Shit….it does happen in medicine, and in "threes" if I’m not mistaken. Yesterday morning I was solo, something that is rare these days but welcomed on occasion. I made the drive to Kanye and was just sitting down to morning report by the staff at the hospital when a call came in from OB for newborn resuscitation. A child has been born over a prolapsed cord and wasn’t breathing.
These situations are true buggers in any country. The child (read brain) has been deprived of blood (read oxygen) due to compression of the cord between the side wall of the pelvis and the infant's body. Any attempt at resuscitation is mis-named. Instead of cardio-pulmonary resuscitation it should be called brain resuscitation.
In newborns the cardio-pulmonary tree is so pristine it usually “starts” without a lot of carrying on. It’s the brain….that jello-like mass of goo that needs the 02 more than the other organs. It can shut down so completely such that blood doesn’t even make it past the neck. Now if you’re a dumb family doc like me with a moth eaten brain in the first place, maybe no big deal. In a child it isn’t compatible with life.
So the flail was on. It was truly other-worldly in that it was conducted in room where there were no less than six deliveries on two beds by three midwives. While we proceeded people casually were moved about accompanied by all the sounds of women in labor, and cleaning ladies mopping floors in between deliveries. Like other hospitals, they had a warmer but no one knew how to use it. They did have neonatal intubation ability and my colleague did admirably in establishing an airway. We had 02, and an ambu-bag, now full of meconium, that I washed out and then used to provide ventilation.
So; “Airway”-got that covered, “Breathing”-yup breathing OK, “Cardiac”-seems to be perfusing well, below the head at least, “Drugs” need bicarb and D-10 or at least D-“something”. As I asked for bicarb I was informed that we were “out of stock”. “Of @#$%#ing bicarb?!” I lit up like a damn cruise liner at night. My colleague shrugged. I fumed and called the pharmacist to the room asking how in the name of all that makes sense we could be out of bicarb, ...today, ...now,... here?!? She shrugged. I asked that she check everywhere as I felt this child’s brain leak through my hands. She left.
We attempted au umbilical line but to no avail as the iv cannulas were too stiff and the feeding tubes too big, so my colleague got a line in the foot; in the foot of a clamped down, meconium stained, non-perfusing deeply pigmented neonate! These guys are amazing. We found some D-50, diluted it up and gave it, some very old bicarb appeared from surgery where it had been used many times from the same bag (no clue about how that made sense), and tried to figure out the difference between milligrams, milli-equivalents, and millimoles as all three were cited on the bag, and we had no idea if it had any bicarb in it in the first place.
By now every baby doc's fear was being realized; we were saving the heart and lungs but the brain was dying or dead. We gave some of the supposed "bicarb", she started to breathe on her own, … and then the seizures started. Well shit again.
We called PMH and were told that since she didn’t need ventilation she didn’t need transfer. We all exchanged looks, calculated doses and rates and put her next to her mother. We couldn’t get her warm so adhering to the adage that “you aren’t dead ‘til your warm and dead and sweet and dead” we heated two liter bags of iv solution, placed them along side of her and gave more D-10 (or D-something).
Blessedly she quietly died last night at 1830.
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