As I walked up the stairs leading to the Paediatric ward, a colleague of mine ran past me in hurry with an x-ray slip in her hand and said "welcome to work, things have been a bit flappy today". That's never a good start to an afternoon shift.
"A 32 week-er needs IV cannula"
"The 3 year-old-boy in ED with possible non-accidental injury needs IV cannula and bloods before his scan"
"Two patients for discharge"
"6 weeks old baby needs IV cannula and lumbar puncture"
"Preterm and breech delivered yesterday with mishapened head still waiting for review"
"Couple of admissions came to the ward and notes are not done"
My colleague seemed overwhelmed when she gave me the handover.
Then the registrar came. I thought I saw the word STRESS on her face. "Rachel, if you have time could you go down to ED to cannulate that boy because the bone scan is going to happen". Then she left in hurry to attend a birth.
I did all I could with the handover. It took me 2 hours before I arrived in the next destination, the special care nursery to finally deal with whatever messes there.
"Rachel, can you speak to the dad in cot 13? He refused any medical intervention for the baby with respiratory distress. We've paged the registrar and she hasn't come yet". A worried-looking nurse said.
Turned out it was the baby from the birth that the registrar attended: Conservative parents who wanted lotus birth but the umbilical cord had to be cut because the baby needed resuscitation given poor breathing effort and there was meconium liquor. Parents refused vitamin K and Hepatitis B vaccine. Baby is now in special care nursery with respiratory distress and parents have refused any sort of medical intervention.
I introduced myself and they seemed nice people. The husband started talking and his wife stayed quiet. It became obvious of the dominant role in the house. I listened to his views then I explained my concern of the baby's deterioration, possible diagnosis and what needed to be done at the same time as I was pointing out the clinical signs and all the flashing numbers on the machine.
"Why don't we just let the baby breathes on his own? He was born just not long ago. Newborn always takes time to breathe up. Just give him some time and he will pick up. The number (oxygen saturation) is 85% and let's not do anything heroic until it is 70%. I don't want CPAP or needle or blood test or IV or antibiotics or anybody sticking anything into him. I won't let you start antibiotic just on the ground of presumed sepsis unless you can prove to me that my baby definitely has infection. Maybe he just aspirated little meconium and that's OK."
I gave my explanation for the second time, "Yes, newborn may not breathe normal straight away but they don't take such long time to establish breathing and this is not normal. The numbers are very concerning and I don't just look at numbers, I look at your baby too. He is breathing very fast and hard and he needs help. Babies don't talk and they can't tell you if they have fever or infection. I cannot prove to you that your baby definitely has sepsis because I don't have blood tests to show you. Your baby is literally throwing his hands up and trying to tell you 'mum, dad, look at me, I can't breathe, I need help, I think I have infection'. It is not normal to aspirate meconium as it belongs to the intestine and can increase the risk of infection if it ends up in the lungs. Babies are unlike adult and they have much lower reserve and can deteriorate rapidly and it can be too late if happens. CPAP is not intubation, they are prongs that we put on baby's nostrils to give pressure to deliver oxygen and help the baby to breathe. What was your concern regarding needle or IV or CPAP?"
I didn't dare to take my eyes off the baby and machine for long. My heart was pounding as I looked at the chest rise and fall of 80-100 per minute with the subcostal muscles absolutely sucked in with each inspiration. Listening to the lungs I felt pretty relief there was no pneumothorax heard but the hard work of breathing kept me on guard and made me so wanted to push some oxygen into this little one more than just 40% of cot air. Then the dad spoke.
"Look, I just want as minimal intervention as possible. Let's just give him his mum's breast milk. If she expresses now will get the colostrum for antibodies to fight off infection. He doesn't need antibiotics. Just leave him alone and let him breathes up. He won't deteriorate suddenly. If he gets worse then you start doing things and it won't be too late."
Talking to him really sucked all my energy but I kept in mind that my patient is the baby, not the dad. Like a primary school teacher, I taught him colostrum and breast milk and how it has no role in acute infection. I ended by saying his baby is now deteriorating and just like any babies he can deteriorate suddenly and die. Yes, I pulled out the Ace card --- DIE. "I am extremely concern about your baby and minimal intervention is not possible now".
He finally allowed me to start CPAP but not the rest. I informed the consultant and she wanted everything to be done and told me to explain to the dad again the importance of getting the blood tests, despite my futile effort for the last 45 minutes.
Miracles do happen. After my conversation ended with the consultant, baby's dad looked for me and said "If you really need to do CPAP, IV, blood tests and CXR, that's fine. But no antibiotics. I just want to make you and myself happy".
That's when it struck me. "This is not about making you happy or me happy. It's about making this baby happy." I cannot believe my 2-hour old patient had become an object of bargain for the ignorant dad.
The next thing he asked "Is there any way that the baby can go on boobs now?" It was a clear and loud NO from me and the nursing staff. Looking at the floppy baby and MAP of 37, the baby scored a fluid bolus and I assured the dad that the baby won't be on boobs for a while until he recovers.
I spent 4 hours in the special care nursery and admitted two other premature babies to the nursery before the consultant made a decision to transfer that sick baby to a tertiary hospital with neonatal ICU as he deteriorated despite maximum ventilatory support in our Level 2 nursery.
I finally went back to the Paediatric ward at 9:30PM and was inundated by parents of three patients wanting to know their test results. So I went to those rooms to explain the results to these three parents that I had not even met their child. Then a nurse informed me a patient's mum called and she was unhappy when she was told that the doctors were busy with a very sick baby and couldn't answer her call. The nurse quoted what the mum said "the doctors are obviously too busy to even pick up a phone to call me back with my baby's result!"
I left the hospital at 11PM. I took my packed dinner that I left in the ward fridge from 2 nights ago that I didn't get to eat.