Gwo Tet De

“He’s blue guys.  And not crying.”  They continue with drying/active stimulation.  “He’s got good tone” the other resident responds.  Looks kinda floppy IMO, but I’m not manually checking him.  You know how they always tell you that good communication is key in high intensity situations?  Well, that is definitely true because I felt like with the language barrier we couldn’t communicate what we were thinking and what we needed to do.  Seconds seem like hours as we are waiting for any signs.  Finally, we each grab for a cord clamp.  I guess our thought cycles synced up.  Clamp.  Clamp.  Cut.  She grabs him by the shoulders and carries a floppy, blue baby over to the neonatal resuscitation table ServeHaiti recently provided to the clinic.  Sidenote: I was actually here the day the docs brought it down.  They were so proud.  Certainly seems like a great idea…Until it’s not useful.

We place him head towards us, face up.  “Do we have any suction?” I ask as she is bulb syringing his mouth and nose.  She’s getting some yellow gunk, for sure.  “You see it” she responds.  “Stethoscope?”  Fortunately there is one hanging on the wall, because none of us had brought ours in the delivery room.  We hadn’t needed one all night.  This was obstetrics.  Who needs a stethoscope?

I place the plastic diaphragm on his chest.  #HolySh!t That doesn’t sound normal.  Let’s try the other side and hope it’s better.  More normal, if he were an athlete.  FWIW heart rates in the 50s are not good for newborns.  “Oxygen?” the other resident asks.  Our nurse tries to hook up the one in the room, but it isn’t working.  “Any mask?”  No.  Of course not. 

I do the only thing that comes to mind.  I start compressions.  I have flashbacks to a premie that Dr. Angie and I delivered in Arcahaie.  The thought crosses my mind to give mouth to mouth rescue breathing like she did, but I’m already fighting with their hands while they place a nasal .  My face getting involved would just be too many moving parts occupying the same space. 

About now I try and stretch to the far reaches of my memory.  As an intern in family medicine at Wesley we go through tons of certifications.  And rightfully so.  As the family doc we could literally find ourselves in most positions where those different class and certification skills would be necessary.  Give me an adult code blue and I’m good.  ATLS?  I probably wouldn’t be the worst at it.  But here I am trying to remember my neonatal resuscitation program.  And it’s not going well.  All I can remember is PPV, which we didn’t have.  So next best thing in a bradycardic infant who is hypoxic is chest compressions, right?  Where’s my iPhone?  There needs to be an app where you take a picture of a patient and it magically tells you everything to do. 

I keep mashing away.  Every now and then he gives me something to work for by moving an arm or leg spontaneously, as if fighting the pain I’m surely causing on his chest.  I pause for heart rhythm identification.  Oh wait, no ekg leads, no O2 sat monitor, just me and a plastic stethoscope.  “Well, the funny sound seems to have gone away.  He’s hinting that he might try and breathe on his own, but still not very consistent with it.  And his heart rate is still low for an adult.  Resuming compressions. 

His eyes open and no longer appear lifeless.  I can hear the occasional grunt from his mouth and nose, which are now turning pink.  #PositiveReinforcement  His arms and legs are offering more signs of tone.  And we finally have the nasal cannula in place, powered on, and all done without unplugging the resuscitation table…again.  BTW, did anyone bother to calculate APGAR scores?  No?  Okay.

You can see the bruise.

I replace the steth on his chest.  Please be normal.  Please be normal.  It is!  Good, brisk heart rate without any murmurs.  He’s pink.  Moving spontaneously and with slightly better tone.  His respirations still leave a lot to be desired, but without deep suction or PPV I’m without any other options.  He’s gonna have to cough and cry it out.  Already a bruise is developing on his chest where I did compressions.  I talk to the Haitian doc about need for antibiotics and extended stay.  At Wesley he would have been a special care admission at the very least, but likely an NICU.  Course, he probably might have been intubated at the onset.

#WardrobeFail x 2

And it’s events like this that make it ever so clear why it’s nice to have a team.  The whole while we were working on the baby the mom sat there unattended.  And then when we were comfortable with the baby we turned our attention to mom for her repair.  I’m used to continuous nursing care and monitoring; this was incredibly painful for me.  I didn’t even offer to sew.  All I could do is retract (ain’t no way I’m gonna do my first third degree perineal lac repair without direct instruction) and watch from across a bed as the infant retracted away. 

But to bring the longish story to an end, he’s doing much better.  He and mom were recovering in the next room when I checked on them a couple hours later.  He was pink and breathing fine.  I still hope they decide to do 48 hours of observation if not also IV antibiotics.  He went through so much those first minutes of life that it’s worth an extra 24 to make sure he leaves the hospital healthy.  Heck, they're all GBS unknown so they should all stay for 48 hours.  But you try telling that to a Haitian family that needs to get back home to take care of the rest of the kids.

#NewbornSelfie

As a stateside update to this story, I was recently involved in an emergent cesarean section for fetal distress.  Turns out there was a placental abruption and the newborn was basically cut off from the maternal blood supply.  Thank goodness we had an operative staff and neonatologist on site.  It simply became a matter of me stepping out of the way and letting the specialists do their jobs.  The surgeon dropped off a floppy, gray baby into a functional resuscitation table where four hands began drying/stimulating.  The neonatologist got a deep suction catheter ready and suctioned about 6mL of cloudy, thick secretions..  One of the nurses auscultated for cardiac and breath sounds.  PPV was applied to help with oxygenation.  Slowly but surely the baby was weaned to room air.  There were three surgeons controlling the hemorrhaging uterus and closing up mom’s abdomen.  The entire team worked like a well-oiled machine and the outcomes reflected it.  Sometimes it’s easy to think we overkill our preparedness in the United States, but when something like this happens it’s crystal clear why it is so important.