Thursday, October 26, 2006

"It"

I'm half asleep in the Peds ED, the only thing that has stood between me and blissful sleep is a 12 y/o with abdominal pain. I was set to send her home until her WBC count clocked in over 15,000 and she bought herself a CT scan. One more rule out appy for my last shift before vacation.
"Do you guys have an attending in here yet" asks one of the residents from the adult ED. We do not in fact have an attending on, not until 8:00am. It is just me the intern and a second year pediatrics resident running a level 1 trauma center. "Call the NICU then, you have a premie comming in".
I start to wake the resident when the firemen walk through the safety doors carrying a towel. They are sweating profusely as they walk quietly to the rescusitation room. The women has her fingers delicatly positioned over the middle of the towel as her index finger softly pumps, one two, three, four.... Her partner is holding an oxygen mask over the towel completly obstructing my view. The nurses with vastly more knowledge and experience than me have already rolled over the warmer and turned it on. The fireman sets the towel down.
It's bright red, about the size of my hand. It eyelids are fused, and it's skin is so transparent I can see it's lung moving beneath impossibly small ribs. The frantic movement I see beneath the sternum I can only surmise is its heart. It is not even clearly human, it insteads looks like some shrunken alien crash landed on this planet. It's head is smaller than a lime, its mouth opens less than the width of a pea. It can't possibly be alive. And then it breathes. So hard that I can watch all the muscles between its ribs retract with every tiny breath. We all stop, the seasoned nurses, the naive intern. The ER is usually one big traffic accident and most of us have long since stopped rubbernecking but everyone comes to see this. And from each one you can here the same audible gasp.
Peter, the NICU resident arrives on the scene and states what I know we all understand in our hearts. "It's not viable, we don't have a tube that runs that small. We just have to get the weight and we can be done" The rule in neonatal recussitation is firmly drawn at 500 grams. Anything bigger we go all out, do everything, even though most will die or be permanently neurologically disabled. Anything less and we do nothing. Like it never even existed. Whether you live or dies depends on whether you can outweigh a Coke can.
It weighs in at 177 grams. According to the report from mom, she thinks she was 18 weeks pregnant. That's less than 5 months.
We rewrap it in the towel, turn off the warmer. Peter goes over to ask the mom if she wants to hold it, say goodbye. She does. I go back to my desk to see what the hold up is on my appy kid. The ED is eerily silent and I can here the nurses in the lounge talking about what has happened, decompressing, trying to forget. A half an hour passes and Peter returns to the Peds ED with the towel.
"OB is going to take Mom upstairs to check her out. I already talked to my fellow and she says that protocol is to put it in a specimen jar and send it to pathology." "Alright, " I say half paying attention, " thanks for all yor help". I hear him sigh and then slowly start to speak again. "the thing is, it's still breathing. " The world grinds to a halt as I turn to face him, to take in what he is trying to tell me. "I have all the paperwork for path, I even have the jar. But it's still breathing. I can't put it in the jar like this. We can't take it to the NICU if were not going to do anything. I didn't think it would still be alive." None of us did.
We agree to keep it downstairs with us. It doesn't have any where else to go. Technically it not alive, but it's still breathing so I can't really say it's dead either. We find an empty room, Peter and I are now co-conspirators of some horrific crime that up until tonight I had no idea existed. We lay it back down on the warmer but we don't turn the warmer on. " Don't wrap it up," he says as I begin to swaddle it. Looking at it breathing, I can't help but think of my daughter when she was a newborn. I want to hold it, to tell it that its okay, to comfort it. Does it feel pain? I don't know. But I do. It must feel something. To go from the comfort of being warm and snug suurounded by amniotic fluid with it's life finely tuned to the rhythmic beating of it's mother's heart. The world now cold and chaotic. We are as foriegn to it as it is foreign to us. " If you expose it then it will go faster."
And so we wait, while it continues to breathe and defy us. We wait as another intern on a different rotation stops by to see how my night went. I bring her in to see it. It is colder now, breathing more slowly. A bloom of bright red covers it's chest. Trauma from the fireman's CPR has ruptured its fragile blood vessels. And so we wait. My appy kid does not have an appy, just some kid with run of the mill abdominal pain. So we wait. Time has slowed to an unbelievable crawl as we wait for death to claim a life that never was. I come in to check on it. It is cold to the touch, it has stopped moving. I pick it up, ready to finally put it in the jar.
Then it breathes.
And so we wait. The nurses change shift and the waiting room fills with patients that have no idea what is happening in room 6. I wait for it to die, to be done. The attending comes in and I tell her about the cordened off room, the squiggly line on the board with no name and no chief complaint. We wait, in truth it is just me who is waiting. Everyone else seems content to forget about it but I keep returning to the room every half hour. To let it know that it has not been forgotten even though I will do nothing for it. I wait.
Four hours after it first appeared in the ED, one of the senior nurses comes in the doctor's area with a towel. There is no doubt what is inside. She gets the jar. I don't even know if it was actually dead when she put it in the jar. I didn't ask to see it, to see for myself that it was over. Who knows maybe she just has more nerve than me. All I know is that it is over. Or it least it should be.
But I am still waiting. Waiting for forgiveness though I my head knows I did nothing wrong. Waiting to stop seeing it breathe in my dreams. Waiting for it to give up on life even though it never knew what life was. Waiting to stop seeing it in my dreams. To stop seeing it in my daughter's eyes when she laughs. Waiting to stop being mad at myself for not holding it and giving it comfort while it died. To give it the gift of humanity that is all our birthrights, when it had, in fact, been born. It had lived though it will have no funeral, no name, no birthday. Just "it". I am waiting. I am still waiting. I wil always be waiting.

25 comments:

Kim said...

Well, if bawling first thing in the morning is good for you, my day will be perfect.

That baby was fighting so hard to live and yet there was no way.

This post will stay with me for a long, long time.

And we both know it wasn't an "it". It was a "he" or a "she" and a human being at a point of development we rarely (thankfully) visualize living outside of an ultrasound.

I think I would have named him/her. But then I'm talking as as woman and the mother of a baby lost at 10 weeks gestation.

Powerful, powerful post.

Kim said...

Well, if bawling first thing in the morning is good for you, my day will be perfect.

That baby was fighting so hard to live and yet there was no way.

This post will stay with me for a long, long time.

And we both know it wasn't an "it". It was a "he" or a "she" and a human being at a point of development we rarely (thankfully) visualize living outside of an ultrasound.

I think I would have named him/her. But then I'm talking as as woman and the mother of a baby lost at 10 weeks gestation.

Powerful, powerful post.

shadowfax said...

Tough day. Thanks for sharing.

Medblog Addict said...

Great post. I am usually a lurker because my medblog obsession is kind of embarrassing. But I wanted to tell that I really enjoyed your blog. Your medical experiences are interesting, but I also like reading about how you try to balance career and motherhood. Also, regarding your earlier post: I was jaundiced once. I recognized my color change, but thought I looked more orange than yellow. But I can't imagine anyone not noticing a color change like that.

Irishdoc said...

Thanks so much for your comments. They really mean a lot to me.

Anonymous said...

First, thanks for visiting my blog and leaving a comment.
Secondly, i have to say u write it as it is.
When i did my NICU posting, i was emotionally so traumatised.
Ur post 'It'Was totally moving. brought back tons of memories.
Wish u could take time to write more often.

QCOMDRJ said...

You can try to rationalize it, or you can move on. On one side, nothing you were going to do was going to make that baby live. But on the other hand, you were perfectly fine in not ending the life prematurely. "It" may have felt pain, it may have felt cold, it may have felt hungry. You cannot fix those things.

Sometimes our jobs just suck. Sorry yours had to today. Maybe tomorrow will be better.

difficultpt said...

I had so much that I wanted to say, but then I read Kim's comment and she said it all . . .

TheTundraPA said...

Just found your blog thorough Grand Rounds. What an absolutely amazing post, beautifully written. I'll be back to read through your archives!

medstudentitis said...

What a beautiful post.

Elizabeth said...

If the baby was breathing and had a heart beat, it was still alive.
It was a live birth then a neonatal death.

I am glad you kept going back, so that the baby was not totally alone as s/he battled for life, even though it was an unwinnable battle because of the extreme prematurity.

As a midwife and a mother, I can`t help thinking it was a shame that the mother wasn`t able to hold her baby in her arms until he/she died, surrounded by love.

Thanks for sharing this. It must have been a really tough day for you.

Flightfire said...

.......wow........

Ugly John said...

Great post, beautifully expressed.

Chili Pepper said...

Irishdoc,

Wow. You blew me away with that story. I am a mom and pregnant with another baby, both healthy *knock on wood*. This story made me teary too. The poor mum, baby and all the medical staff. I understand why you call the baby "it", but it breaks my heart. I can't imagine watching it struggle to breathe. I am glad that you had the courage to check on the baby. Don't beat yourself up too much for not holding the baby. You still made a difference.

Thank you for sharing such a heart-wrenching story.

Chili.

Anonymous said...

I really enjoy the intensity of your Posts. I have been hospitalized over 100 times for a variety of maladies – although most stemming from my auto-immune illness – Crohn’s Disease – and you seem to capture the unique atmosphere inside the hospital. I have linked to your Blog on my “Patient Blog” at www.hospitalpatient.org – and if you deem it appropriate to trade links that would be much appreciated.

Borneo Breezes said...

Moving post.

DocBellaise said...

Hi! I thought I'd commented on this...but I guess not. This was just one of those posts you don't forget. I don't know what I'd do in that situation. That baby was strong. But I think what scares me is how people can get so desensitized to such a point that they see a fighting baby (life) as space that is being taken up. Very good post.

Junior DocSpot said...

Really moving post. How sad. Can completely understand the compulsion to return and to wait. Agree with Kim - definitely a human being.

Gumby said...

I finished reading the post and discovered that I was barely breathing. Powerful and disturbing.

Apollyon said...

Over ten years ago, when I was EMT (before paramedic), I was working with a partner whose wife was pregnant at the time with their second son. Hot, hot summer day - took a call with Engine 34, and get to the apartment in the projects, and there's just blood everywhere in the bathroom, and the fetus in the sink. My partner put his stethoscope on the chest and got nothing. We wrap it up and take mom and fetus to the hospital. Coincidentally, I see my second cousin working in L&D, which I did not know. One of the other L&D nurses unwraps the fetus, and, to my dying days, I will never forget this: "Oh my God, it's still alive!" My blood ran cold. Mark (my partner) almost fell to the floor crying. There was nothing to do as this crazy little heart beat crazily along, with eyes and digits fused, except wait for it to die. Fortunately, Mark's son has been wonderful from his uneventful birth.

Anjali said...

Wow. And very relevant to what I'm currently going through.

To echo and earlier comment, I don't understand why the mother wasn't holding the baby until it died (perhaps it was too difficult for her?). I would have held it until death, and given the baby a name.

Anonymous said...

for fear that 'it' feels pain or cold or fear can't an umbilical line be started and just flooded with morphine? this seems like a way to stop 'it' from breathing and treat any feelings.

gujudoc said...

Wow that story brings chills to my spine. That's horrible the way they just put the fetus or embryo in a jar like that.

gujudoc said...

P.S. to add on to kim's comment, I'd have named the baby a neutral name rather then calling the baby an "It".

Anonymous said...

what about the recent miracle baby...the size of a pen. If she can survive, will new protocols be written?