Neonatal resuscitation

I stepped into the hospital early in the morning, and was hustled into the labour suite by a midwife. There, I found the whole team standing next to the bed of a mother with polyhydramnios and her fetus in breech presentation. Dr. Ogwal, one of the interns was dressed in a delivery apron, in the middle of conducting a breech delivery. How exciting!! I’ve never seen a breech delivery, and probably will have very few opportunities to see it back in the US (only under very specific conditions in multiple gestations, as far as I know). Soon, only the fetal head remained undelivered. Dr. Ogwal flipped the baby’s body over onto the mother’s abdomen in its first somersault, and its head slipped right out. What a sight!

However, the baby was not doing well. It had a grossly distended abdomen, and its lungs seemed underdeveloped. Apgar scores – 4/10 at 1 minute, and it didn’t get much better with time. We immediately started resuscitating the baby, but the baby warmer was not working since the hospital had lost power. So we manually warmed the baby with friction. Its heart rate was about 60, so we did chest compressions. It had central cyanosis, so we bagged it with a face-mask, but all the air seemed to be entering its stomach rather than its lungs. There was no ET tube, so we couldn’t intubate it. Dr. Ogwal fashioned a makeshift nasal-pharyngeal tube with a small piece of tubing for running IV fluids to more effectively deliver oxygen.

The baby’s heart was slowing down more and more – 40 at last count. We had asked for epinephrine over 20 minutes ago, and finally, the sisters managed to find some. However, we only had 18-gauge cannulas – way too large for the baby’s small veins. So we decided to do an intracardiac injection. Nobody knew how exactly to do it, so I looked it up on my iPhone with its super slow internet. The only thing I could find was a rough reference on Wikipedia – “4^th intercostal space between the ribs” it read. So I plunged the needle in the 4^th intercostal space, immediately medial to the nipple. I pressed down on the plunger, delivering the epinephrine into what I hoped was the left ventricle of the baby’s heart. We listened with the stethoscope – no heart beat at all. I shone light into the baby’s eyes – pupils were fixed and dilated. Admist all the hustle and bustle of trying to find the right equipment and medication, etc, we had lost the tiny life that had shone its light so briefly onto this world. The baby’s mother never even got to hold it or see it while it was still alive. I looked at Dr. Ogwal. “I really thought we were going to save it.” “Me too,” he replied. Everyone started walking away from the resuscitation table to join the morning rounds. I slowly wrapped the baby in its blanket, leaving its tiny face peeking out from its blanket. It looked like it was peacefully sleeping, if you ignore the bluish tint in its face. I stared at it. I couldn’t tear my eyes away from this tiny patient whom we had failed so miserably. “I’m so sorry, baby. I’m so sorry.” I started crying. I couldn’t believe it. I really thought our creative efforts and desperate attempt at resuscitation would work. It always did in movies, with the intracardiac injection magically bringing the patient back to life – the patient would awake with a big intake of breath, look around and ask “Where am I?” Why didn’t that happen? Why couldn’t we save this baby?

“Don’t take it home with you,” Dr. Ogwal told me. But why not? Taking our patients home with us will make us better doctors. It will scorch the lessons painfully learned from our failures deeply into our memories, so that we will never commit the same errors again. Or if these failures are the result of unfortunate situations, then it will motivate us to change the situation, to fight for our future patients so that they will not suffer the same unfortunate circumstances. I’m taking this baby home with me. I’m keeping it in my memories and my regrets forever.