Monday, March 17, 2014

Assessing the Damage

You look like your old self again.  I reached into your isolette to move your hand.  It was clutching your ET tube and was afraid you might pull it out again.  It wasn't easy to remove your grip.  "Nooooo," your stubborn determination seemed to say.  It was a kind of stubborn determination that few parents would ever wish to deal with, but in this case, it was such an incredible relief to see.

I had a talk with Dr. Brutal Honesty, this afternoon.  I'm not being sarcastic when I say that he's my favorite doctor because he has no qualms mentioning all of the horrible things that could happen to you in here.  "Why would this make him your favorite doctors?" you might wonder.  Well, because I can trust what he says.  I can take his words at face value.  Most of the other doctors try to shield us from the truth.  While this might relieve the parent of a patient momentarily, it creates an atmosphere where you can never entirely trust what they are telling you.  But Dr. Brutally Honest?  Were you to ever be in deep, irreparable trouble, Dr. Brutally Honesty would casually acknowledge it.  As a result, when things are going well, we can rest easy because we know we've been told the whole truth.  While every other doctor in here has a habit of saying, "Everything will probably be fine!" when things obviously won't be, Dr. Brutal Honesty instead will grin and say things like, "It's better to set your expectations low so that you won't be disappointed if things don't work out."  

So to get to the point, I asked Dr. Brutal Honesty about your episode last night.  It obviously wasn't a good thing, but after examining the evidence, he's not convinced that it would cause any big problems.  As it turns out, your blood after the episode didn't show signs that you ever completely ran out of oxygen.  If you had, your cells would have started making energy via anaerobic channels, thereby generating lactic acid.  This would have acidified your blood, yet when they checked, your blood was the opposite of acidic.  It was slightly alkaline.

What's more, while your heart slowed to just a few beats per minute, it never stopped beating entirely, so even though your blood was quite depleted of oxygen, the oxygen you did have left was delivered in some measure to vital organs.        

But everything isn't roses.  You've been reintubated, and as I write this, I'm watching you writhe about from the tube in your trachea.  Once again, we're back to where we started.  Somehow, it's never felt like such a relief.


  1. I am so very glad to read this. I think I empathize greatly with your story becuase the pregnancy trajectories are similar; my baby is due via surrogacy at the end of April. As for the brutal honesty and matter of factness and the real odds instead of blind reassurances, I prefer that too, possibly because I am a scientist, and I am not frightened by biology, and maybe the training changes the way you look at things.

    I've been meaning to ask: I've heard of exogenous surfactant use instead of giving steroids to stimulate thier production to treat immature lungs (for babies born closer to term): maybe a stupid question, but is that not suitable/not useful in a micropremie?

    1. Sci Chick, exogenous surfactant use is pretty standard for preemies with Respiratory Distress Syndrome, so to answer your question, yes, its very suitable. Ellie was treated with surfactant right out of the gate. Prenatal steroids tend to also increase surfactant production, and pretty much every mother expecting a preemie is treated with that, too. However, POSTnatal steroids tend to reduce inflammation and irritation in the lungs and bronchia, rather than grow new tissue. Prenatal steroids are harmless but postnatal steroids... well, that's a hot topic.

      Postnatal steroids, specifically Dexamathasone, stifles brain growth. The higher the quantity, the more pronounced the positive effects are on the lungs and the negative effects are on the brain. Of course, the risk of going hypoxic has a brutal effect on the brain too, so you kind of have to compare the risks. No NICU anywhere uses high doses of postnatal steroids, anymore. The morbidity rates are astounding. But they are contemplating putting her on a very low dose of steroids, and the so far (sparse and somewhat weak) research shows that micro-doses don't have any significant effect on brain development (but some small negative effect on weight gain during the course). Everything we know about micro-dose steroids comes from a study with a sample size of 70 babies... So we're still somewhat reserved about steroid use, but we'd rather not give her any more opportunities to turn blue again for 6 minutes, either. Unfortunately, it looks like there will probably be steroids in her future.