Born Without A Chance To Live
Hello Synners and welcome to my column: Super CJ’s E.R! This is your favorite doctor, Super CJ. Here’s a little something I wrote. Enjoy.
Multiple Congenital Malformations In A Neonate.
“Life is unfair,” is more than just a cliché. What is the essence of the gift of life if the odds of survival is 90 against 10? What is the essence if every single intake of breath is equivalent to hard labour in a maximum security prison; if every single second is a struggle to breath, a fight to stay alive?
I don’t have the answers. Maybe you do.
Good Friday. As I finished reviewing the very-low-birth-weight [born with a weight of less than 1.5kg] premature Neonate under my care, I had a huge smile of satisfaction plastered on my face. After 21 days on admission, he was already out of the woods,and was just “awaiting weight gain.”
I absent-mindedly told myself that I hope I won’t be getting another preemie anytime soon. Taking care of those little cuties is a back-breaking task that leaves you drained, both physically and emotionally. Especially in a resource-poor setting.
If only wishes were horses! Unknown to me, the universe, ready to fuck me over, was sending another one, a more delicate and complicated case. I was still documenting in the child’s case note when this family came in, with what I presumed was a baby carefully wrapped up in a blanket from baby strollers online like a Burrito. From the way he was wrapped up, and the apparent size, I instinctively knew it was a preemie.
The 38 year old mother, who already had 6 other kids, had suddenly broken her water at 35 weeks of gestation, and had gone into labour proper after 5 days of draining colorless fluid, with the resultant delivery of the preemie.
35 weeks? Not so bad, I had thought. If I could take on 30-week olds, a 35-week old should be a walk in the park. The major problem I would have to watch out for was sepsis, as draining of liquor means a vent in the baby’s protective covering, and having it drag on for 5 days, before delivery, would mean infectious organisms could easily ascend the mother’s genital tract to infect the baby.
I was still questioning the Mom, when the nurse came back to tell me that she just weighed the baby, and the weight was 0.98kg. My heart sank. And it did so for two reasons. One; the chances of survival for preemies is directly proportional to their weight, and 0.98kg is Extremely-Very-Low-Birth-Weight — the type with the worst prognosis. Two; at 35 weeks, the baby should at least have been up to 1.5 kg. So, being 0.98kg means we weren’t only dealing with prematurity; we were also dealing with SGA [Small for Gestational Age]! The stakes had just gotten higher, and his chances of survival slipped a few because of it.
When I examined the child it was apparent why the weight was that small compared to what was expected at his age. He had an abnormal facie, and a grossly deformed left hand: the wrist was bent back on itself, in an impossible angle, with the fingers almost touching the forearm. And he was in respiratory distress, finding it difficult to breathe.
As a rule of the thumb, one Congenital malformation is an indicator to look for another, as they usually come in groups. And with the mother being more than 35 years [reminds me of the discussion we had on Florida’s wall 3 days ago about risk of fetal anomalies increasing with maternal age], and not attending antenatal, one would be stupid not to take a closer look.
The spine seemed okay. And so did the anal opening. But the abdomen was slightly distended [with no jaundice, nor engorged superficial veins to suggest a liver pathology], with no bowel sounds, and he was yet to pass meconium [the dark colored, first faeces passed by babies], all suggestive of some form of obstruction in the lower intestine. Too early to tell though.
There were ballotable masses on either side of the midline, just a little above the pelvis: what I presumed to be the kidneys. Pelvic kidneys? Perhaps even the “Horseshoe” variant? Whatever those masses were, if my suspicion was right, it then means the kidneys were not in the normal position. Thankfully, he was making urine. Way TOO MUCH for his own good, I would say, though. But mother wasn’t diabetic. So, Bartter’s, perhaps?
He was retching intermittently, occasionally bringing out frothy, whitish, mucoid substance. That is usually an indicator of a possible Esophageal atresia, or fistula [meaning the tube leading from the mouth, through the throat, and chest, to the stomach– the gullet, may be blind-ending, or have an abnormal hole connecting it to the wind pipe]. Bad news. The mother’s earlier statement, that her tummy was “so big [they] thought it was either a twin, or a very big baby,” a pointer to polyhydramnious [excessive accumulation of amniotic fluid, making a pregnancy look bigger than it really is], gives credence to this. This is so as babies with a blind-ending esophagus can’t swallow amniotic fluid, like other babies, making the fluid to accumulate, and distend the tummy, making the baby bump appear bigger than it should.
He also had what appears to be a “defect” in the left lower rib cage area, near the heart [3 cm to the left of the Xiphisternum, for medics], and each intake of breath sucks the skin below the margin of the rib cage[coastal margin] in, leaving a hollow depression. A defect in the diaphragm, perhaps? Morgagni’s foramen? Unfortunately there’s no bowel sound, so I couldn’t tell if there was a concomitant herniation of intestinal loops into the chest.
Bottom line? The child needed intensive care, and an urgent review by both a paediatric surgeon, and a neonatologist. Alas! There was no money! The parents are indigent, and they knelt down begging we should just keep him and “try our best.” If the child dies, like they were expecting him to; they would understand, they said.
Sending them away would be a big mistake. They would just go home and probably feed him, and he would aspirate, and die faster than you can say Tboss. And if they don’t — feed him, that is; he would die even quicker of hypoglycemia, and dehydration [as he seemed to be urinating too much, losing so much fluid]. There was also sepsis lurking around the corner. Hypothermia peeping from the window. And respiratory distress compounded by abdominal distention, and the possible diaphragmatic hernia. Fact was that his chances with us was 100% better than going home.
First things first. Warmth was provided with hot water bottles. An intravenous line secured, and a dextrose containing infusion connected. Antibiotics [to prevent infection] and Aminophylline [to help him “breath better”] were commenced. With no bowel sound, abdominal distention, failure to pass meconium, and possibility of an abnormal esophagus, nothing should go into that mouth. So he was placed on “nil by mouth.” He also needed a neonatal NG tube for drainage. But there was none. Shocker!
Intranasal oxygen? He needed those too, but if only wishes were horses!
The following day, he was yet to move bowel, the abdomen had doubled in size, and he was still retching, and vomiting persistently, non-bilious at first, but it later became bilious [meaning yellowish-green in color, containing bile– an indicator of lower intestinal obstruction].
With the persistent vomiting, he was at risk of aspirating stomach contents into his lungs. More so, where the vomitus was also coming out of his nostrils. Thankfully, we had gotten an NG tube for draining the excess gastrointestinal fluids. Alas! An attempt to pass the NG tube was unsuccessful! It went past the posterior nares, past the throat, and halfway down the esophagus, and then stopped. All manoeuvres to advance if further failed.
When I brought it out, it was bent, showing it encountered a resistance, confirming the atreatresia to a reasonable extent. So, if the esophagus was blind-ending, how was the intestinal fluid getting to the mouth? The unfortunate answer is that there’s probably a fistula, an opening, connecting the distal segment to the trachea, in such a way that everything regurgitated would be going straight into the lungs.
A “digital” rectal exam [inserting a finger into the anus. This time, a smaller, non harmful material was used, because of his age] showed the anal canal was well developed, and there was meconium in it. After the examination, there was an explosive gush of meconium. So, the “lower intestinal obstruction” was most likely Hirschsprung’s.
3rd day. The baby was RELATIVELY doing fine. The abdomen was still distended, and he was still vomiting, though. And I knew it was just a matter of time before he aspirated enough , or something else killed him.
At about 3pm, they came to call me.He had vomited again, after which he developed a fever, and started breathing faster than he already was. Instantly, I knew it had happened: he must have aspirated.
When I came, he was burning up, and in severe– no, more like horrible — respiratory distress. He was grunting, struggling to breath, with the chest retracting with each labored intake of breath. There was crepitations in the lung zones, signifying fluid inside the chest.
With that degree of distress, I knew it was time, that nothing would save him. I held him to my chest, “comforting” him. Funny the silly things you do, when there’s nothing else to do [there wasn’t oxygen, nor a ventilator. Heck there wasn’t even a pulse oximeter! And even if all these things were available, I am no intensivist.
When I was done “talking” to him, I counseled the Mom, and handed the baby over to her, so she can hold him and bond with him the much she could (he had been inside the incubator before, and they weren’t allowed to touch him at will)
Brave little child; he held on for an hour longer, before he breathed his last. Mean as it may sound, I was happy, and relieved, when he did. Yea, on one hand I was sad, but I was also happy. Fact was that with the odds, he stood no chance. If the parents were well-to-do, if he was in a better hospital, in a better clime, he MAY have stood a chance. No matter how little, a chance is a chance. Right? But he didn’t have that chance; the universe didn’t give him any.
Respects to the dead.