Types of Patients IX: "Bad Babies"

A touchy subject.

Yesterday, I accepted the care of a 53 day old female with respiratory distress. There is nothing more frightening to me as a parent and as an ER nurse than a baby that can't breathe or isn't breathing well.

As a parent, I recall a time when my infant son choked on a small cracker, and how the minutes he did not seem to be able to breathe shortened my life, I'm convinced, by years.

I recall, too, the several times I have had to resuscitate him when he did not regain spontaneous breathing after having seizures.

There is nothing worse than a child who will not breathe!

As a nurse, flashes of parents' hopes for their child as I care for him or her rush through my head and I realize that I am somewhat the keeper of these. I also become entrusted by the parents as easily, it seems, as one would entrust their poorly running car to a mechanic. I do not want this responsibility, but by virtue of my training and career, I have tacitly agreed to accept it.

Okay. ABCs.

A. Baby's airway was patent but compromised by mucous and secretions from what we suspected was respiratory syncytial virus (RSV), a viral infection of the lungs and airways of children primarily less than 1 year old. It is a common source of bronchial infection and pneumonia in infants.

Attend to positioning, initiate suctioning, both with a bulb syringe and wall-mounted vacuum suction via a Delee suction device, stimulates baby to breath as well as helps keeps baby's airway clear. Check.

B. As already noted, baby's breathing and oxygenation were poor. Respiratory rate was in the 80s-90s (normal values are in the 40s-50s) and oxygen saturation (a less than completely accurate measure of tissue perfusion, i.e., how much life-sustaining oxygen is getting to the organs and tissues) was approximately 88% (normal is 97%-100%).

Provide supplemental oxygen. But for a small infant this isn't the easiest intervention. Nasal cannulas and infant oxygen masks are notoriously less than effective. What is needed is an environment completely rich in oxygen, like in an incubator. We don't have this technology in the ER.

Thanks to our Respiratory Therapist (RT), a infant "hood"--a plastic dome, sort of like an astronaut's helmet, with a cut-out for the neck and sliding access panels--was placed over the baby's head as she laid on the pad of the baby warmer, a special device for infants that is no more than a treatment table with a warming light over it and oxygen tanks and suction canisters attached.

Check.

C. The baby's heart rate was in the 180s (normal is 130-140s). Increased heart rate is, in part, a compensatory response to poor oxygenation and dehydration, a condition that increases when babies are sick. If tissues aren't receiving enough oxygen, the body will attempt to increase oxygen supply by passing more blood through the tissues. To do this, the brain stimulates the heart to beat faster. However, when the heart beats faster, more oxygen is consumed by the heart and the muscle begins to tire. And so, a vicious cycle ensues.

If intervention is too slow or inadequate, baby will literally wear herself out. With a heart rate of 180 and oxygenation of 88%, we were already "behind the eight ball" as a popular expression goes.

Supplemental oxygen is a good first step. Next, intravenous fluid boluses to increase the volume of fluid in the blood stream to off-set the effects of dehydration. Intravenous access also allows for easier drug administration.

Thanks to a Family Birth Center nurse, IV access was achieved within the hour of baby's arrival in the ER. Why didn't I do it? For the same reason I don't change the oil in my car...I can do it, but there are people who specialize in this sort of thing. Part of being an ER nurse is the wisdom and foresight for judicious use of resources. FBC was my resource in this case!

Circulation, check.

There is a D as well (ABC,D): Differential Diagnosis.

We suspected RSV but other conditions could cause what we were seeing. Cold-stress is another possibility. Hypothermia forces a baby to increase heart rate and breathing in order to maintain body temperature. Assessment: In fact, baby's initial rectal temp was 95.4 (normal is, of course, 98.6). Intervention: warm baby up. Using the baby warmer is standard. Warmed IV fluids helps. A special infant chemical-warming pad was also used.

Hypoglycemia is also suspected. Low blood sugar reduces metabolism; reduced metabolism decreases body temperature. No fuel for the fire. Assessment: Baby's heel stick blood sugar was 66, normal. Intervention: IV glucose (if necessary).

Check.

For three hours, we (RT, the FBC nurse, and I) attempted to improve baby's breathing, all of us, baby included, suffering through pronounced and prolonged apneic periods during which baby would stop breathing for up to 7 and 8 seconds at a time. I began to wonder from which episode baby would not recover, requiring a resuscitation effort, the survival rate of which is low.

I don't pray, but I have wishes. I wished that it wouldn't come to this.

Eventually, we transported baby via helicopter to a pediatric emergency room and, I assume, NICU (Newborn Intensive Care Unit) at the nearest large hospital. Although I haven't heard, I assumed baby's prognosis is good.

I would be lying if I denied being relieved and happy that baby was gone and out of my ER. I know my nursing limits. Baby's condition was pushing and, in some ways, surpassing them. I'm not embarrassed to admit it.

We often joke among ourselves concerning triage that there are two categories of infants: good babies and bad babies. Nearly 97-99% of babies brought in by parents are of the former category. Most of these suffer from what we call PPP, piss-poor parenting. It's the other 1% or so that scare me.

My "bad baby" experience reminds me that, no matter what my demons, I need to be ever-mindful of my skills and abilities and the limits to these, and to swallow my pride when it comes to the health of a infant. I hope I did and will always do the right thing.