Just 10 years ago, while there were rare exceptions, most babies born about 10 weeks early, weighing less than 2.3 pounds (1,000 grams) did not live. It was as simple as that. Today, however, there are at least three intensive care nurseries in Washington area hospitals that routinely save 75 percent of infants with birth weights below 2.3 pounds, and some as low as 1.6 pounds (750 grams) -- babies as much as 12 weeks early.
But these hospitals are the exception. According to a recent study of the District's infamous infant mortality rate, some hospitals in the city do not appear to be saving any infants weighing less than 2.3 pounds. (The situation is little different in the suburbs.) What is even more disturbing, the study of 1977 infant deaths in the city -- the first such in-depth look ever undertaken -- found that some institutions do not seem to be making more than a half-hearted effort to save these infants. The report, prepared by the National Capital Medical Foundation for Mayor Marion Barry's Blue Ribbon Commission on Infant Mortality and released this past November, pointed out that in some hospitals tiny newborns were not given so basic an aid as oxygen in the delivery room.
Rather than respond to the problems, most District hopsitals have chosen to quibble over the accuracy of its statistics. A second part of the report, however -- a study of the 1978 deaths -- may lay the statistical arguments to rest when it is released, presumably this spring. For if the 1978 picture is as bleak as that from 1977, it will be clear the problem resides with the hospitals, not the statisticians.
Some of the gains in survival have come as a result of technological advancements, but most of the advances are the result of the fine tuning of medical techniques and nursing care. To learn what that care consists of, Washington Post medical writer B. D. Colen spent a week in a local intensive care nursery. What follows is the actual story of one event that week. Dialogue is verbatim; the thoughts of some individuals have been reconstructed through later interviews. The hospitals' names and all individuals' names have been changed to protect their privacy.
Seven a.m. The sun wasn't up yet, but Jim Hannan had been up for an hour, showering, shaving, gluping a cup of black coffee before heading to the hospital. On the way he used the few remaining moments of quiet isolation to think about the day ahead. The first problem was that this wasn't just any day, it was Christmas Eve. Despite his annoyance when he'd noticed the schedule, he had only himself to blame, for without realizing what he was doing, he'd blithely done his best to honor everyone else's vacation requests and had once again placed himself on clinical the two weeks starting the Monday before Christmas. So in addition to his bureaucratic and teaching duties as Metropolitan Hosptial's chief of neonatology, he was also the senior man in the intensive care nursery and the senior man on call at night for the two weeks.
"It can't be too bad anyway," he thought as he drove. "It's already been the busiest week of the year. Three kids under 1,000 grams since Wednesday. St. Francis Hospital sitting on its rear about taking baby Martin. Jesus! We've been waiting three days to get that kid over there to get his belly opened up and they keep screwing around. The kid's mother already lost three days from work sitting by the warming table waiting for the ambulance that doesn't come. We've only got one unused respirator, even after we transferred two kids back to the regular nursery. Well, at least I can be sure that whatever can go wrong will."
Hannan was still battling traffic when the call came in at 7:31. Mary Anne Nolan, nurse-coordinator on the day shift and the Code Pink nurse for the day, had barely gotten her coat off. "ICN. Nolan," she said, lifting the receiver. "Ravi!" She called toward the small, open combination office-chart room between the two main rooms of the unit, but no response. "Javed! 06!" Dr. Ravi Javed heard her and answered the phone.
"Javed here." He listened for about 20 seconds and then asked, "How many weeks is she? 29? Have they done a sonogram? What complications? We're on our way." As a fully-trained pediatrician doing three additional years training in neonatolgy, Ravi Javed was in charge of the Code Pink team of specialists -- the fellow and two intensive care nursery nurses who were supposed to be, but weren't always, called to be on hand for all of Metropolitan's high-risk deliveries.
While some hospitals in the metropolitan area have arrangements to send nursery personnel to the delivery room when needed, few if any have the system as finely tuned as it is at Metropolitan. Just as all hospitals now have Code Blue teams -- individuals on each shift who have special training and know in advance that they will be called if a patient suffers a heart attack -- so the members of Metropolitan's Code Pink team respond to problem deliveries.
The call to Ravi Javed at Metropolitan -- and what was about to happen in Delivery Room 3 -- fit the Code Pink criteria.
As Javed dashed out the door of the nursery, Nolan grabbed the floral print-covered Code Pink bag under the office counter and hurried along behind him with Susie Phillips, the other RN on the team, running to catch up. Javed was at the stairwell door, about 100 feet from what were jokingly referred to as the elevators. "Probably a 29-weeker," Javed replied, panting slightly. "The mother's been in-house for a week, came in when her membranes ruptured at home. Martinez tried to hold her off, but he can't any longer."
"Why wasn't she on the board?" asked Nolan, realizing as she asked it that it was a silly question, given that only about a quarter of the hospital's obstetricians inform the ICN when they have a high-risk mother in the hospital. So the unit's "In-House" blackboard is some help, but not enough.
Javed, the first of the three out of the stairwell, hit the red button on the wall and the double wooden doors to the delivery area swung open, almost clipping Phillips. The three shed the growns they had pulled over their surgical scrubs, tossing them in the laundry hamper just inside the doors to the delivery suite. They pulled on their booties, caps and masks, with Javed pulling on a full head arrangement that covered his beard as well as his hair. Before adding his mask, he looked like a knight in disposable paper chain mail.
Ninety seconds after receiving the Code Pink call, the team was in DR 3, where final preparations for delivery were under way. Lucy McKnight, 19, single, unemployed, black and scared, lay on the delivery table in the center of the green tiled room, her feet already strapped into the stirrups, her dignity back in the labor room. Always an echo chamber, the noise in the room was particularly bad now, as Javed and his team set up and checked their equipment in the corner to the right of McKnight's feet; the head DR nurse checked the OB insturments, each with its own peculiar clatter and clang; and Dr. Emilio Martinez readied himself for the delivery.
"I need a chair," Martinez announced to no one in particular. But Betty Rogers, who had been with the chief of Metropolitan's medical staff through more deliveries than she cared to count, had the black vinyl seat of an OR stool beneath the pale green seat of Martinez's scrubs before the verbalized thought could become a command. "This isn't the one I'm used to," he said. "Do we have one with a back on it?"
"No, doctor," replied Rogers, as she always answered the stock question.
"Oh, well." He settled himself on the stool. "Have we got some Xylocaine?" He was handed a hypodermic of the local anesthetic. "Mrs. McKnight?" He was seated between the woman's legs, but between the clatter in the room and her contractions, he wasn't sure of being heard. "Can you hear all right, Mrs. McKnight?"
Lucy McKnight mumbled yes between moans.
"We're just going to give you a little oxygen, for the baby," he told the woman, who was trying to ask why a transparent green plastic mask was being fitted over her mouth and nose. "We're not going to put you to sleep." McKnight gasped sharply. "Are you having a contraction?" She nodded. "All right, 'm going to give you something here to deaden your nerves," said Martinez, readying the Xylocaine. "You'll feel a little stick. You can push if you like." Then, to the nurse standing by McKnight's head, "She can push," as though McKnight herself weren't there.
"Can you push?" the nurse then asked. "Take a deep breath, hold it and push again."
"You can push," Martinez told McKnight directly. "You have a few pushes to make." He commented over his shoulder to Javed, "It's hard for her to tell what's what. It's her first baby. She can push it out in the bed or she can sit here and it'll take a while. At least she hasn't had any medication" -- other than the Xylocaine to deaden the nerves in the vaginal area.
"Now, Mrs. McKnight? Do you hear me? Let's see you push down and have a feeling for it."
"Push down hard," coached the nurse.
"Do you have a contraction now?" asked Martinez. "No? Well, if you have one now I think we can do it in one or two pushes."
"Are you having one now?" asked the nurse. McKnight grimaced and nodded slightly. "Push down!"
"That's right," Martinez encouraged her. "That's it. Push down." The top of the baby's head was visible. "You can make it on the next push." McKnight, who had had no preparation for childbirth and didn't know anything about controlling her breathing to stay on top of the pain of the contractions, was yipping like an injured puppy. Her cries were the only sound for about 30 seconds.
"You can make it now if you just push once more. Easy, easy, push gently. Easy does it! You don't want it to come too fast. Easy, easy. It's coming. Just a minute? No good." Martinez's tone changed completely. It was now hard, one of command, not coaxing.
The head had emerged, but so had two turns of the umbilical cord, wrapped tightly around the tiny neck. Martinez quickly clamped off the cord at both points where it emerged from the vagina and cut off the portion strangling the infant. He then grabbed the baby and pulled it out. "I think it's a girl -- in the last book I read," he called to Lucy McKnight, who smiled slightly through the pain.
Nolan plucked the baby from Martinez's hands so quickly it seemed he had never held it, and almost as quickly the room was dominated by the sounds of tiny infant being resuscitated. Inez Robins, the medical student on the Code Pink team, had come in late, but she was there before the baby was born and it was she who was intubating the infant -- inserting a tube into the trachea to insure a clear airway -- for connection to a hand respirator.
Javed took the respirator, a black football-sized and shaped rubber bag with a flow valve attached, and hooked it to the inserted tube. He began pumping vigorously, making a noise similar to a hand bicycle pump. Lucy McKnight, hearing the noise but no baby's cry, strained to see her child."It's a girl," Martinez told her again. "It's about two-and-a-half pounds. It's small," he added redundantly.
"What's the heart rate?" asked Javed.
"I can't tell while you're bagging," replied Phillips, for whom this was the first Code Pink.
"They're resuscitating the baby," Martinez told the worried mother. He did not even look up from between her legs, where he was assisting her in delivering the placenta.
Nolan stepped up to the warming table, a flat, waist-high unit with a heating element suspended above it, making it possible to work on the baby and maintain its body temperature without keeping it covered. She began to suction the baby, clearing yellowish secretion from its lungs. The noise, not unlike that of a vacuum cleaner in a puddle, startled Lucy McKnight.
"Just relax," Martinez told her, "sometimes something gets caught in there. "The noise of the suction was followed by a gurgling noise from the baby and then, three minutes and 20 seconds after her birth, little girl McKnight cried for the first time.
Nolan turned to Phillips and told her, "We'll need the Cavitron, and I think we're going to need the elevator in a little bit." The Cavitron is, as its name implies, a life island. The infant transport machine contains a respirator, oxygen supply, lights, monitors for heart, respiration and central venous pressure, and a heating element over the top in a clear, curved, plastic cover, similar to the defroster unit in the windshield of a 747 jet. The baby can be observed through the radiant heating element, and the curved cover can be slid out of the way enough for the team to reach under the edge to work on the baby and, at the same time, keep the baby warm.
"Did you turn on the warmer and the battery?" she asked Phillips when the trainee returned. "Not the red switch, the warmer and the battery? Okay."
"He doesn't look real pale now," Javed told the team. He continually referred to the female baby as he. "He did look real pale, but he doesn't now."
"Can I have a clamp for the cord?" Nolan interrupted, telling Javed, "We may need a catheter."
"He looks real pink," Javed said, repeating himself.
"Do you want to reduce to 40 percent oxygen?" she asked. "What do we want this baby on, a heater table?"
"And a respirator stand by. What type? Bournes? Susie, push number seven," Nolan ordered, and Phillips pushed button seven, the direct line to the ICN.
"Hello?" called Nolan, no waiting for a reply. "We're going to need a heating table and a volume Bournes."
"A volume Bournes?" asked the hollow voice from four floors above.
Phillips was trying to figure out what to do with the baby's identification bracelet, which was ludicrously large for the infant on the table. "With some of these babies we'll just send the bracelet upstairs," Nolan told her.
"I just don't want it to get lost," she explained.
Nolan turned to Javed. "I'm going to get the Cavitron set up. What IMV do you want?"
"IMV of 30, pressure of 20, 50 percent oxygen and PEEP of five." The IMV, for intermittent mandatory ventilation, is the setting at which the respirator will breathe for the infant regardless of the baby's own activity. The PEEP -- positive and expiratory pressure -- insures that the infant's lungs remain at least partially inflated even at the end of a breath cycle.
As Javed finished ordering the settings for the oxygen and monitoring parameters on the Cavitron that would be used to transport the baby, one of the delivery room nurses told him, "When you get done, the mother would like to know something about the baby."
"Mrs. McKnight? It's a baby girl," Javed began. "She wasn't breathing initially, she was blue, so we had to breathe for her by tube, and she now is looking pink, and she's breathing on her own all right. But we still have a tube in her to help her, okay?"
McKnight clearly didn't know whether it was or was not all right. "I don't know her exact weight, but she looks like 3 pounds. But I don't know the exact weight, and we'll tell you later what it is."
"Can I see her?" the mother asked plaintively.
"You can't see her right now, but when we've finished with her you'll be able to see her, okay?Otherwise, she seems to be in pretty decent shape right now. But she's small, and it's hard to tell what happens in the next couple of days, but she is in pretty decent shape now."
"She wasn't breathing?" asked Lucy McKnight. It was her first question about the condition of her baby, whose birth was more than 10 weeks early.
"That's right," Javed told her.
If a baby, like Lucy McKnight's, is born with breathing difficulties, giving the infant oxygen may seem so basic as to be not worth mentioning, but the recent study of the District's 1977 infant deaths shows that such care is far from routine in this city. As part of the study, the investigators examined the care received by 106 babies who died. But based on their weight at birth, the fact that they breathed for at least an hour, and that they had no lethal malformations, those babies might have lived. What the team found was this catalogue of medical horrors:
More than 53 percent of the infants were not tested for the acidity of their blood, a vital measurement needed to decide on the type of care.
An astonishing 40 percent of the infants with very low scores on their initial neurological and respiratory screening were not given oxygen in the delivery room.
Almost 20 percent of the infants blue from lack of oxygen were not given oxygen in the nursery.
More than 63 percent did not have their blood sugar levels tested.
More than 56 percent did not have their blood pressure taken.
Some hospital officials have argued that these absolutely vital tests and aids may have been performed and supplied, but were not recorded in the charts. If that is the case, they might as well never have been done, for anyone caring for the baby would be unable to tell whether the infant was improving or growing sicker, compared to earlier findings. And if the functions were not performed, it appears that a determination was made that these infants were simply too small to save, a self-fulfilling prophecy.
All babies, even the full size, are a little bit blue when they're born," explained Dr. Martinez to Lucy McKnight, expanding on Javed's reply about the baby's breathing. "Then they get pinker as they start breathing. But she's a premature baby, you know, she's 10 weeks early, and this is as much a surprise to her as it is to you. They're not always in the best shape to start functioning outside the uterus.
"How's the heart?" McKenzie asked.
"The heart's all right," they said. Martinez continued, "The main thing is the breathing, the lungs. It's always the lungs, or almost always."
"She came out in pretty decent shape," Javed said. "She had the cord around her neck twice, but she looks pretty pink right now."
"She does look good now," Martinez reassured his patient. "I'd say 2 1/2 pounds.If everything goes well, it's going to be about five or six weeks before she goes home. But that's just guessing off the top of my head right now. But she'll get the best of care. The neonatologists have the ball now."
The conversation was interrupted by Nolan, who had just wheeled in the Cavitron Life Island.
"We have a one-to-two IV ratio, a PEEP of 20, getting about 50 percent oxygen right now, okay?" said Nolan.
"All right, let's get her moved," said Javed, who watched as Inez Robbins lifted the baby off the table and placed her into the life island. Seventeen minutes after she was born not breathing, baby girl McKinght was ready to leave for the nursery.
"All right, let's go," said Javed. "Is the oxygen set?"
"You have 500 pounds," Nolan replied. "You can take your time."
"Thank you, everybody," Javed told the DR staff, and the baby was wheeled over to the side of the table on which Lucy McKnight still lay.
"Here's the baby," Javed told the mother. "We're helping her to breathe, see? Her eyes are open."
There were tears streaming down McKnight's cheeks as she saw her baby for the first time, a baby she thought she was going to lose. A nurse propper her up for a better look, and she reached a hand out toward the Cavitron. "Little girl," was all she softly said to the baby who could not hear her.
"It's not quite equal to your uterus," Martinez said of the Life Island," but it's the next best thing."
As the Code Pink team wheeled the Cavitron toward the waiting elevator, Javed remarked, "It's a Cadillac. It's too good for Metropolitan."
"Listen," said Robbins, who had just finished a rotation at Suburban General, which like Metropolitan, is one of St. Francis' teaching hospitals, "the only transport we have at General is our arms."
The elevator doors opened at the fourth floor, and the Cavitron was rolled down the hall with Javed pulling and the women pushing it, up to the door marked 445, which Javed swung open with a trumpet-like "Ta! Da!" announcing the arrival of baby girl McKnight to the day shift of the intensive care nursery.
The Cavitron was stopped by the door and baby McKnight was lifted out and onto a waiting scale. The weight of 2 pounds, 13 ounces was recorded, and the minute baby was returned to the transporter for the last 15 feet of her trip to the far corner of the room where an empty warming table, already turned on and heated, stood ready. A blue Bournes Life Support Infant Respirator stood by the warming table, as did 34 peices of equipment and surgery kits, everything in readiness from stethoscopes, to pre-weighed diapers.
"What's the one minute Apgar?" asked Arlene Hollins, head nurse on the day shift.
"Give her a one for heart rate," replied Nolan. "Somebody give me some parameters. What do you want him on? Forty percent oxygen?"
"Hurry up and get her on the ventilator before she gets better," joked Hannan, who had arrived at the hospital a few minutes after the Code Pink call. Javed had taken the infant out of the life island and laid her on her back on the warming table.
"Wait a minute!" commanded Nolan, turning on Javed. "If you don't have the respirator set up, don't grab the baby from the thing." Inez Robbins bagged the baby with the hand respirator while Javed adjusted the Bournes.
"Do we have a girl McKnight?" asked Arlene Hollins, comparing the baby's bracelet with the chart.
Susie bent over and looked at the tiny infant. "Yup! It's baby McKnight and she is a girl."
"First things first," said Javed. "Let's get a Logan bar," the frame used to steady the respirator tube when it is kept in the baby's throat for any but brief periods. The sides of the baby's head were swabbed with Betadine to help prevent infection from the tape and moleskin used to hold the frame in place. The tube protruding from the infant's throat was no bigger than a standard drinking straw. The job of hooking up the respirator was completed, and Robbins turned her attention to attaching the baby's monitor leads. She got the three leads to stick to the infant's chest on the first try, but then made the mistake of trying to reposition one. After four tries she gave up and Javed took over. Phillips then took the baby's temperature by placing an electronic thermometer under the infant's scawny arm. It was 96.9 degrees. The warmer was turned up.
"Nolan, you are going to admit this baby?" Hollins asked.
"All right then, what time does your primary-care baby get fed?"
"All right," said Hollins. "I'll take care of it."
Baby McKnight began fussing. Not crying. Fussing. Not crying. One of the first things that strikes visitors to the ICN is how little crying there is. Two reasons are the incredible amount of time the babies spend sleeping and the fact that most are in incubators. Another is that a baby whose endotracheal tube has been inserted properly cannot cry. "Hold on you poor little thing," Nolan said softly to the fidgeting baby. "It's okay." She adjusted the temperature of the warming table upwards.
"Don't overshoot the temperature," Javed warned. "The skin temperature's higher than it was, so if the baby's warming, don't adjust it yet."
"Do you want to start an IV?" Nolan asked.
"I want to do a catheter first. And we need gastric culture, ear cultures, umbilical culture, everything."
"You don't need to order the cultures. We do them standard."
"I'm not talking standard, I'm talking about what I want to do in addition to standard," Javed told her.
"Oh my God," thought Nolan. "This is not what I need on Christmas Eve." But she also knew better than to respond to Javed's dig and instead explained to Phillips that the cultures were being ordered to see if the infant had picked up any infections during the week between the rupturing of its mother's membranes and its delivery.
Phillips was struggling with a sound amplification system for listening to the baby's pulse. She was getting nothing but scratchy noise. "Let me do it, Susie," said Nolan, taking over. Within moments the corner of the room was filled with a rhythmic sound exactly like that of a submarine's sonar: the amplified sound of the blood rushing through the baby McKnight's veins.
"Do we have blood here?" Javed asked.
"It's right here," said Inez Robbins. She held up a bag containing 50 ccs of blood.
"Should we do the catheter and get it in?" asked Nolan.
"Right," said Javed. "Twenty is low blood pressure. It should be about 25 in a baby this size."
"Are you planning to get a catheter in?" asked Hannan, who had come back to check on things again.
"Right," Javed told him. "We're going to give the blood and get the catheter in.
"Okay, I'm going down to the meeting. If you guys need anything you can page me," said Hannan upon leaving.
The team began preparing the baby for her transfusion, first taping a board to her left arm for the IV insertion. The 3.5-inch board reached from the baby's hand to her elbow. "Can you hold this thing for me?" Javed asked everyone and no one. "I'll get the IV in." He took the hollow needle, the size of a small sewing needle, and probed for a vein in the infant's extended arm. After six tries he finally found a vein. "Let me have the butterfly, please," he asked Phillips.
"Just yell out when you need things," said Nolan, whose patience was being sorely tried. "Phillips doesn't know where things are yet, so just yell."
"Has the blood been checked?" Javed asked.
"It's checked. You can go ahead," she told him. Javed began pushing in the blood, initially giving the infant 15 ccs to get her blood volume, and therefore her pressure, up.
"Do me a favor," he said to Nolan, "cut off the rest of the umbilical, clean it up, recheck the temperature and then we'll have to restrain the baby."
Nolan took care of the first two tasks and then she and Inez Robbins restrained the 15-inch baby by tying her hands and feet to the side of the warming table with gauze strips. The baby's stomach and chest were swabbed with Betadine, and she was then completely draped in surgical towels, with only the stump of her umbilical cord exposed. "Is the baby restrained all fours?" Javed asked instead of looking.
"Yes," Nolan replied flatly.
"I want to clean up this umbilical stump before I do the job," Javed explained, "so I don't have to worry about contamination there. Most people do it afterwards, but I'd rather do it first."
"We always do it first," Nolan told Javed, who had just come over to Metropolitan from St. Francis three weeks earlier.
Javed's insertion of the umbilical catheter was far smoother than his fumbling with the IV, and in one swift move he had the minute catheter inserted in the even smaller umbilical artery, allowing the nurses to draw arterial blood for blood gas work-ups with a simple twist of a stop cock and insertion of a hypodermic.
It was 8:37. One hour and six minutes after the Code Pink team had been called. Baby Girl McKnight, 2 pounds and 13 ounces of baby born 10 weeks early, was established in the intensive care nursery of Metropolitan Hospital. If she survived the next 23 hours without serious complications, the odds were overwhelming that she would survive. Had she been born almost anywhere else in the area, it is likely she would have gone directly from the delivery room to the morgue. For had there been no Code Pink team at the delivery, she would never have begun breathing.