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Service or Martyrdom?

Service or Martyrdom?.

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Beinte-Cinco: Quatro

For the past few days, I have been plagued by extremely premature babies for the first time, all 25 weeks gestational age, with different stories embracing each…

UNO…

Parents are well-to-do. They have a business, requiring husband to be out of town. Allegedly, the current pregnancy is not of the husband’s… Mother came in to the labor room, in active phase of labor, meaning, baby is already about to come out. Based on limited data gathered by my resident, mother is about 25 weeks pregnant, had been having diarrhea few hours prior to abdominal pain.

Baby was born, I immediately provided his needs – intubation, mechanical ventilator support, umbilical vascular catheterization. Despite full support, baby’s oxygenation status was never better. Chest x-ray showed collapsed lungs due to sequelae of prematurity. Husband is out of town, the mother’s companions are her employees, who cannot help me with legalities and decision-making.

Then the obstetrician revealed, (as she has the rapport with the mother), that the mother attempted to abort the baby by ingesting some abortifacient. About six hours from birth, the father arrived, but even if he wanted to be aggressive, the baby couldn’t respond anymore to treatment. They then signed a DO NOT RESUSCITATION order. Baby expired after about 12 hours from birth.

DOS…

Both parents are young and unemployed. Mother is 18 years old, father is 22. She came in too to the hospital because of abdominal pain. When at the emergency room, baby’s head was already presenting so she was rushed to the delivery room. I was called in after the baby was delivered so I rushed like an ambulance driver to the hospital. Baby’s urgent needs were provided and then I talked to the father about baby’s condition, what he needs. Unfortunately, even after he has called all possible resources, he wasn’t able to provide the medication baby badly needed.

Baby was only relying on the mechanical ventilatory support. However on the 30th hour of life, he started showing signs of deterioration. His mechanical ventilatory settings were unusually high that eventually led to rupture of both lungs (just as when I left the hospital). I had to rush back to possibly rescue baby. His x-ray revealed rupture of both lungs, with air escaping out but still within chest cavity, thus compressing both the lungs, and the heart. If this were not addressed, baby will die in a few minutes..

I called in a pediatric surgeon to insert tube to drain the air, while I only deed a rescue needle thoracentesis. Alas, after our attempts to rescue baby, he didn’t make it. He expired at about 38 hours from birth.

TRES…

I was informed that there is a pregnant mother, on her 28th week gestational age, for control of labor, but if she will deliver, I will attend to the baby. At least, the baby was older this time (and so I thought)… I instructed then the NICU staff to prepare equipment that baby will need upon delivery. Only two hours after the referral, the phone rang again, calling me now to the delivery room as the baby’s head was already almost out. At least this time, I was already able to have dinner.

I rushed to the hospital and in less than 10 minutes, baby came out. But baby wasn’t looking normal, he was deformed. His head and face were deformed, the abdomen was as large as the head (normally, for a preterm, the head is larger, abdomen and chest are almost the same in diameter), the feet are compressed, looking like club foot. When I was asked what the gender of baby was, I couldn’t commit whether baby is a boy or girl. It seemed like there are scrotal sacs, but empty (which is expected at this gestational age), there was a protrusion that is hard to discern if its penis or clitoris. (In cases where genitalia is ambiguous, we are not obliged to assign a gender until we were able to document it by chromosome (DNA) analysis, so as to avoid mistake in gender assignment). Baby’s skin were also showing red spots highly suggestive that baby has congenital infection, probably german measles or cytomegalovirus. The large abdomen suggests that liver or kidney is enlarged. Whether it is a tumor or a reaction to maternal infection during the course of pregnancy, I could not be certain. Physical assessment also revealed that baby is only 25 weeks, and not 28 weeks as thought of by the mother.

Upon birth also, heart beat was already less than normal, and he was already gasping (an ominous sign of arrest). I already knew that resuscitative efforts in this kind of situation will be otiose. So, I immediately called in the grandmother (as the husband is abroad) and explained how futile resuscitating baby is. We provided comfort care, had baby baptized, and waited for baby to expire.

In retrospect, I learned that at 5 months gestational age, baby’s ultrasound revealed that there was polyhydramnios (excessive amount of amniotic fluid). The placenta was large too, heavier than the baby, also substantiating my suspicion that mother had a lethal form of asymptomatic infection that grossly affected the baby.

After 58 minutes from birth, baby expired.

QUATRO…

It was a Sunday, it was supposed to be lazy day, rest day for me, but for some crazy reason, the world does not want me to fully enjoy my rest days, this day included. I was called in for emergency cesarean delivery at a hospital for the birth of yet again 25 weeks old baby. Baby had to be delivered as the hand is already coming out of the vagina.

Upon arrival at the hospital, the obstetrician and her assistant was already operating on the mother so I barely had time to prepare. Baby came out in few minutes and needed resuscitation as he was not spontaneously crying and breathing. We had to provide bag-mask ventilation but the equipment was dysfunctional. Also, many equipment that baby needs is not available in that hospital so I had to immediately transfer baby to a higher center. The baby is the 2nd child, the 1st child being 13 years old already and parents want the baby to live. What am I to do but to stress myself thus? (evil-grin) 

The ambulance and I rushed to the other hospital in convoy. Again, his needs were provided. This time, I or perhaps the baby was lucky because the father was able to provide that much needed surfactant. Also, the baby’s lungs are not that collapsed compared to the other ones I previously mentioned.

It seemed that the mother has uterine infection as the bag of waters broke one day before she had labor pains. Usually infections at this week of gestation is lethal/deadly to the premature baby.

The baby is currently stable at present, although still requiring mechanical ventilatory support.

 

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My Bargain With The Almighty

In commemoration of the Lenten Season, I’d like to share one of my Lenten experiences. This happened last year though.

I received a call of referral to attend to the delivery of a baby who was initially diagnosed  as a case of hydrops fetalis (baby is swollen all over his body).

Hydrops fetalis (not the actual case; photo courtesy: http://www.medadteam.org)

My case is that of a baby who is term, who was worked up (as mother is considered high risk, >35 years old primigravid –first time pregnant ) and initial ultrasound during middle of  pregnancy revealed hydrops fetalis. A repeat ultrasound again after one month described the baby to be hydropic. With this, parents were advised not to expect much, that the baby has a slim chance of surviving. Parents were then preparing (emotionally and psychologically) that baby will not survive for a long time after birth. Mother was admitted when labor started but cervix remained at 9cm for several hours. Because of this, a second opinion was obtained from another obstetrician, who repeated the ultrasound. The result was… UNEXPECTED! Baby had no hydrops, instead he has a mass (tumor) at the abdomen. So this then made us rattled and shift paradigm. Parents, who were resigned to the feeling of hopelessness, had to be informed that the initial consideration was wrong and the baby might still have a chance of making it in indeed this is a tumor. (A tumor can just be removed and then presto! Chemotherapy might also be done, if indicated). From the initial state of unpreparedness (emotionally, psychologically, financially) for a longer baby’s stay in the neonatal ICU, the parents now had to. (Mother is 40, a teacher, while father is a contractual laborer). After all, this is going to be their first baby. An emergency cesarean section was thus scheduled.

The baby was born weighing 3.6kgs, with noticeable swelling at the abdominal area. When baby was stabilized and brought to the NICU, ultrasound of the abdomen and surgical consult was in order. The ultrasound of the abdomen revealed a complex mass with calcifications, and an x-ray done afterwards was suggestive of meconium peritonitis. An emergency operation of the baby was scheduled but the parents (who were not expecting this) didn’t consent. I went back later in the day and tried to explain the findings of the surgeon, and that I think convinced them to sign the consent. (Meconium peritonitis means that a part of the intestine ruptured while the baby is still in the uterus, and thus meconium — baby’s stool, leaked into the entire abdominal cavity. This can cause the other segments of the intestines become irritated and develop a reaction against the meconium). The operation was successful, and the point of rupture was located, cut and then the intestines were then re-attached/re-anastomosed. A drain was in place that will be removed when baby will show signs of healing.

(Meconium peritonitis; Not the actual case. Photo courtesy: http://www.scielo.br)

Baby was brought back to the ICU immediately after the operation, stabilized. Antibiotics were given to cover for possible/ongoing infection. However, just as when we decided to begin feeding baby, he started having fever. Initially, I thought perhaps the antimicrobials were not doing their job so I had to switch to stronger kind. But the fever was unrelenting, while I kept on changing antibiotics every after five to seven days. I even referred the baby already to an Infectious Disease specialist to no avail. Also, from being able to breath on his own, baby now had to rely on continuous positive airway pressure. Platelets were also dropping to alarming levels. Blood was also coming out of the mouth and from the endotracheal tube. I suggested to the mother, (not to insult their financial capability but out of concern because I considered their sources of income and the baby’s mounting expenses), that I will refer the baby to social service so that they will be classified charity case, they agreed with great sigh of relief. Their emotions and mental status were already on roller coaster.

After almost one month from birth did I think that perhaps the baby might have contracted a tuberculosis from the mother during the time of pregnancy and this is the manifestation. It was as this point that I was bargaining with the almighty, asking Him to give the baby to his mother (as she is already high-risk with her old age). And in exchange I will not charge them professional fee as long as baby goes home alive. But exactly one month from birth, baby succumbed on Good Friday. I failed… but stood true to my bargain with the Lord, I did not ask the parents to pay me… It was painful. But on the other hand I thank the Lord for relieving the parents already of the pain they had been going through. They accepted baby’s death with ease. In fact before baby died, parents already signed a “do not resuscitate” order…

 
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Posted by on April 22, 2012 in Personal

 

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