Lightening Crashes

I had not met her before, though I had heard the birth story. Rapidly and unexpectedly, in the wee hours of the morning, her baby, an arguably nonviable fetus, was born. There was no time for lengthy discussion, and her baby was resuscitated. At two days of age, I am going to explain to this mother that her baby has a unilateral grade IV intraventricular hemorrhage.
I spend several minutes explaining in the simplest terms what IVH is and why premature babies are at risk for it. I methodically explain the four grades of IVH which relate to severity. I carefully outline the potential complication of post hemorrhagic hydrocephalus with grade III and grade IV hemorrhages and the possible need for a VP shunt with this complication. I then cautiously explain the association of grade III and grade IV hemorrhages with profound neurodevelopmental impairment.
This mother nods understanding throughout the discussion. Her expression is one of quiet comprehension. I wonder does she really understand or is she just pretending to follow. At this point I tell her that her baby has a grade IV hemorrhage on one side of the brain. CRACK! It's as if I've been concealing a blunt object and have now delivered a powerful blow to the face. Tears followed by sobs and the shattered appearance.
I feel villainous. How could I attack this poor defenseless person with so cruel a weapon? I spend several minutes answering questions related to prognosis and expressing my condolences before I retreat to allow her time to reflect.
A partner senses my brooding and inquires about it. I tell him what I've been doing. It's almost like a confession as I describe my conversation. He tells me that whenever he has an experience like this he reminds himself that, "if the mother doesn't cry, then you haven't made your point". I still feel terrible, but gain some comfort in knowing that if I were in that situation, I would want to get the point.

"We reserve the right to refuse service to anyone talking on a cellphone"

This morning one of my partners asked for me to share my view on cellphone use in the delivery room. He was speaking specifically about the emerging phenomenon of multiple family members taking photos, notifying friends, or uploading a "birth documentary", and he knew that I could offer a lighter perspective on this practice. Before I knew it, I was barreling through a sprawling and cathartic dissertation on the growing use of cellphones. I love my cell phone, but here are some of my observations.
One of my most favorite situational cellphone use complaints is when I go to do a prenatal consult and the father, family member, or friend sits in the corner talking on the cellphone. You never hear "Oh my goodness! Is she alright?" nor do you hear "I'm sorry, I'll have to call you back" just the distracting chattering on some topic that is clearly more important than the potential complications facing the soon to be born fetus in the room. Even better is if during the discussion with the mother, a cell phone rings at high volume blurting "ITCHA BIRFDAY SO I KNOW YOU WANNA RIDE OUT" (better when the full ring is allowed to play and then answered).
While some years ago, when I was a resident and people still had home telephones I used to complain about the fact that many mothers would call with a question about their child, but when you tried to call them back, you'd get the recorded "The party that you are trying to reach has 'privacy control'. Please state your name at the beep." However, now I find it much more frequent that I get to "enjoy the music while my party is reached". So in the wee hours of the morning, As I prepare to deliver some concerning news about a baby's deteriorating condition I may get to first listen to "Shorty's like a melody in my head... nah na nah nah everyday...". Great now I'm ready to talk about potentially grave circumstances!
At this point, unexpectedly, my partner trumped me. He explained that he made one of these phone calls one night and got the voice mail box which in a rather saucy voice said, " HEY This is so n so! Leave me a message... If you're HOT... I'll call you back!"
He decided to just try calling back later!

The Pneumatocele

I'm taking care of a former premie right now who has all of us a bit puzzled by her absolute refusal to part with her ventilator. Despite requiring very little support while on the ventilator, as soon as her endotracheal tube is removed she "tries to run for the bright light". She had a severe pneumonia several weeks ago with MRSA (a kind of staphylococcus which is sometimes a problem in hospitals and can be difficult to treat). With treatment and time, her lungs have improved dramatically, however, she developed a cystic cavity in the right upper lobe of her lung. We call this a pneumatocele, and it sometimes occurs with this type of pneumonia. In consultation with the pediatric pulmonologist, our current hypothesis is that while the ET tube keeps the trachea open, upon its removal, the pneumatocele impinges upon it and causes it to collapse. So the plan is to look down the trachea with a flexible scope to look for any obstruction. If there does appear to be some impingement, a surgical procedure may be necessary.

Chest xray demonstrating a pneumatocele in the right upper lobe

The Prenatal Consult (Part VI)

This is part VI of a series of posts which also currently includes part I,  part II , part III, part IV, and part V.
One of the biggest challenges for all premies is getting adequate nutrition. So this is usually the next area of discussion that I address with parents during the prenatal consult. The last trimester of pregnancy is one in which a lot goes on nutritionally for babies and missing out on it puts them at quite a disadvantage.
I start by pointing out that the premature intestine, like other organs, does not function the same way as a full term intestine. It doesn't move things along very well, it doesn't absorb nutrients as well, and it is at risk to develop some complications (like NEC) that can be problematic. So in the beginning we start by infusing "IV Nutrition" (otherwise known as hyperalimentation). I always point out to mothers that this is a similar way of delivering fat, protein, carbohydrate, vitamins and minerals to what occurs in utero, however, it is inferior. We then begin feeding a small amount of breast milk by NG tube and then gradually increase this over about a week to ten days. I explain that we introduce enteral nutrition this way, and strongly encourage the use of breast milk in an effort to reduce the incidence of NEC. Once the baby is receiving all of the feedings by this route, we use a human milk fortifier to increase the calories as well as some of the vitamins and minerals that are essential for bone mineralization.
I also explain that babies don't develop the reflexes that are necessary to suck, swallow, and breath in a coordinated fashion until they reach about 34 weeks gestation. For this reason, until they are ready, they are fed by a nasogastric tube. Once the baby is able to feed once or twice a day, we gradually increase the number of feeds that the baby gets by bottle as opposed to NG tube. In order to be discharged, the baby must be capable of taking all of the feedings by mouth.
The next topic that I cover is the risk of infection and the likelihood of blood transfusion. So tune in next time.

Friday Pizza Buffet - Attack of the Urchins!

When I'm working nights, my wife, daughter, and I have a friday ritual as friday night is my last night to work. We go to a local pizza buffet that we love and have a feast for lunch. We used to live near a popular location, but recently moved near a less popular location. It's really been nice. We usually have the whole place to ourselves save for a quiet few others who honor the pizza with soft spoken conversation during lunch. There's never any jockeying for position or trying to time when the cookie pizza will be fresh, hot, and not picked over. Today, our in laws were in town doing us the huge favor of fixing up our old house which we intend to rent. So we thought it would be nice if we drove across town so that they wouldn't have to drive far. My wife went back and forth over the driving across town versus the more serene environment. I didn't have the energy to have an opinion so we drove over to our old feed trough. As we pulled up, to my horror, we noted multiple buses unloading children in uniforms all wound up with the energy of some kind of disorganized trip and prepared to clamor for pizza. As we walked in, I groaned, in fact I believe a few explitives slipped out. It was total chaos! Urchins scrambling about like they were shot out of a pinball machine. Asking, "are you in line?" to the child on their left as they squirmed in front of me in just enough time to scoop up the last two pieces of pepperoni. As I sulked over my plate, head realing with overstimulation, I glanced over at my 11 month old daughter perched in her high chair happy as a clam stuffing about one out of every two chunks of pizza that my wife cut for her successfully into her mouth. She was absolutely thrilled taking in all of the activity like it was the best tv show ever. While I made a mental note to take a page from her book once in a while, I still ran from that place like there was no tomorrow. From now on, friday pizza buffet is permanently relocated!

Attention! Infection Control Barriers - Do Not Remove From Premises!

 So I confess. I sometimes wear my scrubs to and from work laundering them at home, especially when I'm working nights. Through the years I've attempted a change in this habit a number of times but I always seem to gravitate back to the practice at some point. This morning as I was headed home, I overheard a hospital administrator who had spotted a poor post call resident heading out to the parking deck in scrubs saying, "I don't know why they won't just change into their clothes here before leaving!" My primal "haven't slept at home in several nights" alter ego started to pipe up, but I stifled him. Still, in my head the thought "when was the last time you spent the night in the hospital? Wanted to get home to your family, to your bed badly enough to not care what you were wearing? Once you've taken a trip around that block a few times, get back to me on your thoughts here!"
Much has been made over the years about the practice of wearing home laundered scrubs to and from work. I'm not talking about wearing them to Starbucks or the grocery store. Just to and from work. While there are strong opinions on both sides, I think that it's worth noting that there is no evidence that home laundering scrubs increases the risk of spreading infection. In fact, there are published studies in the American Journal of Infection Control 2001, the American Journal of Maternal Child Nursing 2004, and the Journal of Hospital Infection 2006 all of which found no difference in the rate of infection when comparing home laundering to facility laundering of scrubs. There is so little evidence that facility laundering is superior that the CDC makes no recommendation on the subject. It seems that we may be making a mountain out of a mole hill.
Hospital laundered scrubs are not comfortable. I know, I know, this seems like a petty complaint. But when you're spending a number of nights living in these things when the opportunity for sleep could come at odd times, failing to nod off because your garb is stiff and chafing is really, really annoying! A few times through the old Maytag at home renders them much more comfortable. But still not stylish enough for Starbucks, restaurants, or the grocery store!

The Adult Isolette - Order Yours Now!

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Just kidding! When I was a resident rotating in the NICU, I'd come in during the wintertime and spend the first hour or so sticking my hands into these wonderfully warm incubators to examine babies. After being outside, it seemed soooo comfortable and enticing. I would dream of having my own adult sized version that I could climb inside and go to sleep. Since that time, I have often joked about my plan of designing "The Adult Isolette". If spring doesn't come around soon, I may just start really building one!

The Prenatal Consult (Part V)

This is part V of a series of posts which also currently includes part I,  part II ,  part III, and part IV.
The next topic that I cover with parents during a prenatal consult is retinopathy of prematurity or ROP. This is another complication that relates to neurodevelopmental outcome as severe ROP can cause blindness. I start by explaining that this complication also increases in likelihood and severity with decreasing gestational age. I continue by explaining that as a fetus develops in the womb, the small and fragile blood vessels that supply the back of the eye or retina don't grow into the area completely until somewhere around 32-34 weeks gestation. As these blood vessels proliferate and grow, oxygen is toxic to the process. A baby in the womb is exposed to considerably less oxygen than a baby outside of the womb. In addition, premies often have lung disease that requires the use of supplemental oxygen. The result can be ROP.
Currently all babies born at less than 1500g or less than 30 weeks gestation receive a thorough ophthalmology exam by an ophthalmologist at around 34 weeks adjusted age. If ROP is present and severe, the baby may undergo laser treatment in an attempt to spare some of the vision.
Tune in next time for Part VI!

Caught Off Gaurd By A Profound Kinda Crazy!

One day a little while back I had this encounter with a parent that I feel is worth sharing. It was the end of a rather uneventful but long day, and I was ready to check out and go home. The nurse practitioner informed me that one of our mothers was here and wanted to speak to me. I had only been seeing the baby for one day, so I was not fully up to speed on the social situation. The NNP told me that the mother who had been transferred from another hospital, and had two other children that she did not have custody of (Major red flag here!) likely due to some poor decision making in her past. She told me that the mother had spoken to her attorney who had told her that we could not do a drug screen on her breast milk. She wanted to have a discussion with me. Oh Joy! Just what I wanted to get into at the end of this long day!
So I took a deep breath and began whipping myself into a frenzy. "We have to do whatever is in your baby's best interest." "The only way to ensure that we are doing the right thing for your baby is to test your breast milk or use formula." Yep, I was steeling myself for a fight.
I approached the bedside and introduced myself to a somewhat large, wild eyed mother who spoke very dramatically as she addressed me. Standing behind her was her rail-thin mother in a tie-died shirt, denim jacket, with a bandanna around her forehead (Janis Joplin would be proud of her legacy). The mother stated that her lawyer had told her that breast milk could not be screened for drugs. Other people had told her that it could. She wanted to know who was right. It slowly occurred to me that she didn't want to argue the legality of testing her breast milk, she just wanted to know if it was technically possible.
She then launched into a very long and somewhat entertaining attack on the government agency responsible for removing her other children from her custody. Her lawyer wanted us to "keep her baby in the hospital as long as possible. Because that way they can't get their hands on him!" She went on to tell me that there was a big "black market" for babies in her home county and she had fallen victim to it. It was all a massive government conspiracy against her (she was really getting worked up and her mother was nodding and expounding and cussing). She even told me that the ethnicity of the baby's father would make this baby particularly desirable for this government run "black market". It was really pretty surreal standing there taking it all in. Somehow I managed to keep it together. You see, I'm equipped to handle crazy, I just wasn't prepared for this particular kind of crazy. It requires listening to the delusion without feeding it or openly challenging it. I ultimately reassured the mother that we would be able to screen her breast milk for the presence of illicit drugs, and that while we couldn't keep her baby in the hospital in order to "keep 'em from gettin' their hands on him", he would likely need to stay for at least a few weeks for medical reasons.
What a way to end a long and uneventful day!

The Prenatal Consult (Part IV)

This is part IV of a series of posts which also currently includes part I,  part II , and part III.
The first topic that I cover in my head to toe discussion of possible complications is Intraventricular  Hemorrhage (IVH). I start by reminding them of our discussion of developmental outcomes. I then state that one of the potential complications related to developmental outcome is IVH. Simply stated, IVH is bleeding in a particular area of the brain. At the center of the brain are several fluid filled chambers known as the ventricles. As a fetus develops in the womb, there is a network of very fragile capillary blood vessels called the germinal matrix which is located at the center of the two lateral ventricles. This network of blood vessels becomes hardier and less fragile as the fetus develops, and ultimately goes away by about 34 weeks gestation. The earlier during gestation that a baby is delivered, the higher the chances for IVH. It is also associated with some other factors such as the presence of infection and overall stability of the baby. We screen all babies less than ~ 32 weeks gestation with a head ultrasound at about a week to ten days of age.
When IVH occurs, it is graded in severity as grade I-IV. Grade I is limited to the germinal matrix, while grade II involves extension of blood into the ventricle. Grade III bleeding extends into the ventricle and causes dilation of this fluid filled space. Grade IV extends into the brain tissue itself. Grade III and IV hemorrhages may progress to a condition known as post-hemorhhagic hydrocephalus in which the flow of fluid in the ventricles is obstructed and they become markedly enlarged. Such a condition may require surgical intervention. In terms of prognosis, grade III and IV hemorrhages are associated with worse neurodevelopmental outcomes while grade I and II hemorrhages are not necessarily. The strongest preditor is the need for surgical treatment of post-hemorrhagic hydrocephalus. I always point out to parents, however, that a head ultrasound is not an IQ test. An abnormal one does not mean for sure that a child will be affected developmentally and a normal one doesn't mean that a child will have no neurodevelopmental problems.
At this point, I pause for questions before moving onto the topic of Retinopathy of Prematurity, a topic that I will post about later.