help! the baby's not breathing!

Today was supposed to be my half day (finishing at noon - it is the only way the rota remains legal as I will be working 52 hours (4 night shifts) over the coming weekend), but I didn't get away until 3 in the afternoon.

The labour ward bleep went off at about 11 in the morning. "Hello is that the Paed?" said the midwife. (that's what they always say - they get really confused if you answer the phone and say you are a 'Neonatal' SHO) "We are in theatre now, it's a 35-weeker with dextrocardia and situs inversus, and IUGR."
"Are you starting right now?" I asked, as they always seem to call me before the anaesthetist has even turned up to put in the spinal. "We've already started," she said. This was quite inconvenient as the baby was likely to have other congenital abnormailities and to require resuscitation, and she was only giving me 7 minutes' notice. (It usually takes 7 minutes to deliver the baby from the time of first incision at an uncomplicated caesarian section) On hindsight, I should have called the registrar first-off, but I didn't know how bad things were going to be.

I hadn't been able to find any scrubs of the right size in the morning, so it took me another 3 minutes to grab a Medium top (the smallest I could find) and to put on shoe covers and a hat. By the time I got to the theatre, I had just enough time to check the resuscitaire.
Before I knew it, a tiny, floppy bundle the shade of a blueberry had been placed before me. It was the most deformed baby I had seen in my life (believe me I have seen some freaky babies) and it was clearly hydropic. The moment I saw the baby, I asked the midwife to page the registrar immediately. I dried the baby as best I could, gave it 5 inflation breaths, and then more breaths through a facemask. The baby gasped and moved its arms, but then it stopped moving, and stopped breathing. Its heart rate slowed and it turned even bluer. The anaesthetist came over to see if he could help. I tried adjusting the mask on the baby and repositioning its head, but nothing seemed to work. One thing I should have done in retrospect is used higher pressures - something that would have been more obvious had I been ventilating the baby manually. I got the anaesthetist to give some chest compressions. I thought about intubating the baby (something I have yet to do successfully ever) or at least looking down its trachea to see if there was anything blocking the flow of air (possibly meconium or vernix). The baby had an abnormally small jaw and a tiny mouth. I had difficulty even getting the laryngoscope blade in, and when I tried to lift the scope, there was very little give in the jaw. I couldn't even see the vocal cords, but was afraid to pull any harder. So I went back to trying to ventilate the baby through the mask. At the age of 6 minutes (though it felt much longer at the time), the baby was starting to look like a specimen from the pathology museum.
Just as I thought I'd lost the baby for good, S*, my registrar turned up. He's really experienced and it took him 3 trys to intubate. As soon as the tube was in, the baby began to pink up. His heart rate picked up. He was still completely limp though.
Back at the Neonatal unit, the baby had an arterial line put in to check his blood pressure. The first attempt resulted in a wound (from a tiny needle prick) that just would not stop bleeding. The umbilical vein too, oozed for ages. I was allowed to attempt cannulation of an umbilical artery (again something I have never done before), but it was difficult, and I didn't get it in. An echocardiogram (done on the ward using the same machine I took my brain pictures with) showed that the baby's heart was contracting very poorly, and was grossly enlarged.
By then it was nearly 14:00. I headed back to the labour ward to get a full maternal and antenatal history. It turned out that the cardiac anomaly had been discovered 5 weeks ago, and that the Fetal Cardiologists at the Big University Hospital had done a scan and reassured everyone that 'cardiac function [was] normal'. They even went on to say that they planned to see the baby in their outpatient clinic at the age of 4 to 6 weeks! As things have turned out, this was a false (and arguably dangerous!) assurance. I just hope I haven't contributed significantly to the baby's (already) poor prognosis.

Day off

...and I find myself playing Maths teacher to my little brother, who is sitting his GCSEs at the moment. Here he is in a rare moment of concentration:

Through the anterior fontanelle

I took some cool pictures today - using an ultrasound scanner. Too bad they had to remain in the patient's notes! Premature babies' brains are slightly different in structure to term babies' brains. In particular, they are more prone to bleeding into them, so the babies on the Unit often need cranial ultrasounds. The fact that babies' skull bones are not yet fused means it is possible, by holding the probe over the largest gap between the bones (i.e. the anterior fontanelle), to get an ultrasound image of the brain. Occasionally one finds unexpected malformations of the brain, such as this example (I only have a picture because I presented this case at Thursday's perinatal morbidity meeting):


Even with this poor quality image, it is possible to discern that the lateral ventricles are fused. This is known as holoprosencephaly. In its most extreme form, this results in cyclopia, seen here in a kitten. The baby whose brain is seen in these ultrasound images weighs a mere 480g and was born at 24 weeks' gestation.

a walk down church street

bouncing babies!

The day before my exam, and I am up at 06:45 to go to work - a day as the sole paediatric doctor on the postnatal ward. Our hospital serves an area of London (Tower Hamlets, Hackney and Newham) that boasts Britain's highest birth rates (or for full figures, go to the Mayor of London's website and download 'Borough Fertility Rates'), but I have never felt it quite like I did today. Once again the ward was full, with the overspill housed on the antenatal ward. The spectre of having to do 20 baby checks (mind-numbingly boring after the first 5 minutes; also think: vernix, wee, poo and baby sick) all by myself loomed large.
[baby count: 2]
Imagine my delight when an unsuspecting Swedish elective medical student pitches up at 9 o'clock. "I have to do 4 baby checks," he says, anxiously. Well, you've sure come to the right place, I think to myself. From my previous experience of teaching medical students (teaching them how to examine a breast and then letting them clerk in breast cancer patients), having a medical student actually doubles the time it takes to complete the task. But I enjoy it - I like to think it is not because it makes me feel important. I guess it's nice to have some company (and be outnumbered by midwives about 10 to 2 instead of 10 to 1) and it makes me think about why each step in the baby check (or Routine Neonatal Examination) is important, because I quiz the med students about it (and then embarrass myself when I don't have all the answers, like how long it takes for a Mongolian Blue Spot to fade). Well, he was pretty good, he got the hang of it after just one demonstration, and then was able to help me out.
[cumulative baby count: 6]
A couple of our Native medical students turned up an hour later, in their usual inappropriate attire (large dangly jewellery and !nail extensions!). I have tried to shake my negative impression of the students from our local med school ever since the Fetal Haemoglobin incident (which Ching can tell you about), but have not so far succeeded. If this had been Edinburgh, we would've run out of babies to examine by then, but as we have an unceasing supply (the moment you discharge a baby, a new mother and baby appear in their place. Literally.), these stragglers had plenty of babies to try their hand on. I resisted the urge to chuck the long-nailed student out of the room. They each examined 4 babies, and I signed them off for a job fairly adequately (if incredibly inefficiently) done. I had to secretly go back and redo the ones seen by the long-nailed girl, though.
[cumulative baby count: 14 ]

After lunch, I went over to the Neonatal Unit in search of the registrar to ask his advice about a couple of things from the morning. Instead, I found yet another medical student, who was desperate to fill his baby check quota. 4 medical students in one day?!? This was becoming like ER. He seemed like the keen sort, so I brought him over to the postnatal ward. After 2 babies, I said he could go if he liked, but he said he wanted to do the antanatal ward ones too.
[cumulative baby count: 18]

And that is how I examined 18 babies with the help of 4 medical students.

Inedible Cookies No. 2

Am currently on study leave (hence actual time to spend in front of computer) and have discovered (though coming rather late to it) numerous blogs with amazing pictures of incredibly complex food (I think 'food porn' is the correct term). Here is my (; version (please note the culinary disasters are genuine!):-

Inedible cookies No. 1
On Saturday I craved a sugar-fix, and what better way to raise the blood glucose than to imbibe sugar blended with a load of pure animal fat and refined carbohydrate. A recent trip to Edinburgh stoked my appetite for shortbread, and the website of the self-proclaimed Ultimate Guide to Scotland provided what surely must be a fail-safe recipe. The recipe called for ground rice as well as plain flour, and having none of the former to hand, I substitued raw bulgur wheat.

Ingredients:
200g butter
175g plain flour
50g bulgur wheat
85g caster sugar

When I was working on my BSc thesis way back in 2001, my supervisor once said "a lab protocol is NOT a recipe. You have to follow a protocol to the letter." His advice served me well. Therefore I deduced that the converse must be true, and ignored the details of the recipe completely, sprinkling a few scant handfuls of flour over my creamed butter-and-sugar, and randomly grating the rind of an orange into the mixture, along with the crumbs from a packet of salted cashewnuts I found under my desk, and a tablespoonful of ground cinnamon.

The mixture looked fairly inhomogenous, but came together sufficiently to sit gloopily in the centre of a baking tray. By then I had turned the computer off, so I simply made up the oven temperature. I guessed it to be about 200 degrees celcius, without pre-heating. Shortbread is often thought of as uninteresting and stodgy, but this version was turning out to be anything but. The cookies seemed to come to life and sprawl as they baked, until they coalesced to form a bubbling lumpy pool. It smelled good though. And here is the end result:


My flatmate tried one and it almost broke his teeth.

Inedible Cookies No. 2
3 weeks on, and a little wiser, I cycled to Hackney Central Woolworths to get a measuring jug for 49 pence before embarking on my next attempt at cookie-making. This time, I decided I would study several recipes from those glossy-looking foodie-type weblogs to figure out the correct proportion of fat : sugar : flour. A ratio of 2:1:2 seemed fairly safe, so that is what I used:

Ingredients
250g butter
120g caster sugar
250g flour
zest of 1 lemon
spoonful of greek yogurt
crushed almonds

Ah, the taste of a Mediterranean Summer! A citrusy note and greek yogurt, to make it, like, Greek. These ingredients were quite challenging to blend, not least because I had only a wooden spoon and a flat-bottomed casserole dish with which to mix everything. I nearly got a splinter. The cookies looked OK as they baked. The oven temperature was 180 degrees celcius, preheated this time. Cooking time was 13.3 minutes, the mean time from among the recipes I looked at.

The cookies came out looking ok, but when I bit into one, it was raw in the middle. So I shoved them back in, for another 15 minutes. And the same thing happened. These cookies must have a really high specific heat capacity. So I gave up, removed them from the oven, and finished them with some caster sugar on top.


My flatmate tried one and he says they are better than the last batch. He also mentioned that I should maybe stick to Medicine.