"Alphabet Soup: AMA, RSV, RR, SpO2, VBG, pCO2, pH, PICU"

01/02/2011 1845hrs: I come in 15 minutes before my shift as usual & overhear "RSV baby going home AMA". Putting my things down, out of the corner of my eye I see the frustrated parents bundling up a tiny baby, an 8-weeker born 5 weeks premature so he's really only 21 days old. The parents seem anxious to get home & are content that the baby appears to be breathing better & is more comfortable, their reasoning is "we live so close, we'll come right back if anything happens" according to the other nurse & doctor who let them sign out. The ER is packed to the rafters as usual, but I take note of the litte guy leaving, his cute little face covered up with a hat & a bulky winter jumpsuit, and his brief story stays in the back of my mind.

01/03/2011 0500hrs: I instantly recognize the father's voice: "We were here last night & now our baby is having trouble breathing." In a minute I count the little baby's respiratory rate at 60 & the SpO2 is only 91% on room air. In seconds we're in the resuscitation room adjacent to the triage room & by the providence of God I have an albuterol neb in my pocket. The doctor sees me carry the baby in & judging by my facial expression she understands the severity. We take off the familiar blue winter jumpsuit: a further assessment reveals that the baby is struggling severely, with sternal, intercostal & subcostal retractions, wheezing in all fields, and continues to desat to the low 90's on room air; he's also incredibly irritable, truly inconsolable, the only way he knows how to express air hunger. The distraught father comes outside and asks "so how serious is this thing?" - briefly hesitating (how do you tell someone their 2 month old baby could die if his body gives out trying to keep up with these demands) I tell him it affects different babies differently, sometimes it can be very, very serious, as it appears to be in this case. Labs are still current, I start his little IV & draw a venous blood gas off the IV, immediately putting it on ice for the lab to run. The pulse ox probe lights up his entire foot like a little alien limb that glows in the dark, cardiac leads the size of a dime are attached to his chest & plugged into the monitor, revealing a heart rate above 160bpm at all times as the baby continues to cry & struggle. The albuterol & saline nebs calm him down & he dozes off but the respiratory rate never drops below 50-55, at times climbing up to 85 per minute at rest without agitation. More alphabet soup comes in: a critical value is reported by the lab to the doctor: pH 7.11 (the comfortable range for all bodily functions is 7.35-7.45, anything outside that window & the condition can quickly turn fatal) & the pCO2 is 67 - the baby meets criteria for intubation but he's stable with supplemental O2 & saline/albuterol nebs round the clock, his respiratory rate & heart rate decrease to more appropriate levels for a neonate and his SpO2 is stable. At 0730 we go up to the PICU, my little guy sleeps the whole ride up there, with the saline neb propped up next to his face.

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Follow Up:
01/08/2011 0300hrs: While re-reading the ER chart, as I often do, trying to re-live the situation and make sure everything possible was done for the patient, I notice new xray reports that have merged with the chart: my little man has been intubated for the last 2 days and has developed pneumonia. I wish I hadn't looked.
01/11/2011 0300hrs: The little man got extubated yesterday.