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Category Archives: Bronchopulmonary Dysplasia

When All Else Were Done…

When All Else Were Done….

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When All Else Were Done…

She could have been my smallest survivor…

Mother was hypertensive, first baby to have been successfully conceived after 8 years of waiting. Unfortunately, the hypertension was causing distress to the baby, so she has to be born prematurely, or the mother will seize… or die.

She was pretty 515 grams, 25 weeks, brave baby girl. As most prematures would, she was immediately in distress thus intubated, and breathing was assisted by mechanical ventilator. She was given surfactant again thus after 5 days from birth, she was already off from the ventilator and was merely on low-flow oxygen support. She was also being fed already and was tolerating the gradual progression of feeding. But the drastic event happened on the 6th day of life: she all of a sudden vomited blood.

I was called when the resident was already attempting to rescue baby. As soon as I arrived, baby was already in a very compromised state. I had to bring back the mechanical ventilator to aid her breath. She was bleeding from all over, including her lungs; good thing her brain was spared. But alas, complications upon complications set in. Respiratory failure, kidney failure, patent ductus arteriosus. Considering the long wait of the parents to have a baby, that motivated me more to try to tug baby away from the grips of death.

One week from birth, as they were that excited to successfully have a child whatever the gender is, the father went overseas to work and help finance the expenses the baby will incur no matter how much it would take.

Baby was able to pull through from those complications, but with one grave sequela, she had bronchopulmonary dysplasia. Her lungs weren’t able to resist this complication such that on x-ray, it literally looked like a sponge. As a consequence, I couldn’t take her off from the mechanical ventilator.

She later on was also having regurgitation, and the milk that regurgitated were being aspirated, thus aggravating further her respiratory condition. I tried the textbook managements to no avail. Then out of frustration as her hospital bill was already mounting up I resorted to nonconventional remedies just for her to be able to be weaned off; mechanical ventilator is the real burden on one’s financial resources. I even already tried using those asthma inhaler puffs attached to make-shift gadgets; yes, my creativity had been challenged for real by this baby. Despite her dependence on oxygen and the respirator, she was gaining weight. Though her weight is far from what was expected for her age in weeks, still it was an upward climb.

All of a sudden, the respirator got accidentally removed from her system. I was so afraid because it happened when I was out of the hospital. But… she tolerated it, she was able to tolerate just breathing low-flow oxygen delivered by a nasal cannula. Finally, the mother can cuddle baby!!!

I was already planning how to discharge baby. Mother was already trying to find oxygen tanks and gauge that they can use if ever baby goes home. From 515 grams, baby was now 1.5kgs, after 3 months on respirator! The excitement was so pent up… until one early morning.

She strained hard while defecating… until her heart beat stopped. An anethesiologist colleague was at the adjacent operating room at that time and she intubated her and initiated resuscitation. I was awakened by the distress call. Upon learning that the residents started reviving the baby, I began giving instructions through the phone. (This was then the time when I had no car, I had to commute! But at that time that the call came in, it was busy hour. No cab could be hailed and all the jeeps were full from the place where I live). I was walking to almost running hurriedly towards the main highway, phone on ears as I don’t use bluetooth headset then. Then I successfully rode a jeepney and transferred to a cab en route to the hospital. Upon arrival (it took me about 30 minutes), I took over the resuscitation command. We were able to pull baby back but with a heavy prize. The period that her heartbeat stopped and blood was not circulated to her heart and brain really was significant that baby already began to seize, she was in coma.

I immediately notified the mother with a breaking heart. How do I tell her? The day before, she had been cuddling baby on her chest, doing her motherly “job” changing her diapers, feeding her, and assisting the nurse to bathe her. And now, I am going to tell her that her daughter almost died defecating, but is now in a vegetative state? How could I do that?

She arrived, and I explained how things happened. She was sad, tough, but breaking inside. I was teary-eyed because the baby was endeared to me. I was in pain. Then I asked to be excused as I realized I looked disheveled. I went home, took a shower and prepped for work. As I was doing that, the residents still kept calling me on the updates and I giving my instructions in return.

When I arrived again later, the mother, surrounded by her relatives, gave me the blow. She decided to bring baby home, while she still has heartbeat. I was crying in front of her when I heard her say that, but it was the wisest decision a person could muster on a painful moment such as that. I hugged her tightly, and then gave instructions to the nurses to prepare baby. As she was a very dear tyanak to me, I made sure that I was with the baby when she left the hospital. When everything else was settled, it was now time. I was bag-ventilating the baby while the nurses carried her until we entered their service car. Fighting back tears, I removed the endotracheal tube… Within few seconds… she was gone.

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(Image courtesy of http://thesaltlist.wordpress.com/2011/04/15/the-great-euthanasia-debate/)

 

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Service or Martyrdom?

Service or Martyrdom?.

 

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Service or Martyrdom?

This is a retro-blog.

I remember one patient who was referred to me for neonatal care. It was about 4 years ago. A mother had to deliver prematurely by cesarean section because of premature rupture of membrane and uncontrolled uterine contractions.. Baby was 28 weeks gestational age. There was no more room for control of labor, and preparing the baby’s lungs for eventual delivery; the cesarean section had to be done outright. Both parents were employed at that time, so I thought there was no problem about financial resources.

Again, as for all babies being born prematurely, he needed to be administered surfactant. It was night time, banks were closed so there’s no way the father can tender cash at that time. I told him to go to another hospital, secure surfactant with my name as guarantor and sign a waiver for them to pay for the drug in 24 hours. The medicine was released to him and thus I was able to administer it immediately.

(Image courtesy of www.nhlbi.nih.gov/health/health-topics/topics/pda/)

Baby was already being weaned from the respirator, when a new problem arose, a patent ductus arteriosus. This posed a threat as it increased the volume of blood that goes to the lungs for oxygenation and predisposing to a chronic problem: bronchopulmonary dysplasia. Oral medication given via tube to treat the problem. Then another problem set in: persistent pulmonary hypertension and renal insufficiency bordering renal failure, plus signs of systemic infection showing. I did some double volume blood exchange transfusion here besides giving respective medicines.

Baby’s persistent pulmonary hypertension responded to sildenafil. After the exchange transfusion, baby started urinating. Then the murmur disappeared. However, it took a some time to wean the baby off from the respirator because of one problem: baby developed bronchopulmonary dysplasia. I had to give cocktail of medications. Finally baby was weaned off from the respirator and was extubated but still dependent on oxygen support. There were even times when after extubation and when his BPD would exacerbate, it would require some hourly aerosolization to open up his distal airways.

When baby was almost two months, he was then discharged from the hospital, free from oxygen support, feeding well, and gaining weight daily. Due to big hospital bill, they asked if it is okay for them to sign a promisory note for their payment of my professional fee. Should I say no? I never proposed any condition at all. I just called the hospital to give my approval. They also partially paid their hospital bill.

One week from discharge, they followed up at the clinic. Few days after that, the hospital declared bankruptcy and closed. Then, my fear came true. They disappeared and never came back. They never at least had the courtesy to tell me that they can’t pay my professional fee. Nada! Boom! Ba-bye! I had their number. Sometimes I ask my secretary to remind them, but then they just say they will come to no avail. Then I recall how was I attending to that baby before, I had no car then. I would wait for a cab to visit the baby. Then during early mornings, I had to walk for about 10-15 minutes going to the main road to hail a cab to go back home. And then this is what I deserve.

The perks of a neonatologist. Other colleagues surely do have their own stories and could be worse than this.

 

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