“She’s abrupting!” Dr. Akimova yelled.
The charge nurse filled in the info. “It’s a 34-week abruption. They just got here. Should be a girl.”
Without having done OB, the only thing Michael knew about abruptions was that they were very bad—bad enough for someone to try a C-section in an ambulance.
Eyes forward, never back.
“Aww, fu—” Morgan was becoming someone else through the night. “3.5 ET tube, and crash line kits, now! Get me epi doses.”
Michael was reciting the epi dose when the respiratory therapy grabbed his wrist. “Do you know how to do infant CPR?” For the first time, RT was rattled.
“Yes. Circle the chest or two fingers?” Michael tried to remember the first thing to do in any code was to take your own pulse.
“Two fingers on the chest. We need the access. That’s going to be your job. When she tells you to start, start. When she tells you to stop, stop. You don’t do anything else,” RT commanded him.
They didn’t have any more time for instructions because there was the baby, blue and silent—much larger than any of the others he’d seen today. Morgan immediately intubated, visualizing the airway without difficulty.
Morgan was pressured now. RT handed her the ET tube without an order. “Come on. Come on… I’m in. Get me the Neo puff.” Michael knew what that was now—it was the breathing machine RT had been using all night.
“I’m confirming placement,” RT said. “I’ve got breath sounds, but no pulse.” Her fingers were on the umbilical cord, barely clamped off.
“Start CPR,” Morgan ordered Michael, who immediately began to press two fingers into the baby’s chest at a rate higher than 100 times per minute. “Give me the epi now. We’re putting it down the ET tube.”
Michael could barely spare a glance at the nurses and OB still moving frantically, scooping blood out of the abdomen. He had a vague idea of what was going on, but his sphere of knowledge narrowed down to his job of acting as the baby’s heart. The flimsy chest was so flexible, and he had to take care to let it recoil. Was he breaking ribs?
“Open the line kit,” Morgan ordered. RT was pouring epinephrine down the endotracheal tube. “Hold compressions. Check a pulse. Hold on to the umbilical cord, tell me if you feel anything.”
Michael moved down to the cord. “I don’t feel anything.” The umbilical cord was warm, gooey, and definitely not pulsating.
RT shoved his hand out of the way. “I agree, no pulse. Resume compressions,” she ordered and went back to breathing for the baby.
Michael restarted. Dr. Morgan opened the large IV kit. “Tie off the cord at the base. Get me a pulse ox on the baby and saline flushes for when I push the epi.” The fear in her eyes was reflected through her protective eye shield when she spoke to Michael. “You’re going to have to stop compressions for me to put this in. Pass me everything when I tell you. Don’t ask questions. Scalpel.”
Morgan gripped the umbilical cord by the clamp and sawed off the top. It didn’t bleed because it was tied off at the bottom. She threaded the IV into the largest opening in the cord, which Michael guessed was the umbilical vein. “Saline flush.”
Michael handed one over, rechecking his cards, which told him they had poured 3 ml of epi down the ET tube, and they would be needing 0.5 ml now.
Morgan pushed the saline down the catheter and said, “It’s flushing. Give me the epi now. Pull me 30 ml of normal saline. Recheck the pulse.”
“Nothing,” Michael said.
Her hand joined his. “No pulse.”
“Resume compressions. I need the saline slow push.” One of the nurses stepped up to enact the order. “Get me Verona now,” Morgan called. Michael started compressions again, a sinking feeling lodged in his chest. He’d never seen panic like this, not even during the mass casualty incident. Everyone was doing their job, but the terror on their faces.
The nurse on the phone said, “Dr. Verona is running a code in NICU. Orders?”
Morgan looked at the clock. “How many minutes?”
The nurse holding the medication clipboard said, “We’re at eight minutes.”
“How many minutes since the epi? One down the ET tube and one down the line?”
“Almost two minutes.”
“We can push another round of epi,” Morgan said, gathering her emotions back down. “Follow the protocol. It’s probably hypovolemia from blood loss. Could it be a pneumothorax?”
RT shook her head. “I’ve got breath sounds on both sides. Recheck.” Morgan did so herself.
“Damn, breath sounds on both sides.” Morgan instructed them to push more epi. “Switch out for compressions.”
Michael stepped back and repeated, “Hypovolemia?”
Morgan took a second to make sure the mom was still intubated. “The placenta ripped off the uterine wall. No placenta means no blood to baby.”
“Transfuse?” Michael suggested because that’s what you’d consider in adults.
“Not without a heartbeat. She was probably down before we started.” She ordered a third and fourth round of epi with saline bolus chasers. The CPR continued, but the minutes ticked by without a pulse.
The phone rang, and the charge nurse announced, “It’s Dr. Verona. We’re putting him on speakerphone.”
At this point, Michael had switched back in to do more CPR.
“Tell me what’s going on, Morgan.”
“This mama abrupted.” She turned to Akimova, who gave her a quick thumbs-up before returning to her sewing, “The mom stabilized, but the 34-weeker is down now twenty minutes. We did five rounds of epi, four via crash line. We never got a heartbeat.”
They could hear the slow exhalation over the phone. “You gotta call it, Morgan. She’s been down too long. You’re not getting her. You never had her.”
Morgan swore under her breath, a string of expletives Michael had not expected out of this pediatrician. “Yes, sir. I understand.”
“Sorry, Morgan. Wish I could be there.”
She hung up the phone, and Morgan looked at her crew. “All right. Just so everyone’s clear. The baby never had a heartbeat. We’re at Apgars of 0, 0, 0, 0, and 0 at 20 minutes. We’ve five rounds of CPR with epi. Dr. Verona says it’s time to stop. I’m going to do a final survey, and I’m going to call it. What religion is this family?”
“Christian,” the anesthesiologist said from her spot at the head of the bed.
“Okay. Hold compressions. Stop the Neo puff. Any one able to say a prayer?” Morgan sounded defeated.
Michael closed his eyes for half a second, wondering if the baby was being greeted by his brother, Josh, at this moment when the spirit moved from one side to the other.
One of the nurses who wore a crucifix stepped up and said the Lord’s prayer. RT set down the Neo puff and started peeling off the monitors. The charge nurse checked for a pulse.
The room was quiet except for the small beeps of the mom’s monitors.
“Dr. Morgan,” the charge nurse said urgently.
“Yes, Sharon,” Morgan sounded exhausted.
“I have a pulse.”
“What?”
“Yes, I have a pulse. Right now. It’s increasing. I’m over 60… It’s over 100.”
Morgan swallowed hard to collect herself and ordered quietly. “Resume respiratory support. Call the NICU back.” She didn’t request CPR because, according to the protocol, no compressions with a heart rate over 100.
Verona answered, “Is it done?”
“Sir, we have a pulse now.”
Her superior didn’t say anything for a while. “You have a pulse. How many weeks is this baby?”
“34.” There was a new look in Morgan’s eyes. Michael could swear it was resignation.
The phone line communicated dead air for a few more beats. Finally, Verona spoke, “Do not warm the baby. Meet us at the NICU for the cooling protocol.”
No one was very happy as they rushed the infant to the NICU. The nurses were at a different bed space, piling ice packs and other unidentifiable equipment. Verona was there, standing with his exhausted NICU residents. Michael couldn’t even follow the orders in his exhaustion. It sounded like they were talking about making the baby cold.
“Back to L and D,” Morgan told him, almost forcing herself to take steps forward.
“They’re cooling her?” Michael asked.
“Yes. Cooling her may save her brain.”
“Does that work?”
“Better than the snowball in hell,” Morgan said. “This might be the greatest miracle ever where the baby comes back from the dead or she might be an organ donor. This could be my best night of residency or my worst.”
Michael wondered what he could say, so he picked something. “I don’t know anything about babies or the NICU. But I can read. You did everything on that chart. Not one person in the OR argued with you or had another suggestion. If I know nurses, they tell you when they think you suck.”
Morgan sighed. “You’re right. This is how it goes sometimes. Why don’t you catch some sleep or something. I’ll guard the board.”
Michael could have used the sleep, or maybe—he checked the clock. It was almost 0400. He could check for a post-it note soon. Was Angela having a better night?
Chapter 27
It was one of those rare nights when Angela was a white cloud.
A white cloud is a night or series of nights where the doctor is both lucky and good. Every patient who came in either was not super sick or if they were sick, you save them. A black cloud is when every single patient of the night shows up and dies. The patient comes into the ER for a toenail infection and they have a heart attack and die.
But not tonight. Angela was an unstoppable cardiac force today.
After her first patient didn’t show, she read a few more echos, got her depo shot, and noticed she had two clinic appointments. During echo, she had her half day weekly clinic, but someone had thoughtfully cleared her schedule for part of the afternoon to give the results of echos in person.
