"Best of" Week: Reality Rounds

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For They Know Not What They Do

Our eyes meet briefly.  She is desperate, and scared.  I look away.  The pain is intense.  It makes it hard to think, hard to concentrate.  She is six months pregnant and in active labor.  There is no stopping it.  All is explained to her.  The slim chance of survival.  The enormous chance of death and profound disability.  “Do everything please.  My baby.”

We do everything.  The father watches us, stands over us and prays.  His infant could fit into his hand.  520 grams, barely a pound in weight.

We do everything.  Dry the infant with towels.  Careful.   Not too rough.  Do not want the gelatinous, friable skin to break and bleed unto the blankets. Listen for heart sounds.  Heart rate is barely 60 beats per minute.  No need for chest compressions.  We breathe air and oxygen into the tiny lungs.  Careful.  Too much air can blow a hole in the tiny lungs.  Too much oxygen can cause lung damage and blindness. We walk the wire.

The physician intubates the baby’s trachea.  The endotracheal tube is as small and narrow as a pen.  The heart rate rises.  Forgive me for sadness that the heart rate is increasing.

We rush the baby to the neonatal intensive care unit (NICU).    The baby’s heart rate is still low, in the 70’s.  We cannot detect a blood pressure.  We handle the baby gently.  Any sudden changes in movement and blood flow can cause bleeding in the fragile ventricles of the baby’s brain.   His oxygen saturations are in the 50’s (normal is upper 80’s and 90’s).  Forgive me for wanting to stop. We push epinephrine (adrenaline) into the tiny airway, hoping to increase the heart rate and circulation.  It works.  We flood the infants lungs with Surfactant, a soapy looking liquid medications, that keeps the baby’s alveoli (small lung sacs that exchange oxygen) from collapsing on themselves.  His oxygen saturations start to rise, 80%, 90%.  We decrease the amount of oxygen the baby is getting, so as not to further damage his fragile lungs.

Central lines are placed in the infants umbilical cord.  We check a blood sugar.  It is 12.  (Normal is above 45).  The clock is ticking.  Every second with no blood sugar feeding the brain, the cells will die.  We do not wait for the X-rays to start the IV fluids.  We give a bolus, a whopping two ml of D10W sugar water.

His blood pressure is barely detectable.  We give two boluses of normal saline, five ml each.  The blood pressure stays low.  We need to start a dopamine drip.  The central lines are not in good position. We cannot risk starting a vasoconstrictive drug in these lines. This could cause a vasospasm in the vessels feeding the infant’s intestines, starving these tissue of blood and causing them to die.    I start a peripheral IV in the baby’s arm.  His skin is see through, it is not hard to find a vein.  I cannulate the infant’s vein, which is as thin as a hair.  He does not flinch.  I flush the cannula gently with fluid.  The baby’s skin is so thin, you can see the flush of fluid travel in the vein, up to his heart.   Forgive me for being proud of this skill.

The father comes in the nursery to see his son.  He touches the baby.  The skin feels cold.  The baby lays under a radiant warmer, on a warmer mattress, and he is wrapped in clear plastic to prevent further heat loss.  The father talks and prays over his baby.  The baby twitches and squirms in response.  His eyes are still fused shut, he can not open them.  We council the father again of the possible outcomes for his son.  A 3% chance of survival while suffering profound neurological defects.  We explain the chances of infection, heart defects, bleeding of the brain, chronic lung disease, cerebral palsy.  The father nods his head.  He only sees his son, not the future, not statistics.  He wants everything possible done to save his son’s life.  Forgive him for he does not know, can’t possible know.

We continue to work on this tiny baby throughout the day.  Two nurses, a neonatologist, a respiratory therapist, constantly at the baby’s bedside.  Ventilator, central lines, peripheral lines, four IV pumps, cardiac monitors, leads, tape covering the baby’s arms, abdomen, and face.  He lays there motionless, as the best of medical care and technology fight to keep him alive.

Forgive us for we know what we do.



This post originally appeared on Reality Rounds on August 11, 2009 and was submitted by the author for “Best of” Week.


Prematurity is the single largest cause of infant morbidity and mortality in the United States.  The anonymous NICU nurse who blogs at Reality Rounds submitted this post as part of her continuing effort to educate the public on what it takes to care for these vulnerable patients.


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