The following is a fictitious account of a NICU (Neonatal Intensive Care Unit) admission from start to finish. Names were chosen at random and do not represent a real person, living or dead. nor does it represent a particular patient, but is cumulative of years of NICU experience. It is intended to be an informative insight for those unfamiliar with the inner workings of a healthcare facility. It is not in any way to be considered medical advice.
Things are not going so well for the Allen family. The baby is not due for another 3 months. But the pains keep coming, and now there is spotting. Mom-to-be is scared. Dad-to--be is trying to maintain an aire of control. Imminent grandparents offer whatever support they can, realizing the immense danger mom and baby are in.
The doctor is called, the hospital notified, and final preparations are secured for the...for the, uh. Wait, should we prepare for the delivery of our baby? Should we "lay in supplies" for an extended hospital stay? Is mom going to survive? The intense drive to get mom to the hospital just increased exponentially. Dad is beginning to lose control. Mom feels the baby trying to be born, in spite of her profound wish for him to stay put. She is afraid, possibly convinced, that the hospital staff will not be able to prevent the birth, as in her mind she has already started mentally preparing herself for a premature baby .
No one knows exactly what to do upon arrival to the Emergency Department, (ED). Grandma and Grandpa are ushered to the waiting room while Mom and Dad are spirited to an exam room in the Labor and Delivery ward. This convinces Mom that her instincts were right; her baby is coming, and even the hospital staff know nothing can stop it.
A few hours later little Baby Boy Allen is born. Birthweight is 1000 grams, barely over 2 pounds .He is tiny, but fighting for life, struggling to survive in a world he is not ready for. His head is the size of a tennis ball, and his feet could easily fit inside a matchbox: at the same time, the problems facing the Allen family, as a whole, are gargantuan.
The fundamentals required for normal breathing are impossible for young Mr Allen. The human body senses high CO2 (Carbon Dioxide) and/or low O2 (Oxygen) and stimulates a breath. This breath is accomplished through negative pressure being generated in the lungs, drawing air in from the atmosphere, air that is 21% oxygen. Oxygen, for all intents and purposes, is a drug, a vital part of humanities basic survival requirements, and dangerous in excess. CO2, on the other hand, is a by-product of breathing. The two gases must exchange place or our bodies will cease to function. His desire to breath, or better yet, his ability to desire to breath, is in place, but is essentially non-functioning due to his profound prematurity. The baby "forgets to breath," and must be stimulated. Otherwise he will be intubated, a procedure that entails inserting a tube into his trachea (airway) allowing efficient gas exchange to take place. Once intubated, young Mr Allen is placed on a ventilator.
A Registered Respiratory Therapist (RRT) is someone who is trained to setup and manage a ventilator, otherwise known as a "breathing machine" or "life support." This an apparatus that will "push" fresh, oxygen rich air into his lungs, which will then recoil, driving CO2 poisoned air out through the ventilator circuit. A ventilator circuit is another tube, only longer and more flexible. It contains a wire that heats the air going into the baby. This is important, as an infant, even born at 40 weeks(normal gestation period) cannot maintain his own body temperature, so forcing cold air into is lungs would be detrimental. There are 2 types of ventilators, conventional, as described above, or High Frequency. A High Frequency Oscillator (HFO) is reserved for those babies with marked pulmonary (lung related) disfunction. It pushes gas into the lungs, as does a conventional vent, but then pulls gas out of the lungs. The "breaths" are extremely small, but counted in the hundreds per minute. This is very friendly to premature or damaged lungs because lung expansion is minimal but ventilation is maximal.
Should young Mr Allen require it Nitric Oxide, or NO, can be given. This is a function of the NICU RRT as well. NO is a specialty gas that will cause the arteries in his diminutive lungs to expand, thus allowing more oxygen to enter his blood stream. Though expensive, NO is a wonderful tool in the NICU arsenal. A growing number of babies are helped every year by NO.
The latest addition to the Allen family, Trevor, (named after Grandpa Allen, a soldier who lost his life in Iraq), is now being intubated and will be connected to a conventional ventilator. Mom and Dad Allen are informed by the Neonatologist that Trevor will be in the NICU for a long time, that the approximate discharge date is the original "due date." Of course, this depends entirely on Trevors progress.
Things go reasonably well the first couple of days. Trevor is doing well. A head sonogram is completed which shows a small head bleed, not uncommon in his situation. The positive pressure required to ventilate Trevors lungs is causing this small hemorrhage, but hopefully it will resolve on its own. His lungs are also being damaged by the pressure required to keep hm alive. BPD, or Bronchopulmonary Displacia, is seen on his xray. The neonatologist (neo) noticed a "murmur," ( a swishing" sound ) coming from the heart and orderd a cardiac consult. This is a series of tests and examination which include an Electrocardio Gram, (ECG, formerly known as an EKG) and a sonogram of the heart. Results indicated a Patent Ductus Arteriosus , (PDA). This is a communication between the Ascending Aorta, the artery leaving the heart, which is carrying oxygen to the body, and the Pulmonary Artery the vessel carrying CO2 from the body to the heart for transport to the lungs. The PDA is necessary during development inside the womb. It is detrimental outside the womb, and will normally close once a baby breaths on his own. This is one step in converting from fetal circulation to normal circulation. Many times medication can be given that will close a PDA. There are occasions where surgery is need, and Trevor needs it. Babies that receive a PDA ligation have a good chance of survival. Our "Trevor" would likely go on to be weaned off the vent, oxygen, and all support and go home with happy parents and an excellent future. Some do not fare so well.
In addition, his lungs have been stressed by increased blood pressure as a direct result of his PDA. Because the higher systolic pressure, needed to pump the blood to the body , was delivered to his lungs via the PDA, complications arose, requiring the HFO (High Frequency Oscillator). The CardioThoracic surgeon was called and a PDA ligation was performed. This is a procedure where a tiny clamp is secured around the PDA, instantly closing it, and thrusting the baby into normal circulation. This is only one of many lows experienced by the Allen family.
When a baby is born prematurely the NICU team activates protocols and readies a bed space. Equipment is assembled at the bedside, as well as supplies anticipated. I cannot speak from a NICU parents perspective, but I am a parent, as are most NICU personnel. Everyone working in a NICU is there by choice. It is an intensely demanding specialty that most healthcare workers have difficulty handling because it prompts the most basic human emotion and instincts. NICU nurses are notorious for their fierce, and I mean fierce, protection of their "micro patients." Where an adult pt might not see his nurse for a while, NICU patients are constantly supervised. The frailty of the NICU patient is evident in their ability to die quckly.
If you are able, hold you breath for 30 seconds. After you resumed breathing, did it take you long to recover? A neonate, (a patient in the NICU), can have his heart rate plummet from a normal of 160 bpm to an emergency state of 80 bpm or less in that same time frame. This would require being "bagged," or ventilated with a rescucitation bag and chest compressions would be started if this action does not prompt a heart rate of 100 or more. This is extremely frightening to new NICU parents, but is a routine occurrence to staff. After a few days the new parents are accustomed to these events and take them in stride, even "scolding" the baby to "behave."
Infections are a threat to the neonate in a phenomenal way. A term baby is vastly immunocompromised, where a neonate is propoundly so. The womb environment is not sterile, but entities are in place to protect the fetus. Once birth occurs the rules change entirely. There are no "policing" organisms, which means everyone involved with the patient, staff and all visitors, are responsible for maintaining clean technique at all times. Staff are required to "scrub in," almost as if preparing for surgery. Visitors, including parents and grandparents, are required to scrub in as well, and to wear "isolation" gowns. Each facility will have different protocols, but basically are the same.
A baby born at only 22 weeks gestation has an extremely slim chance for survival. The odds improve as gestational time increases. The modalities required to keep a baby alive often cause injury as well. The human body is not designed to breathe with assistance. As a result of this assistancce, dependency on machines and medication develops, and must be maintained unless adequate weaning in initiated and extends to fruition. No two babies are exactly the same , though multiple birth babies can mimic each other very well.
Without a doubt good prenatal care is crucial to a babys health and development. This, of course, includes proper nutrition and absolutely no smoking.
